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CUSP Framework

Though CUSP itself is comprised of five steps, the program is a continuous, cyclical process. Steps for launching a CUSP team before and after kickoff are described below.

Pre-CUSP Work

At least 2 months prior to CUSP kick-off:

  • Assemble an interdisciplinary unit-based safety team.  This team will be the driving force for improvement and should represent all of the disciplines who work on the unit, including nurses, physicians, pharmacists and support staff. Everyone has a role in safety.
  • Partner with a senior executive. Secure the commitment of a senior executive to the unit’s safety team.
  • Conduct a culture assessment. Get a baseline for future improvement by measuring patient safety culture using a valid, reliable survey.
  • Gather unit-specific information. Collect safety culture survey results, reported events, claims experience, and any other pertinent information about the unit. This information will help to acquaint the senior executive to the unit.

CUSP Framework

1. Train staff in the science of safety
Provide this training to all members of a unit—anyone who spends greater than 60 percent of their time working on the unit-- before the CUSP kick-off meeting, and regularly thereafter for new staff. Johns Hopkins recommends that all staff benefit from science of safety training, regardless of whether or not their unit will be a CUSP unit:

  • understand that safety is a property of the system
  • understand the basic principles of safe design that include: standardize work, create independent checks (checklists) for key processes, and learn from mistakes
  • recognize that the principles of safe design apply to teamwork as well as technical work
  • understand that teams make wise decisions when there is diverse and independent input

2. Engage staff to identify defects
Ask each staff member to answer a simple, two-question survey: How is the next patient going to be harmed on this unit? How can we prevent this harm from occurring? This survey embodies the core CUSP principle of respecting the wisdom and observations of frontline staff, who have both the expertise and the knowledge needed to improve safety. Also find potential areas of improvement based on review of incident reports, claims, and sentinel events.

3. Senior executive partnership/safety rounds
Perform monthly safety rounds in which the executive interacts with staff on the unit and discusses safety issues with them. All staff should be invited to attend. This is one of the most effective approaches to bridge the gap between senior leaders and frontline staff. Not only does executive become more familiar with safety issues at the ground level, but this leader has access to organizational resources that can help the team to accomplish its safety goals. . Evidence indicates that rounding with an executive monthly has increased culture of safety, which in turn reduces infections—and that sustained rounding with an executive leads to further improvements.

4. Continue to learn from defects
Use the Learning from Defects tool to address the top risks identified by the team. This tool will help frontline providers investigate safety defects by looking at one defect, break down the factors that contributed to the defect, implement changes to reduce the probability of it recurring, and summarize what was learned from this investigation. The tool seeks to answer the following four questions:

  • What happened?
  • Why did it happen?
  • What did you do to reduce risk?
  • How do you know that risks were reduced?

A defect is any clinical or operational event or situation that you would not want to happen again. These could include incidents that you believe caused patient harm or put patients at risk for significant harm.

5. Implement tools for improvement
The safety team members highlight several priority areas needing improvement and use the many tools in the public domain to address them. Examples: Morning Briefing(for communication and rounding efficiency), Shadowing Other Providers (for collaboration, teamwork and communication) and Daily Goals(for communication and care plan). See CUSP Tools for Improvement for more options.

A critical success factor of using tools for improvement is measuring compliance with the tool. It is not enough to simply state that the tools are being used. Staff-friendly reports of compliance should be posted in the ward, along with infection reports. The combination of these reports (seeing infections decrease as compliance increases) should be a motivating factor for continuous improvement.

We suggest that each unit adopt and implement three tools per year.

Ongoing CUSP Framework

Establish real-time data feedback
To drive improvement and keep frontline staff engaged, post staff-friendly reports of compliance in the unit, along with infection reports to show their correlation. Safety teams should periodically (every three to six months) complete the team check-up tool to identify needs and problems the safety team has been facing.

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