Hello.
I'm Dr. Carolyn Clancy, director of the Agency
for Healthcare Research and Quality, or AHRQ.
I'm very proud of AHRQ's work to help find solutions
to today's most pressing patient safety problems and to share
that knowledge with all of you.
Today you'll be learning more about the importance
of using a comprehensive unit-based safety program, or CUSP,
to prevent infections and improve the quality and safety of the healthcare
that you deliver to your patients every day.
The CUSP model was originally developed
at Johns Hopkins University with funding from AHRQ.
A team at Johns Hopkins developed the model following the tragic
and accidental death
of an 18-month-old girl named Josie King at their facility.
Josie died of severe dehydration and misused narcotics.
After working closely with her family,
the team designed the CUSP framework with the aim of reducing harm
by creating a culture of patient safety at the hospital unit level.
CUSP can be used by care providers in any setting.
After implementing the program on your hospital unit, patient safety
and care quality outcomes will improve dramatically,
as we saw when CUSP was used
to reduce central line bloodstream infections, first in Michigan
and then across the country.
The toolkit has individual modules that feature videos,
slide presentations and teaching tools.
When used together these materials provide a comprehensive approach
to preventing infections and improving patient safety.
For example, one of the modules will help you work with your colleagues
to make sense of problems observed by the team and to put processes
in place to help make sure adverse events don't happen again.
You and your team are the key to the success of CUSP
and other safety improvement efforts.
And while AHRQ helped to generate the evidence base for CUSP,
we could not have gotten this far without the leadership
of the American Hospital Association,
which led the national implementation of the CUSP framework.
Now we'll hear from AHA's Rich Umbdenstock
about why CUSP should be an essential part of the work you do
in your healthcare facility every day.
Hello.
I'm Rich Umbdenstock, president and CEO
of the American Hospital Association.
The CUSP toolkit is a valuable resource for healthcare organizations
that want to prevent infections and improve safety.
In it you'll find a comprehensive framework
for implementing a unit-based culture change.
And changing culture is the way we will change the habits and behaviors
that keep us from achieving our safety goals.
As we all know, even one instance of patient harm is one too many.
As your organization looks for ways to increase the quality
of care your patients receive, the CUSP framework provides you
with the knowledge, tools and materials you need
to implement powerful unit-based cultural change.
And that in turn will improve the care your patients receive.
The Agency for Healthcare Research and Quality partnered with the AHA
on the national implementation of the On the CUSP: Stop HAI initiatives,
and the AHA was able to leverage its strong collaborative relationships
with hospitals to work closely with AHRQ to implement the CUSP framework
in hospitals across the country.
We know that CUSP works because of the improvements in patient care
that hospital unit teams achieved while participating
in the initiatives.
The teams that participated in the CUSP projects hailed
from hospitals across the country.
Each was unique in its size, location, facility type
and care specializations.
The success witnessed in these diverse hospital units proves
that CUSP is an invaluable tool
for implementing unit-based culture change
to improve patient safety outcomes.
Now, the success witnessed
on the national level would not have been possible without the support
of our project participants.
Special thanks are in order for the state hospital associations,
their member hospitals and the unit teams
that participated in these projects.
I also would like to congratulate each and every one of you
for the achievements that your teams are making in patient safety.
Your continuing hard work
and dedication are making our hospitals safer
and are improving the care our patients receive.
CUSP provides users with a practical set of tools
that support sustainable culture change on the hospital unit.
It empowers unit staff members to take an active role
in improving patient safety on their unit
by improving unit-level communication and teamwork strategies.
We know that CUSP will prove to be an invaluable tool for your hospital.
To help explain the success of the CUSP intervention,
I would like to introduce to you our friend Ann Mercer
from Mercy Memorial Hospital in Monroe, Michigan.
Ann will share with you the success that her team had
with implementing CUSP to improve patient care
on their obstetrics unit.
My name's Ann Mercer.
I am a registered nurse who also has an MBA in health administration,
and I am a nurse manager of an OB unit currently.
My entire 35-year career has been in maternal-child health.
One of the tools that you use is the staff safety assessment,
and the staff safety assessment gives you an overview
of what your department's issues are.
From nurse-physician interaction, it reviews how the nurses feel
and look at the department.
It reviews how physicians feel and look at the department.
It talks about communication issues.
It talks about how safe the staff feels.
Do they feel like they're understaffed?
Do they feel like they're tired,
that there may be a safety event looming in the future?
It really gives you an overview of your unit needs.
The relationship between physicians and nurses is vitally important
for safety of the team, and I think it's something
that really needs to be worked on.
When you're looking at safety issues you have to empower every member
of the team to be able to speak up.
You really have to have situations where physicians
and nurses can get together.
You want the physician in CUSP to really understand how
to communicate well with the team.
We tried to do some team-building exercises.
We try to do that every six months, and we allow them to get together
and have some open dialog.
What are the issues?
What concerns do physicians have?
What concerns do nurses have?
How can we bridge that?
And allow them to hear each other so that if they're able
to hear each other, then when they're in a situation that's critical,
then they will be able to communicate better.
You want the physician in CUSP to really understand how
to communicate well with the team.
We put together a whole post-partum hemorrhage kit,
and the physicians were absolutely fascinated by that.
We put the whole list together.
We got their input.
And one time one of the physicians came up on the unit.
"I want to see exactly where you're keeping "
that post-partum hemorrhage kit, because I want to know
in case we have an emergency.
I want to know exactly where it is."
CUSP gets you some formalization of tools put together to help you
so that in emergent situations you feel prepared.
Usually one of the things that we do
when we make rounds is we ask the patient "Do you feel
like you got all the information you needed to take care
of yourself and the baby?"
[baby crying]
"Are there any concerns that you have "
that you want to share with us?"
And thank them for letting us take care of them,
because it really is a team effort, and it's a privilege to be able
to provide the safest care for them.
I think the thing that I would really tell people is
that CUSP gives you a blueprint for patient safety,
and it's an ongoing situation.
You're never done assessing your patient safety.
I think the other thing that I would say if you're going to embark
on CUSP is you need all members of the team representative.
You can't just have your nurses involved
and they want to move it forward.
You just can't have your administration do it
without physician and nursing support.
You really need everybody to come together to say "This is important."
As you can see, CUSP is a unique and powerful tool
that hospitals can use to improve patient care outcomes.
Its approach to unit-centered culture change has contributed
to impressive gains in the realms of quality improvement
and patient-centered care.
Through CUSP and other safety initiatives,
hospitals are working together to share knowledge and information,
because we are committed to improving safety
and transforming the quality of patient care.
Thank you for the work you do every day.