Got culture change? CUSP tools can transform safety

Challenges include engaging senior leadership

The Agency for Healthcare Research and Quality (AHRQ) has created a website with a wealth of tools to help hospitals set up the Comprehensive Unit-based Safety Program (CUSP). ( Frontline users that have implemented CUSP say they not only reduced infections, but dramatically transformed their overall patient safety culture.

While a proven method to reduce central line associated bloodstream infections (CLABSIs), CUSP is adaptable to various projects and can also be used to prevent non-infectious adverse events. It combines clinical best practices with an understanding of the science of safety, improved safety culture, and an increased focus on teamwork. Because different users will need different resources, the toolkit is designed to be modular and flexible to local needs.

"It is essentially a multipronged quality improvement program, and very importantly it is customizable and self-paced," said Carolyn M. Clancy, MD, director of AHRQ. "It includes instructive guides, presentation materials, and implementation tools such as checklists and videos that demonstrate desired behaviors. As a physician myself, I need to point out that the toolkit was developed by clinicians for clinicians."

The CUSP evolved out of an effort to prevent central line associated bloodstream infections by Peter Pronovost, MD, PhD, senior vice president for patient safety and quality at Johns Hopkins Medicine. The current model in the toolkit can be used to address a variety of infections, harms and hazards.(See related story, below.)

CUSP key tenets include a 'just culture'

The Comprehensive Unit-based Safety Program (CUSP) tool kit includes many modules and elements, but a few of the basic principles include:

Understand the Science of Safety: The CUSP team and unit staff members should watch the 'Science of Safety' video to make sure everyone is familiar with the concepts, particularly the three principles of safe design:

  • standardizing
  • creating independent checks
  • learning from defects

Assemble the Team: The ideal CUSP team has six characteristics:

  • Understands patient safety culture is local.
  • Comprises engaged frontline providers who hold themselves responsible for patient safety.
  • Includes staff members who have different levels of experience.
  • Is tailored to include members based on the nature of the clinical intervention they are planning.
  • Meets regularly (weekly or at least monthly).
  • Has adequate resources to do its job.

Engage Senior Executives: Ensure a senior executive is assigned to a CUSP team. Each CUSP team must have one senior executive team member. This executive should meet with the unit team regularly and be included in any project-related communications. Recruiting senior executives in these initiatives forges bonds and improves communication among hospital staff members, which will ultimately increase patient safety and reduce unnecessary expenses and harm. Remember to appeal to the senior executive's interest in maintaining patient safety, as well as the hospital's financial gains that will result from participating in the CUSP initiative. Display statistics that show how the initiative reduces both patient harm and the average cost per occurrence for the hospital.

Teamwork and Communication: Clear communication among health care providers is paramount. Communication failures lead to patient harm, increased length of stay, provider dissatisfaction, and staff turnover. Effective communication is particularly important in the unit if complicated care plans are to be effectively managed by the care team. People who use complete communication provide all relevant information while avoiding unnecessary details that may cause confusion. People who use clear communication convey information that is plainly understood and use layman's terminology with patients and their families. They use common or standard terminology when communicating with team members.

Just Culture: A Just Culture is a system that holds itself accountable, holds staff members accountable, and has staff members who hold themselves accountable. The work environment is ruled by both transparency and accountability and supports improved outcomes by emphasizing both robust systems and appropriate behaviors.

Editor's note: The complete CUSP Toolkit is available at the Agency for Healthcare Research and Quality's website at:

"[CUSP] is an iterative process because we are always learning," Pronovost said. "The first [step] is to make sure all of the staff know the science of safety – there is a science that underlies it. Too few of us clinicians were trained in that. There is a great program in the tool kit for this."

With high staff turnover a common problem at some facilities, the CUSP science safety module can also be used as a primer for new employees.

Recruiting hospital leadership

Involvement of executive leadership is stressed heavily in CUSP, suggesting that interventions undertaken without clear administrative support are less likely to be successful.

"The senior leadership at our hospital is involved in this [CUSP] process," said Theresa Hickman, RN, nurse educator at Peterson Regional Medical Center in Kerrville, TX. "Every month I make a report on how we are doing, and it goes straight to the board."

The CUSP tool kit suggests recruiting executives who can authorize the use of the resources needed to help unit-based teams resolve patient safety issues. Senior leaders should be familiar and comfortable with the goals of the project. Executives who have a vested interest in the quality of care make great CUSP team members, the program emphasizes.

"Leadership is so key — leadership becomes part of that unit team trying to fix problems," Pronovost said.

However, the CUSP program concedes that senior executive buy-in might be the most significant obstacle a team faces, particularly if the administrator does not have a clinical background.

"In these situations the use of a tool like an Opportunity Estimator, which calculates estimated lives lost and dollars spent as the result of CLABSIs, can engage hospital executives with the prospective cost savings that can result from CUSP implementation," the CUSP tool kit states. "Encouraging senior executives, particularly those without a clinical background, to 'shadow' a nurse or physician champion can [also] help them to better understand unit challenges firsthand."

Team building is a critical part of the program, as health care workers are empowered to work for positive change in ways that may break down some of the traditional roles in medicine. The key CUSP team members—nurses, physicians, and senior executives—are needed to ensure that the initiative is implemented on the frontlines and adequately resourced. However, input and participation is then needed from other unit or hospital specialists. These team members include:

  • infection preventionists
  • medical directors
  • pharmacists
  • respiratory therapists
  • patient safety officers
  • chief quality officers
  • ancillary or support staff

"The team is a concept really — it is not necessarily a list of people," said Michael Tooke, MD, chief medical officer at Memorial Hospital in Easton, MD. "When you put in a central line, at any given point in time the team is an entirely different set of people because it depends on who is on duty. So it will not work without [complete] unit-based participation. These lines are put in in the middle of the night by different nurses and doctors. It has to be engrained in the way the entire unit takes care of patients."

On the other hand, Tooke's ventilator-associated pneumonia [VAP] prevention team is a multispecialty group that makes rounds in the ICU twice a day. "So that team is pretty much the same people," he said. "They make rounds to make sure that the ventilator care is appropriate."

In addition, urinary catheters are placed all through the hospital, thus prevention of catheter associated urinary tract infections [CAUTIs] must involve teams throughout the facility to determine if and when catheters can be removed.

"So you have a [CAUTI] team at one level – say the overall nursing and medical staff — but then each unit has a team because there is a nurse manager that is making sure the protocol for getting out Foley catheters is the same," he said. "The team is set up depending on where it is, the breadth of the intervention, and who is there the day that the device or the intervention is put into place."

Four E's take the fifth

The CUSP toolkit suggests keeping the "4 E's" model in mind in both starting and sustaining initiatives:

Engage: Engaging a staff member is an example of adaptive work in which CUSP teams help unit staff understand the effects of a preventable harm caused by a clinical problem. One method of engagement is sharing stories about patients affected by this problem and estimating the number of patients who could be harmed as a result of this problem.

Educate: CUSP team members transmit information to staff and senior leaders regarding actions to take to prevent clinical problems.

Execute: An example of adaptive work, execution is based on the principles of safe system design: Simplify the system, create redundancy, and learn from mistakes.

Evaluate: Evaluation is an example of technical work in which unit teams collect and submit data related to any clinical problem to analyze the progress of an intervention.

"We also added another E — enthusiasm," Tooke says. "We acknowledged every victory. One month without infections, 100 days, a whole year. We had a unit-based celebration every time we had a victory. This helped reinforce the role of ownership of this project to those at the bedside. We have gone from keeping track of days since the last infection to days until the next celebration."

Learning from mistakes

If an infection or another adverse event occurs, the CUSP model recommends a "learning from defects" approach that often reveals that systems contribute to the underlying causes of problems. The CUSP mantra in this regard is: "Every system is perfectly designed to achieve the results it obtains." Learning from defects is termed "second-order" problem solving, which examines the underlying causes and processes that contributed to the event. Clinicians are generally adept at "first-order" problem solving, which is "recovery" problem solving to correct errors after they occur.

"But we want them to learn — not just recover — from those mistakes," Pronovost said. "In other words, make sure another patient won't be harmed."

Tooke cited this defect-evaluation aspect as an example of ongoing use of the CUSP tools to improve medical care.

"We experienced two bloodstream infections in patients that were undergoing an innovative therapy on one of the medical floors," he said. "We used the [defects] tool to work through the process and determine the root cause of those infections. We haven't had a similar infection on that floor in over a year."

The majority of the CUSP Toolkit modules focus on quality improvement projects at the unit level, where culture is necessarily local. However, the program also includes a "spread" module that helps an organization move the components of a successful intervention from the unit level to the larger organization. By the same token, a CUSP program that began in a unit and then went hospital-wide may ultimately be adopted by a completely different facility.

"We have a growing list of research studies that show in one institution, one community dramatic results, but getting this into communities across the country — that is a really big deal," Tooke said.