The Comprehensive Unit-based Safety Program
CUSP is a culture change model that has been successfully applied to improve the way physicians, nurses, and other clinical team members work together. CUSP is associated with improvements in patient safety, clinical outcomes, and safety culture.10-13 The CUSP model draws on the wisdom of frontline providers who have practical knowledge about safety risks to their patients. Through use of the Learn From Defects tool, it provides a way to help analyze and reduce the risk of those hazards. The model emphasizes the importance of a diverse team, focuses on the input of direct care providers, discusses the importance of a common goal, identifies issues that the team can successfully solve, and integrates these elements as part of the team’s routine work.
CUSP helps hospital units move from a culture in which a punitive response to error prevails to a culture of safety—a learning environment in which errors are treated as an opportunity to learn about root causes and prevent future errors and risks of harm. Similarities to important components and teachings found in CUSP can be found in the literature on other change leadership models listed in Table 1.
The CUSP Toolkit
The CUSP Toolkit is available on the AHRQ Web site and includes training tools to make care safer by improving the foundation of how physicians, nurses, and other clinical team members work together. It builds the capacity to address safety issues by combining clinical best practices and the science of safety. Created for clinicians by clinicians, the CUSP Toolkit is modular and modifiable to meet individual unit needs.
The 10 CUSP Toolkit modules are—
- Learn About CUSP: Provides an overview of the CUSP model and resources to use when applying CUSP.
- Assemble the Team: Explains how to identify and engage team members and defines their roles and responsibilities.
- Engage the Senior Executive: Defines how to bridge the gap between senior management and frontline providers and remove barriers to implementing improvement projects.
- Understand the Science of Safety: Discusses the importance of understanding system design, safe design principles, and valuing diverse input from team members.
- Identify Defects Through Sensemaking: Explains how to engage frontline providers in identifying system defects and make sense of root causes.
- Implement Teamwork and Communication: Describes the importance of effective communication and transparency; helps users identify barriers to communication and apply teamwork and communication tools from CUSP and TeamSTEPPS®.
- Apply CUSP: Indicates how CUSP can be applied to diverse settings and safety issues.
- The Role of the Nurse Manager: Explains the responsibilities and leadership role of nurse managers in quality and safety improvement initiatives.
- Spread: Illustrates how to share, tailor, and implement components of a process that have worked well at the unit level.
- Patient and Family Engagement: Highlights the importance of patient and family participation during the patient’s hospital stay, ensuring that they are active participants in the patient’s care.
Table 1. Culture Change Model Comparison
| Objective | Comprehensive Unit-based Safety Program (CUSP) | Kotter: Leading Change | Kouzes and Posner: Leadership Challenge | As Applied to CAUTI |
|---|---|---|---|---|
| Developing Engagement | Science of Safety, the Josie King Story | Create a Sense of Urgency | Encourage the Heart | Share among staff stories of patients who have had catheter-associated urinary tract infections (CAUTIs). |
| Team Development | Senior Leader Partnership With the CUSP Team | Create a Guiding Coalition | Model the Way | Team makeup ideally includes all types of staff involved in caring for a patient with a urinary catheter, from senior leadership to transporters and medical assistants. |
| Developing Alignment | Assemble the Team, Engage the Senior Executive | Develop a Shared Vision | Inspire a Shared Vision | Setting CAUTI prevention as a shared strategic hospital and unit goal increases success. |
| Sharing Approach | Understand the Science of Safety | Communicate the Vision | N/A | CAUTI project champions inspire and motivate teams by sharing what is possible and has been done in other similar units. |
| Empowerment | Direct Care Provider Involvement, Teamwork and Communication Tools | Empower Others To Act | Enable Others To Act | Assess for catheter presence and indication. Remove when no longer needed. Do not place catheter unless for appropriate indication. Consider creating and implementing a nurse-driven protocol to assist with these interventions. |
| Implementing Change | Learn From Defects | Generate Short-Term Wins | Challenge the Process | Improve utilization practices. Evaluate improvement in adherence to indications and in symptomatic CAUTI. |
| Spread | Learn From Defects | Consolidate Gains and Produce More Change | N/A | When CAUTI prevention processes show success on one unit, expanding the program to other hospital units. |
| Sustainability | Part of the Daily Work | Anchor New Approaches in Culture | N/A | Evidence-based improved care processes for patients’ urinary needs become fully embedded in unit and hospital routines and standard of care. |
Planning for Sustainability
The best time to begin thinking about sustaining project gains is at the beginning of your project implementation. Start thinking early on about how your team can make CAUTI reduction processes part of your routine, day-to-day work. For example, include evidence-based best practices for prevention of CAUTI in the policies and procedures related to the care of patients’ urinary needs. Consider the types of resources that will be needed for long-term maintenance of your improvement efforts, and start to identify who will be accountable for sustaining the work and how they might incorporate the work into existing processes.14 Embedding catheter insertion competency testing into new hire orientation and annual skills updates for existing staff are examples of ways to ensure CAUTI interventions become part of standard work.
Identifying physician or nursing champions for your CAUTI prevention project will also aid in sustaining improvement over time. Go to “A Model for Sustaining and Spreading Safety Interventions” for more information on planning for sustaining improvements.
Tool
Appendix A. Checklists for Assessing Executive and Physician Champion Potential
These checklists, developed by Andrea Silvey, Ph.D., M.S.N., chief quality improvement officer of Health Services Advisory Group, provide concrete examples of qualities to look for when considering executives or physicians for project champions.
