A health system in Maine is improving patient safety with the Comprehensive Unit-based Safety Program (CUSP). This approach emphasizes empowering frontline staff.

  • Staff identify problems in their own units.
  • Solutions may involve working with multiple disciplines in the hospital.
  • An executive sponsor is an active member of the team.

A health system in Maine is seeing good results with a safety program designed to unite frontline clinicians and provide specific tools to address hazards in the healthcare setting.

Northern Light Health in Brewer, ME, is using the Comprehensive Unit-based Safety Program (CUSP) to improve patient safety in several ways, from standardizing crash carts to preventing patient-to-patient assaults.

CUSP was developed by safety and quality researchers at the Johns Hopkins Armstrong Institute for Patient Safety and Quality and the Agency for Healthcare Research and Quality (AHRQ). (See the story in this issue for more details on CUSP.)

The CUSP approach was brought to Northern Light Health three years ago by Tim Dentry, then chief operating officer and now president and chief executive officer of the system. He learned the system in a previous role at Johns Hopkins, where the program is embedded in the system’s culture.

CUSP was attractive to Northern Light Health leaders for its potential to improve the system’s culture of safety, says Jeffrey Parsons, Esq., vice president for risk and patient safety.

“From a risk perspective, we struggled with the improvement side of things. Risk management is great after the fact, going in after the event with root cause analyses and finding out what went wrong, but the real goal is to go upstream and address the issues that gave rise to those harm events,” Parsons explains. “One of the areas where we struggled was frontline engagement. This was a great solution to that because the frontline workers came up with what mattered to them and their patients.”

Northern Light Health started using CUSP in two units at different hospitals, then deployed it systemwide the next year. This year, the health system is expanding CUSP in a broad range of departments.

At first, CUSP was used on a unit-specific basis, with an individual unit seeking safety improvements that could be implemented there, Parsons says. But as CUSP expanded, participants saw opportunities to develop safety improvements beyond their own units.

“They started seeing that if they reached out and included radiology, lab, or pharmacy, they could really address deeper root causes associated with the issue,” Parsons says. “It’s a nice, blended model that uses the unit-specific approach with CUSP but strategically and effectively bringing in a multidisciplinary approach.”

Frontline Staff Empowered

CUSP emphasizes the frontline responsibility and accountability for patient safety, says Navneet Marwaha, MD, vice president and chief quality officer with Northern Light Health. The program emphasizes that frontline workers can most effectively identify hazards and develop solutions, she says.

“If you ask leaders to identify the problems across the system, chances are they are aware of only a small percentage. But the frontline staff know 100% of the problems they are facing because they do this work day in and day out. They develop the workarounds because the system doesn’t provide support, or they don’t have the right processes in place,” she says. “CUSP tells them they are the experts in their work and the challenges they face, so they will find the solutions. The leader who is removed from the day-to-day work of the unit is unlikely to know what the right solution is.”

One CUSP initiative involved standardizing crash carts in one Northern Light Health facility, Northern Light AR Gould Hospital in Presque Isle. A crash cart in the emergency department might be stocked and stationed differently than a crash cart in another unit. That could slow the response of staff in a cardiac or respiratory crisis, Marwaha says.

Staff realized they were losing valuable time looking for supplies, so they used the CUSP method to identify the hazards and develop a standard format for the crash carts no matter where they were located in the hospital. But the task was not simple.

“Everything we do in healthcare is complex and there rarely is a simple solution to any problem. By following the CUSP program, they realized that they needed to talk to central sterile processing, their colleagues on their different medical and surgical floors, and others,” Marwaha explains. “It was not as simple as one unit deciding on a standard format and telling everyone else to do the same thing.”

Addressing Patient Handoff

Success with that effort led to using CUSP to address the handoff and transport of patients diagnosed with high-risk infections, such as Clostridioides difficile. Hospital leaders realized the system needed a way to clearly identify those patients and communicate the risk to others as the patient moved between units or facilities.

Frontline staff worked with infection control practitioners and representatives from various units to develop an effective way to communicate a high infection risk when patients were moved in the system.

“For the teams that have tried it, CUSP has really broadened their knowledge about the interconnectedness and complexity involved with keeping our patients safe,” Marwaha says. “It has broader implications for improving engagement and teamwork, which will further the mission of the organization. Northern Light’s key strategic initiative now is to have CUSP unit-based safety teams at every member organization.”

The goal is for each facility in the health system to staff half its units plus one more outpatient or nonclinical unit with a CUSP team.

“We are on the threshold of reaching a tipping point of becoming where this will be considered the way we do business and the way we do improvement and safety,” Parsons says. “The next strategies will involve how we capture and celebrate all the successes of our CUSP teams rather than concentrating on the number of CUSP teams we have in motion. We want to celebrate the achievements as part of our culture.”

Patient Violence Cited

Northern Light Health asked leaders at each facility to look for opportunities to improve patient safety with CUSP. Northern Light Acadia Hospital, a psychiatric facility in Bangor with a pediatric inpatient unit, highlighted the problem of patient-on-patient assault. Unlike patients in a typical acute care hospital, pediatric inpatients at Acadia Hospital spend most of their time together, ambulatory, and active, Marwaha explains.

That creates a risk of patient-on-patient violence among young people who can be vulnerable and also prone to physical interaction, she says. Using the CUSP model, the frontline staff at Acadia Hospital determined the common factor in many violent incidents was that staff did not know who was prone to violence and needed more attention.

The psychiatric technicians who spend the most time with the young psychiatric patients were not adequately conveying information at shift handoffs, Marwaha says. They needed to communicate more effectively about negative group and interpersonal dynamics among the patients.

Through CUSP, staff updated the 24-hour safety huddle report provided to all psychiatric technicians, administrators, and anyone helping on the pediatric unit. The improved report format provides information about patients experiencing problems with particular issues, like respecting boundaries or one group of patients not getting along with another group, alerting staff to patients who are at risk of assaulting others.

Executive Sponsor Is Key

A key benefit of the CUSP model is how it engages frontline staff across multiple disciplines. This includes an executive sponsor, who is an active member of the team, Parsons says.

“That has proven in multiple instances to be a huge part of the team’s success. Sometimes, just the presence of the executive sponsor or the way that sponsor asks questions and supports the team indirectly provides the team a sense of empowerment and allows them to move forward,” Parson says. “When there are true barriers, that person can step in and help. But what I’ve heard more often is the confidence and empowerment that the executive sponsor brings to the team. That has been critical.”

At first, Parsons said he was uncomfortable with one aspect of CUSP, but since has learned to embrace it. In the beginning, he had a hard time letting the teams choose what topic they wanted to work on.

“As a risk manager, I know where the events are happening and what units are having less of this problem and more of that. That was hard at first because they would choose something to address and I knew there were other issues I might have chosen instead,” Parsons says. “But the front line knows. I may see data, but the front line knows what is important to the safety of the patients and happiness of the staff.”

Parsons now focuses on providing useful information gleaned from the massive amounts of data collected by the health system to the frontline staff — data that can help them choose CUSP projects and guide those efforts, he says.

“We have to trust the process and provide these teams with as much information as we have related to these safety issues,” he says. “We trust our staff to know what is important. They have not let us down.”

Marwaha underscores the importance of frontline staff owning the process, although the participation of an executive sponsor also is crucial.

Staff may focus on seemingly small issues, not a grand patient safety initiative driven by tons of data and best practices, Marwaha notes. That is fine because they are addressing the issues they know have a real effect on patient care and safety every day, she says.

“What gets these teams really energized is tackling an issue and seeing that they are responsible for the improvement, that they own this area,” Marwaha says. “It can be something as simple as how their utility room is stocked, whether they can find what they need. Or, it might be having a place to put extra beds and wheelchairs to keep the hallways clear, or having a necessary form in the same place in every unit so you can find it easily.”

Once the teams know they have been trusted to address issues with their own solutions, their interest grows and they are eager to take on larger, more complex problems, she says.

Organizations adopting the CUSP approach should invest in a good understanding of improvement science and methodologies, Marwaha notes. It is common for an organization to throw a lot of effort and resources into an improvement initiative and see some initial good results — but a year or two later, everyone wonders why the improvement was not sustained.

That can happen with CUSP improvements if frontline staff are not educated on improvement science, Marwaha says. This includes how to define a problem, what is going to change, different hypotheses about contributions to the problem, and other structured ways of studying an issue.

“For organizations that commit to CUSP, there has to be a parallel commitment that we are ready to deploy this training and development of our staff to understand improvement science so they can go about in a scientifically structured manner and sustain the improvements they have made,” she explains.

Marwaha notes it is important to provide staff protected time to do this work, instead of piling it on top of their duties and pulling them in different directions.

Do not be surprised if staff meet the introduction of CUSP with a roll of the eyes and a dismissal as just another flavor of the month in patient safety, Marwaha says. That reaction is understandable, but should be countered with an explanation that CUSP is different in its approach.

“When I hear that skepticism, I stress to them that this is just a structured way of doing our daily work. You’re already doing this, but we want to make it more efficient,” she says. “This approach can give structure to our work. A lot of the time our frontline staff feel like they are running around with a fire extinguisher all day putting out fires, but this can change their daily work from putting out fires to fire prevention.”


  • Navneet Marwaha, MD, Vice President and Chief Quality Officer, Northern Light Health, Brewer, ME. Phone: (207) 973-7000. Email: nmarwaha@emhs.org.
  • Jeffrey Parsons, Esq., Vice President, Risk and Patient Safety, Northern Light Health, Brewer, ME. Phone: (207) 973-7000. Email: jparsons@emhs.org.