Hi, I'm Peter Pronovos I want to take a few moments to reflect on our journey
to cusp that we've been on together and how that journey can continue.
In the past decade we've learned a lot and we still have a lot to learn.
We're convinced that it's best to learn together and
that shared learning is done best within a structure.
Our own CUSP journey began on a snowy February night
when two year old Josey King died from a clasby.
A preventable harm.
At that time, the infection rate at Johns Hopkins
was through the roof, 11 per 1000 catheter days.
I was part of that, I didn't mean to be.
A year later, Josie's mom Serell, asked me if
Josie was less likely to die today from preventable harm.
We've been working hard to make that answer yes.
We got our infection rates down at Hopkins.
We formed a partnership with the Michigan hospitals to get rates down there and for
more than ten years we've spread CUSP
state by state through the state hospital association.
And it is one if not the only success story where we took a major
harm, killing each year as many people as
breast or prostate cancer and dramatically reduced it.
The media tends to reduce the success to a
simple checklist, but we know CUSP is much more complex.
CUSP teams all over the country have developed
skills to identify and mitigate their own specific harms,
recognizing the secret sauce that has made CUSP
endure, improving teamwork and institutionalizing a culture of safety.
Positive results have been sustained for 15 years at Hopkins.
Ten in Michigan and four in many state hospital associations.
But we need to learn more.
For example, we know how to implement CUSP in one
ICU, but how do we spread it to other units?
What's the right infrastructure at the hospital and department levels?
We've been playing with the idea of a fractal
like a fern to support both learning and accountability.
We still need to better understand what it takes to do this.
What we've heard from a lot of you is, how do we learn together.
ARC has made available, a free toolkit from
our collaborations with them, the AHA and HRET.
We've also been working with private industry,
to learn how to disseminate CUSP Through
peer-to-peer learning, and we formed a partnership
with the CDC to help spread CUSP.
We know that simply having a website with downloadable tools telling
us what to do is not going to be good enough.
This is tough stuff.
So our question is this: How do we develop
together new knowledge about implanting, sustaining and spreading CUSP?
And most importantly, how do we continue to reduce patient harm.
It's very encouraging that AHRQ and hundreds
of hospitals have gotten on the CUSP bandwagon.
But many AHRQ programs are integrating CUSP.
CUSP UTI, CUSP surgery, CUSP Vap.
And many of you are doing partnership with patients.
We need to continue to nurture CUSP and help it grow and
avoid misinformation that may limit the results we believe we can get.
The partnership around the National [UNKNOWN] Eye Project with hospitals,
state hospital associations, AHRQ, AR, HRET and others has been amazing.
But with that funding over now, hundreds of you are reaching out.
Asking how do we connect?
How do we continue to grow and learn together?
Where's the learning going to take place?
There's been no mechanism to do this.
That's why our team at the Armstrong Institute decided to put one together.
As you may know, the Armstrong Institute seeks to partners
with patients, their families, and others, to eliminate preventable harm.
Optimize patient outcomes and experience and reduce healthcare waste.
We've linked researchers and clinicians and educators to
create a forum where we can bring together
the best in the science of patient safety
making it simple and practical for all healthcare settings.
To help create an infrastructure to allow us to
grow CUSP together, we've created the Guided Patient Safety Network.
We call this GPS for CUSP.
We believe there's an enormous opportunity to co-develop
and share tools openly and for you to be
the leaders yourselves as we try to push the
envelope in spreading the culture and science of safety.
Equally important to the GPS for CUSP is
to keep us from reinventing the wheel, because we
don't know what's happening in another hospital until
we read about it in a peer reviewed journal.
We want GPS for CUSP to be a living
organic network that allows us to connect, share and grow.
We felt the energy of the National Stop BSI Project.
I suspect many of you did too.
Our goal is to harness that energy in this GPS network.
The Armstrong Institute will put information out there
for you to react, and shape, and use.
And we'll want and need your ideas and experiences.
We heard from hundreds of you that you want to learn and work together.
And we couldn't agree more.
We're looking forward to advancing together
the important work we started together.
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