The Johns Hopkins Comprehensive Unitbased Patient Safety Program CUSP

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The Johns Hopkins Comprehensive Unit-based
Patient Safety Program (CUSP)

• Peter Pronovost, MD, PhD,
• Johns Hopkins Univeristy

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How can this happen?

• Improvements in safety represent the greatest
  opportunity to improve patient care

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How can we improve

• Every system is perfectly designed to achieve
  the results it gets

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Aviation Accidentsper million departures
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Primary accident causes ()
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Today, pilots can fail their certification based
on poor interpersonal, or non technical
aspects of their performance.
Teamwork by Edict
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Lessons Learned

• Focus on interpersonal improvements
• Frontline staff must assume responsibility for
  quality and safety
• Safety interventions must be goal directed
• Culture changes incrementally
• Document (measure) improvements

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Johns Hopkins Comprehensive Unit-based Patient
Safety Program (CUSP)
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The Johns Hopkins Comprehensive Safety Program

• Evaluate culture of safety
• Educate staff on science of safety
• Identify staffs safety concerns
• Executive adopt an ICU
• Prioritize improvement efforts
• Implement improvements
• Share stories and disseminate results
• Evaluate culture

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Summary of Science of Safety

• The safety problem is large
• We will make mistakes
• We must focus on systems rather than people
• We need a culture to identify what is broken and
  fix it
• Leaders control the potential to change systems

www.icusrs.org
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NEJM
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Evidence Regarding the Impact of ICU Organization
on Performance

• Physicians
• Nurses
• Pharmacists

Pronovost JAMA 1999, 2002 Pronovost ECP 2001
Pronovost JAMA 1999, 20002
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Incident Reporting
httpicusrs.org
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What can we do to improve safety

• Accept that we make mistakes
• Focus on Systems
• Prevent mistake from occurring
• Make mistake visible
• Mitigate harm should it occur

Helmreich, Nolan
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To prevent mistakes

• Create culture of safety
• Reduce complexity
• Create independent redundancy to ensure key
  processes occur
• Evidence-based therapies
• Bottle necks

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Culture in Safe Organizations

• Commit to no harm
• Focus on systems not people
• Communication/teamwork
• Assertive communication
• Teamwork
• Situational awareness
• Disclosure
• Celebrate safety
• Workers viewed as heroes

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of respondents within a clinic reporting good
teamwork climate
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of respondents reporting above adequate teamwork
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ISSUES IDENTIFIED ACROSS ICUS

• Patient transport
• Medication errors
• Communication
• Central line infections

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Percent Understanding Patient Care Goals
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Impact on ICU Length of Stay
Daily Goals
654 New Admissions 7 Million Additional Revenue
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ICU catheter-related blood stream infections
Education
Line Cart
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Checklist
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Rate/1,000 Catheter days
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NNIS Mean
0
Jul
Sep
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Culture
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of respondents within a clinical area reporting
good safety climate
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What can you do

• The safety program provides a practical, goal
  directed tool to improve safety culture and lead
  to measurable improvements in safety

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NEXT STEPS

• Communication
• Safety Tales
• Sharing Lessons Learned
• Additional Training
• Nursing units and Departments
• Medical/nursing students

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Is Safety your Hedgehog Concept
What can you be great at
What are you passionate about
What is important
Jim Collins
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Who is willing to shave their Head

• Who is willing to commit to improving patient
  safety

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