Paula Kent

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.

Implementing a Team-Based Daily Goals Sheet in a Non–ICU Setting

A tool was developed to improve communication in non-intensive care unit inpatient units. This tool clarifies patient-centered goals, provides an accurate information source for each patient, and helps nurses communicate more effectively with one another and the surgical team.

Implementing a Multifaceted Intervention to Decrease Central Line–Associated Bloodstream Infections in SEHA (Abu Dhabi Health Services Company) Intensive Care Units: The Abu Dhabi Experience

OBJECTIVE To determine whether implementation of a multifaceted intervention would significantly reduce the incidence of central line-associated bloodstream infections. DESIGN Prospective cohort collaborative. SETTING AND PARTICIPANTS Intensive care units of the Abu Dhabi Health Services Company hospitals in the Emirate of Abu Dhabi. INTERVENTIONS A bundled intervention consisting of 3 components was implemented as part of the program. It consisted of a multifaceted approach that targeted clinician use of evidence-based infection prevention recommendations, tools that supported the identification of local barriers to these practices, and implementation ideas to help ensure patients received the practices. Comprehensive unit-based safety teams were created to improve safety culture and teamwork. Finally, the measurement and feedback of monthly infection rate data to safety teams, senior leaders, and staff in participating intensive care units was encouraged. The main outcome measure was the quarterly rate of central line-associated bloodstream infections. RESULTS Eighteen intensive care units from 7 hospitals in Abu Dhabi implemented the program and achieved an overall 38% reduction in their central line-associated bloodstream infection rate, adjusted at the hospital and unit level. The number of units with a quarterly central line-associated bloodstream infection rate of less than 1 infection per 1,000 catheter-days increased by almost 40% between the baseline and postintervention periods. CONCLUSION A significant reduction in the global morbidity and mortality associated with central line-associated bloodstream infections is possible across intensive care units in disparate settings using a multifaceted intervention.

Examining Variation in Mental Models of Influence and Leadership among Nursing Leaders and Direct Care Nurses

This study explored similarities and differences in the views on team membership and leadership held by nurses in formal unit leadership positions and direct care nurses. We used a mixed-methods approach and a maximum variance sampling strategy, sampling from units with both high and low safety behaviors and safety culture scores. We identified several key differences in mental models of care team membership and leadership between formal leaders and direct care nurses that warrant further exploration.

Summary of Proceedings From the Association of American Medical Colleges 2011 Integrating Quality Meeting

As Editor-in-Chief of the American Journal of Medical Quality (AJMQ), and as a member of the Association of American Medical Colleges (AAMC) Integrating Quality (IQ) Steering Committee, I am particularly pleased to bring this special supplement to fruition. The supplement highlights proceedings from the AAMC 2011 IQ Meeting, which was held in Chicago, Illinois, on June 9 and 10, 2011. Having delivered the keynote address at the 2010 version of the IQ meeting, I have seen firsthand how far this important initiative has come. Let us examine the full title more closely, that is, “Integrating Quality: Linking Clinical and Educational Excellence.” How exactly can we link clinical improvement and educational excellence? I believe the genesis of this linkage can be traced directly to October 26, 2009, when the Lucien Leape Institute at the National Patient Safety Foundation published Unmet Needs: Teaching Physicians to Provide Safe Care. The recommendations contained in this report came from an expert roundtable comprising Lucien Leape Institute board members and invited experts (including this author) from medical education and related fields. The report described the existing system of medical education as greatly lacking in the arena of quality and safety and called for sweeping reform of both undergraduate and graduate medical education curricula. My colleagues and I used the unmet needs report as a jumping-off point. Indeed, Academic Medicine received scores of papers from a national solicitation, and those that were published in this journal laid out multiple worthy plans for integrating clinical improvement and educational excellence in such a way that the die was cast by late in the fourth quarter of 2009. In the editorial accompanying the Academic Medicine special issue, I noted that there were “growing choruses of voices from across all of organized medicine, which have collectively spoken out about the crucial need for better care.” Astute observers noted that “unless everyone in health care recognizes that they have 2 jobs when they come to work every day—that is, doing the work and improving it—we will have difficulty maintaining and nurturing our true professionalism . . . continuously moving toward new and better levels of performance.” At this point, the AAMC launched its IQ initiative. Lending their national authority to this important topic, the AAMC has come a long way in providing leadership for this crucial linkage. They have gone beyond the Lucien Leape unmet needs report and eclipsed all previous work in this arena. The June 2011 meeting is further evidence of their success, luring hundreds of individuals to Chicago to ponder issues that only 3 or 4 years ago seemed like the distant future. This is all well and good, but the AAMC cannot rest on its laurels. What will success look like when we finally link clinical improvement and educational excellence? I envision the development of a national core curriculum on quality and safety, applicable to both undergraduate and graduate medical education settings. I envision a world where quality and safety are not simply add-ons or electives to be slotted somewhere in the second semester of the fourth year of medical school. I also envision growth in the number of endowed chairs in quality and safety and a great expansion in the number of master’s programs in our field. Furthermore, with the implementation of the highly anticipated Accreditation Council for Graduate Medical Education institutional visit program, we finally will quantify institutional responses to the quality and safety agenda at the residency training level. We will no longer be able to check a box regarding our capabilities in systems-based learning and practice-based improvement. We will have to prove, once and for all, that house officers get it—that they are intimately involved in self-evaluation, measurement, and improvement. House officers will embrace the 2 jobs that all practitioners must have. 445460 AJMXXX10.1177/106286061244 5460American Journal of Medical Quality