The Comprehensive Unit-based Safety Program (CUSP)

CUSP is a five-step program designed to change a units workplace cultureand in so

doing bring about significant safety improvementsby empowering staff to assume
responsibility for safety in their environment. This is achieved through education,
awareness, access to organization resources and a toolkit of interventions.
Adopted by about 40 units at The Johns Hopkins Hospitaland hundreds of units
outside of HopkinsCUSP has been used to target a wide range of problems: patient
falls, hospital-acquired infections and medication administration errors, to name a few.
This five-step program has also provided a framework to get units involved with, and
committed to, organization- and national-level safety goals. In fact, CUSP was used by
more than 100 intensive care units in the State of Michigan in their much-heralded work
to drastically reduce central catheter-related bloodstream infections.
CUSP works because it recognizes the central importance of culture in sustainable
patient safety improvements. A units safety culture can reliably predict a wide range of
complications and infections, as well as such operational outcomes as nurse turnover.
Because culture is local, it must be targeted at the unit level, with support at the
organizational level.
Why CUSP Works
While many hospitals safety initiatives fail to produce quantifiable, long-term results,
CUSP can lead to sustained improvement because caregivers see that they can play a
role in safety, and they recognize that they have organizational support to bring about
change. The program has been successful for several reasons.

It focuses on culture. To fix a problem in safety, you cant simply hand

caregivers a checklist or write a new policy. You need a community of health care
professionals who are willing to embrace new practices and roles, and who
understand why making these changes is important to safety. CUSP provides a
structure to help change the workplace culture that can make or break your
efforts.

It integrates safety practices into daily work. Safety becomes embedded into
the fabric of the unit and ceases to become an extra initiative with which staff
must comply.

It translates. CUSP works across the health care world, regardless of region,
language spoken or type of health care organization. Thats because its core
principlesthat errors are most often the result of broken systems, and that
culture is linked to the quality of careare common wherever you go.

It has easier buy-in. When a CUSP unit decides to take on a project, caregivers
are more likely to become engaged in the effort because the initiative comes
from them. CUSP embraces the wisdom of the frontline caregivers in identifying
safety issues and working to resolve them.

It brings accountability. CUSP provides a structure for your unit staff to

measure their progress on different outcomes, to recognize their successes, and
hold themselves responsible for improvements.

It keeps leaders grounded. Executives need to understand how budgets,

staffing and organizational structure all have an impact on the level of safety.
Working with a unit gives them first-hand knowledge of those barriers, and helps
inform their decisions.

CUSP Framework
Though CUSP itself is comprised of five steps, the program is a continuous, cyclical
process.
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 units safety team.

Conduct a culture assessment. Get a baseline for future improvement by

measuringpatient 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 unitanyone 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 infectionsand 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).
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.

Sumber :
http://www.hopkinsmedicine.org/innovation_quality_patient_care/areas_exper
tise/improve_patient_safety/cusp/