Lori Paine

Implementing and Validating a Comprehensive Unit-Based Safety Program

Background: The IOM identified patient safety as a significant problem. This paper describes the implementation and validation of a comprehensive unit-based safety program (CUSP) in intensive care settings. Methods: An 8-step safety program was implemented in the Weinberg ICU, with a second control (SICU) subsequently receiving the intervention. Unit improvement teams (physician, nurse, administrator) were identified to champion efforts between staff and Safety Committee. CUSP steps: (1) culture of safety assessment; (2) sciences of safety education; (3) staff identification of safety concerns; (4) senior executives adopt a unit; (5) improvements implemented from safety concerns; (6) efforts documented/analyzed; (7) results shared; and (8) culture reassessment. Results: Safety culture improved post versus pre-intervention (35% to 52% in WICU and 35% to 67% in SICU). Senior executive adoption led to patient transport teams and pharmacy presence in ICUs. Interventions from safety assessment included: medication reconciliation, short-term goals sheet and relabeling epidural catheters. One-year post-CUSP implementation, length of stay (LOS) decreased from 2 to 1 day in WICU and 3 to 2 days in SICU (P < 0.05 WICU and SICU). Medication errors in transfer orders were nearly eliminated, and nursing turnover decreased from 9% to 2% in WICU and 8% to 2% in SICU (neither statistically significant). Conclusions: CUSP successfully implemented in 2 ICUs. CUSP can improve patient safety and reduce medication errors, LOS, and potentially nursing turnover.

Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit

BACKGROUND A culture of teamwork and learning from mistakes are universally acknowledged as essential factors to improve patient safety. Both are part of the Comprehensive Unit-based Safety Program (CUSP), which improved safety in intensive care units but had not been evaluated in other inpatient settings. METHODS CUSP was implemented beginning in February 2008 on an 18-bed surgical floor at an academic medical center to improve patient safety, nurse/physician collaboration, and safety on the unit. This unit admits three to six patients per day from up to eight clinical services. RESULTS Staff implemented several interventions to reduce safety hazards and improve culture. Surgical patients admitted to one clinical service were cohorted on this unit to increase physician presence. A team-based goals sheet was implemented to improve communication and coordination of daily goals of care. Nurses were included on rounds to form an interdisciplinary team. Five of six culture domain scores demonstrated significant improvements from 2006 and 2007 to 2008. There was a 27% nurse turnover rate in 2006 and a 0% turnover rate in 2007 and 2008. CONCLUSIONS Improvements were observed in safety climate, teamwork climate, and nurse turnover rates on a surgical inpatient unit after implementing a safety program. As part of the CUSP process, staff described safety hazards and then as a team designed and implemented several interventions. CUSP is sufficiently structured to provide a strategy for health care organizations to improve culture and learn from mistakes, yet is flexible enough for units to focus on risks that they perceive as most important, given their context. Broad use of this program throughout health systems could arguably produce substantial improvements in patient safety.

The association of childhood sexual abuse with depressive symptoms during pregnancy, and selected pregnancy outcomes

OBJECTIVES The objectives were: (1) to investigate the association during pregnancy of sexual abuse before the age of 18 on depressive symptomatology in pregnancy, controlling for the presence of negative life events and challenges; and (2) to investigate the association of selected pregnancy outcomes (maternal labor and delivery factors, infant birth weight and gestational age) with sexual abuse before age 18. METHODS Three hundred fifty-seven primiparous women aged 18 years and older were interviewed between 28-32 weeks gestation with reference to current functioning and past history (Objective 1). Medical record information was abstracted after delivery for pregnancy, labor and delivery factors, and pregnancy outcomes (Objective 2). RESULTS Thirty-seven percent of the women reported past sexual abuse. Prevalence was not associated with ethnic background, educational level, or hospital payment source. Previously sexually-abused pregnant women reported significantly higher levels of depressive symptomatology, negative life events, and physical and verbal abuse before and during pregnancy. There were no significant associations found between past sexual abuse and labor or delivery variables or newborn outcomes. CONCLUSIONS Previously sexually-abused pregnant women reported a wider constellation of past and current functioning problems than nonabused women although past sexual abuse was not associated with pregnancy outcome. Prenatal care provides a unique opportunity to evaluate the impact of life history and current life events during pregnancy, and to develop a coordinated intervention plan.

A Web-based Tool for the Comprehensive Unit-based Safety Program (CUSP)

BACKGROUND An organizations ability to change is driven by its culture, which in turn has a significant impact on safety. The six-step Comprehensive Unit-Based Safety Program (CUSP) is intended to improve local culture and safety. A Web-based project management tool for CUSP was developed and then pilot tested at two hospitals. HOW ECUSP WORKS: Once a patient safety concern is identified (step 3), a unit-level interdisciplinary safety committee determines issue criticality and starts up the projects (step 4), which are managed using project management tools within eCUSP (step 5). On a projects completion, the results are disseminated through a shared story (step 6). CASE STUDIES OSF St. Josephs Medical Center-The Medical Birthing Center (Bloomington, Illinois), identified 11 safety issues, implemented 11 projects, and created 9 shared stories--including one for its Armband Project. The Johns Hopkins Hospital (Baltimore) Medical Progressive Care (MPC4) Unit identified 5 safety issues and implemented 4 ongoing projects, including the intravenous (IV) Tubing Compliance Project. DISCUSSION The eCUSP tools success depends on an organizational commitment to creating a culture of safety.

A Check-up for Safety Culture in “My Patient Care Area”

The two-page Culture Check-Up Tool, which takes 30 to 60 minutes to complete as a group exercise, can help clinicians recognize and fix culture problems.

Paying the Piper: Investing in Infrastructure for Patient Safety

BACKGROUND Although the best allocation of resources is unknown, there is general agreement that improvements in safety require an organization-level safety culture, in which leadership humbly acknowledges safety shortcomings and allocates resources at the patient care and unit levels to identify and mitigate risks. Since 2001, the Johns Hopkins Hospital has increased its investment in human capital at the patient care, unit/team, and organization levels to improve patient safety. PATIENT CARE LEVEL An inadequate infrastructure, both technical and human, has prompted health care organizations to rely on nurses to help implement new safety programs and to enforce new policies because hospital leaders often have limited ability to disseminate or enforce such changes with the medical staff. UNIT OR TEAM LEVEL At the team or nursing unit level, there is little or no infrastructure to develop, implement, and monitor safety projects. There is limited unit-level support for safety projects, and the resources that are allocated come from overtaxed department budgets. ORGANIZATION LEVEL HOSPITAL LEVEL AND HEALTH SYSTEM: Infrastructure is needed to design, implement, and evaluate the following domains of work-measuring progress in patient safety, translating evidence into practice, identifying and mitigating hazards, improving culture and communication, and identifying an infrastructure in the organization for patient safety efforts. REFLECTIONS Fulfilling a commitment to safe and high-quality care will not be possible without significant investment in patient safety infrastructure. Health care organizations will need to determine the cost-benefit ratio of various investments in patient safety. Yet, predicating safety efforts on the mistaken belief in a short-term return on investments will stall patient safety efforts.

Re-examining high reliability: actively organising for safety

In the 15 years since To Err is Human was published,1 the US healthcare industry has worked diligently to improve patient safety. Although progress has been made in reducing hospital-acquired conditions2 and, in some cases, rates of surgical mortality,3 healthcare has not achieved broad reductions for most patient harms. In recent years, healthcare has borrowed ideas from industries that have strong safety records, including teamwork and error reporting from aviation, and process improvement techniques from manufacturing. Healthcares latest patient safety push is to encourage hospitals to become a ‘high reliability organisation’ (HRO).4 HROs have maintained remarkable performance despite complex and risky work. These ultrasafe organisations never set out to be HROs. As Rochlin5 observed: HROs ‘seek an ideal of perfection but never expect to achieve it. They demand complete safety but never expect it. They dread surprise but always anticipate it. They deliver reliability but never take it for granted. They live by the book but are unwilling to die by it’. HROs understand that reliability is an endless journey rather than a simple destination. Evidence suggests that healthcare is starting to organise for higher reliability. Standardised protocols and checklists,6 preprocedural and postprocedural briefings,7 incident reporting and daily huddles,8 although imperfect,9 ,10 may hold promise for enhancing safer care. These types of activities may be part of an institutions master plan to create a comprehensive operating management system—an organisation-wide integrated approach to manage risk and to achieve safe and reliable performance—similar to the systems found in other industries such as oil and gas. Yet, we think it is more likely that these efforts represent piecemeal and fragmented initiatives adopted to solve particular problems. Regardless, high reliability remains elusive. One explanation is that organisations have failed to widely institutionalise high-reliability habits of …

The Johns Hopkins Hospital: Identifying and Addressing Risks and Safety Issues

BACKGROUND At The Johns Hopkins Hospital (JHH), a culture of safety refers to the presence of characteristics such as the belief that harm is untenable and the use of a systems approach to analyzing safety issues. PATIENT SAFETY AS A LEADERSHIP AND ORGANIZATIONAL PRIORITY The leadership of JHH provides strategic planning guidance for safety and improvement initiatives, involves the patient safety committee in capital investment allocation decisions and in designing and planning new hospital facilities, and ensures that safety and quality head the agenda of board-of-trustees meetings. Although JHH takes a systems approach, structures such as monitoring staff behavior trends are used to hold people accountable for job performance. CHALLENGES AND LESSONS LEARNED JHH encountered three major hurdles in implementing and sustaining a culture of safety. First, JHHs decentralized organizational structure contributes to a silo effect that limits the spread of ideas, practices, and culture. JHH intends to create an internal collaborative of departmental safety initiatives to foster opportunities for units to share ideas and results. Second, in response to the challenge of encouraging teams to think and act in an interdisciplinary fashion, communication and teamwork training are being used to enhance the effectiveness of interdisciplinary teams. Further development of valid and meaningful safety-related measurement and data collection methodologies is JHHs largest remaining challenge.

The Armstrong Institute: An Academic Institute for Patient Safety and Quality Improvement, Research, Training, and Practice.

Academic medical centers (AMCs) could advance the science of health care delivery, improve patient safety and quality improvement, and enhance value, but many centers have fragmented efforts with little accountability. Johns Hopkins Medicine, the AMC under which the Johns Hopkins University School of Medicine and the Johns Hopkins Health System are organized, experienced similar challenges, with operational patient safety and quality leadership separate from safety and quality-related research efforts. To unite efforts and establish accountability, the Armstrong Institute for Patient Safety and Quality was created in 2011. The authors describe the development, purpose, governance, function, and challenges of the institute to help other AMCs replicate it and accelerate safety and quality improvement. The purpose is to partner with patients, their loved ones, and all interested parties to end preventable harm, continuously improve patient outcomes and experience, and eliminate waste in health care. A governance structure was created, with care mapped into seven categories, to oversee the quality and safety of all patients treated at a Johns Hopkins Medicine entity. The governance has a Patient Safety and Quality Board Committee that sets strategic goals, and the institute communicates these goals throughout the health system and supports personnel in meeting these goals. The institute is organized into 13 functional councils reflecting their behaviors and purpose. The institute works daily to build the capacity of clinicians trained in safety and quality through established programs, advance improvement science, and implement and evaluate interventions to improve the quality of care and safety of patients.

Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study

Background Second victims are healthcare workers who experience emotional distress following patient adverse events. Studies indicate the need to develop organisational support programmes for these workers. The RISE (Resilience In Stressful Events) programme was developed at the Johns Hopkins Hospital to provide this support. Objective To describe the development of RISE and evaluate its initial feasibility and subsequent implementation. Programme phases included (1) developing the RISE programme, (2) recruiting and training peer responders, (3) pilot launch in the Department of Paediatrics and (4) hospital-wide implementation. Methods Mixed-methods study, including frequency counts of encounters, staff surveys and evaluations by RISE peer responders. Descriptive statistics were used to summarise demographic characteristics and proportions of responses to categorical, Likert and ordinal scales. Qualitative analysis and coding were used to analyse open-ended responses from questionnaires and focus groups. Results A baseline staff survey found that most staff had experienced an unanticipated adverse event, and most would prefer peer support. A total of 119 calls, involving ∼500 individuals, were received in the first 52 months. The majority of calls were from nurses, and very few were related to medical errors (4%). Peer responders reported that the encounters were successful in 88% of cases and 83.3% reported meeting the callers needs. Low awareness of the programme was a barrier to hospital-wide expansion. However, over the 4 years, the rate of calls increased from ∼1–4 calls per month. The programme evolved to accommodate requests for group support. Conclusions Hospital staff identified the need for a multidisciplinary peer support programme for second victims. Peer responders reported success in responding to calls, the majority of which were for adverse events rather than for medical errors. The low initial volume of calls emphasises the importance of promoting awareness of the value of emotional support and the availability of the programme.