AHRQ Safety Program for
Mechanically Ventilated Patients
Overview of the Comprehensive Unit-based
Safety Program for Application to Mechanically
Ventilated Patients
AHRQ Pub. No. 16(17)-0018-27-EF
AHRQ Safety Program for Mechanically Ventilated Patients January 2017
Overview of CUSP for MVP 1
Learning Objectives
After this session, you will be able to—
• Explain the vision of Comprehensive Unit-based Safety
Program (CUSP) teams
• List the five steps of CUSP
• Describe the benefits of the Staff Safety Assessment (SSA)
• Administer the SSA
• Conduct a premortem exercise with your team to proactively
identify risks
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COMPREHENSIVE UNIT-BASED
SAFETY PROGRAM (CUSP)
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Why CUSP?
• Designed to improve safety culture and help users
learn from mistakes
• Values the wisdom of frontline staff
• Empowers staff to be actively engaged in safety
improvements
• Linked with improvements in clinical outcomes and
human resources outcomes
• Helps eliminate barriers between staff and senior
leadership
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CUSP Vision
• We treat each patient the same way we would want
our family members treated
• We do not accept any preventable harm as an option
• We don’t settle
– Our safety culture empowers us to achieve excellence in
patient safety and quality
– We believe in our power to speak up when we have safety
concerns, and we share this belief with others
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CUSP Vision
• We keep an eye on our systems, with the goal of
designing and improving systems that support us in
our aim of delivering safe, quality care
• We see defects as opportunities for continuous
learning, and as a team, we tackle these
opportunities because together we are stronger
• We see patients and family members as part of our
care teams, because we know that safe, quality care
demands their involvement
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Steps of CUSP1
COMPREHENSIVE UNIT-BASED SAFETY PROGRAM
1. Educate staff on Science of Safety
2. Identify defects
— How will the next patient in your clinical area be harmed?
— What can be done to prevent or minimize this harm?
— How can we get the patient off the ventilator faster?
3. Partner with a senior executive
4. Learn from defects
5. Improve teamwork and communication
ADAPTIVE COMPONENTS
1. Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient
safety in intensive care units in Michigan. Journal of Critical Care. 2008
Jun;23(2):207-21. PMID: 18538214.
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Steps of CUSP
1. Educate staff on Science of Safety
— Help teams develop lenses to focus on system factors that can
negatively impact care
2. Identify defects
– Learn from staff reports of safety concerns, event reports, etc.
– Be proactive—ask staff how the next patient will be harmed
3. Partner with a senior executive
– Work with a senior executive to develop a shared understanding of
local defects
– Build consensus, plan to mitigate defects, and develop shared
accountability for implementing the plan
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Steps of CUSP
4. Learn from defects
– What happened?
– Why did it happen?
– How will you reduce the risk of it happening again?
– How will you know that risk is reduced?
5. Improve teamwork and communication
– Tap into the insights of diverse team members
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Successful CUSP Teams
• Are composed of engaged frontline clinicians who take ownership of
patient safety
• Include staff members who have different levels of experience and
perspectives
• Represent all stakeholders by bringing multiple disciplines together
• Meet regularly
• Have adequate resources including protected time
– 2–4 hours per week for a CUSP champion
• Share leadership
• Work together to make decisions
– Avoid preconceived notions
– Engage in breaking down silos within unit
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Core CUSP Team Roles
• CUSP Facilitator • Nurse Champion
• CUSP Champion • Senior Executive
• Unit Manager • CUSP Coordinator
• Provider Champion • Others
Tip: The CUSP Tool: CUSP Roles & Responsibilities provides a detailed list of
expectations as well as reflection questions. Find this and other CUSP tools at http://
www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/index.html.
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Safety Program Team Members
Essential Team Members Enhancing Team Members
• Nurses • Physician assistants
• Physicians • Nurse educators
• Infection preventionists
• Occupational therapists
• Patient safety officers
• Respiratory therapists
• Chief quality officers
• Physical therapists • Ancillary staff
• Executive partner • Pharmacist
• Nurse leaders • Social worker
• Clinical technicians • Patient and family
representatives
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Strong CUSP Teams
• Share a strong team orientation
• Understand the advantage a team approach offers
• Share a mental model of the team’s mission
• Work together to achieve the mission
• Build frameworks for team behaviors or norms
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STAFF SAFETY ASSESSMENT (SSA)
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Principles of Science of Safety
• Use strategies to improve system
performance Standardize
– Standardize care Care
– Create independent checks
Create
– Learn from defects Independent
Checks
• Apply these principles to technical
work as well as teamwork Learn From
Defects
Tip: Science of Safety videos (23 minutes) are available at
http://
www.ahrq.gov/professionals/education/curriculum-tools/cusptoo
lkit/modules/understand/index.html
.
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Staff Safety Assessment
• Taps wisdom of frontline providers
• Helps providers understand the patient safety
risks in their clinical areas
• Gives insight into potential solutions to these
problems
• Leverages frontline wisdom to guide safety
improvement efforts
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Staff Safety Assessment
How will your next
1 ventilated patient be
harmed?
What can be done
2 to prevent or
minimize this harm?
How can we get the
3 patient off the
ventilator faster?
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Staff Safety Assessment
The SSA should be—
• Coordinated by a safety program lead or designee
• Administered to ALL staff
– Immediately after training on the Science of Safety so
providers have lenses to see system problems
• Incorporating an SSA collection box
– To encourage staff to report safety concerns
– To drop completed forms in an accessible location
• Completed at least every 6 months
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SSA: Next Steps
Present the Science of Safety video and
administer SSA during these ideal times:
• Medical staff grand • Lunch session
rounds • Special educator sessions
• New staff orientation • Annual recertification
• Regularly scheduled staff requirements
meetings
Tip: Make the Science of Safety video available in
the break room and on the hospital intranet.
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Training Steps and Tools
NEXT STEP TOOLS TO USE
Educate team on Science of Safety Science of Safety video (23 minutes)
Record staff that completes training Science of Safety training attendance
sheet
Administer SSA SSA
Collate results of SSA and Reference this presentation for help
share with team with sharing results
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Interpreting SSA Results
Prioritize identified defects using the following criteria:
• Likelihood of the defect harming the patient
• Severity of harm the defect causes
• Frequency of the defect occurrence
• Likelihood of preventing defect in daily work
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Key Takeaways
• Patient safety efforts are not just about checklists
• CUSP brings adaptive work into the change process
• CUSP teams integrate the principles of safe design into the
day-to-day activities
– Standardize care
– Create independent checks
– Learn from defects
• SSA taps the wisdom of frontline staff
— How will the next patient in your clinical area will be harmed?
— What can be done to prevent or minimize this harm?
— How can we get the patient off the ventilator faster?
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PREMORTEM EXERCISE
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Preparing To Lead
• In a postmortem, an autopsy is performed to learn
why a patient died. While it may be helpful to those
interested in the results, it does not help the central
figure in the medical drama—the patient.
• The Premortem Exercise is used to identify potential
barriers and vulnerabilities to project success before
they occur. It builds intuition about and sensitivity to
future problems.
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Premortem Exercise
Step 1
• Imagine that we are 2 years into the future and,
despite all of the team’s efforts, the project has failed
catastrophically. Things have gone completely wrong
on a number of fronts.
• Now, ask:
– What does the worst-case scenario look like?
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Premortem Exercise
Step 2
• Generate the reasons for failure.
• Brainstorm reasons you believe this failure occurred.
• Now, ask:
– What could have caused our project to fail?
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Premortem Exercise
Step 3
• Prioritize your list of potential reasons for failure.
• Address the top two or three concerns.
• Now, ask:
– What specific actions can you take to avoid or
manage these concerns?
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Premortem Exercise
Step 4
• Throughout your program, periodically review the
potential problem list with your team.
• This process will raise team awareness of emerging
problems and allow the team to anticipate solutions.
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Premortem Exercise
Summary
1. Two years out, what does the worst case scenario
look like?
2. What could have caused your project to fail?
3. What specific actions can you take to avoid or
manage these issues?
4. Review and anticipate potential problems
throughout the program.
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Questions?
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References
1. Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety
in intensive care units in Michigan. Journal of Critical Care. 2008
Jun;23(2):207-21. PMID: 18538214.
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