CUSP: A Framework for Success (Transcript)

March 7, 2012

Operator: Excuse me, everyone, and thank you for holding, please be aware that each of your lines is in a listen-only mode. At the conclusion of today's presentation, we will open the floor for questions at that time. Instructions will be given as to the procedure to follow if you’d like to ask a question. I will now like to turn the call over to Barbara Edson. Ma’am you may begin.

Barbara Edson: Thank you so much and good afternoon, everyone, and welcome to the call. We're sorry we're a few minutes late. We understand that there are quite a number of folks listening in, so we really appreciate you all being on the call today. Today's call, we’re going to go ahead and talk to you a little bit about the Michigan experience. Then we’re going to have the opportunity to have Chris Goeshel speak to us from Johns Hopkins to talk about CUSP and how CUSP has been effective and some of the components of CUSP. And then we will proceed in listening to Mary Jo Skiba go ahead and talk to us a bit about the implementation of this work. We will follow up with some questions for you all that we would like you to go ahead and answer as we go ahead and work through the call. It's going to be information that we hope that you can provide back to us for some feedback. With that, I do want to recognize that we have Marge Cannon and Minette from CMS and the QIO program, and we are real pleased to have them on the call today. With that, I would like to turn this call over to Chris George. Chris is a partner of ours at the national project team from Michigan Hospital Association’s Keystone Center that has really worked diligently in this area of the work that's been done in Michigan, around the Keystone work, and we will go ahead and discuss that with you all. Chris, are you there?

Chris George: Yes, I'm here. Thanks, Barb. Hi, everyone, it's a pleasure to be on this call today. And we are going to start off with setting the stage a little bit before we get into the deeper dive of the Comprehensive Unit-based Safety Program, just to sort of frame this around the work that's been done in Michigan and why it's important to improve culture and some of the results that we have seen through our work. I know that there are several of my colleagues on the line today from Michigan, so I hope that you appreciate our Pure Michigan slogan that we have incorporated into this presentation. I just want to start off with -- I think that how a lot of the work in Michigan has been characterized in some situations is that we implemented the magical checklist. We just want to make sure that everyone realizes that it was about a lot more than implementation of a checklist. And when we started working on the elimination of central line-associated blood stream infections in Michigan, yes, we asked teams to implement a checklist to make sure that they were following all of the steps of proper line insertion. But, the checklist was a little bit different from what some people may have thought of in that the only options for the checklist were “yes, the component was followed” or “yes, it was done with correction.” So what I'm saying is that “no” was not an option. Not doing part of the checklist was never really an option in this work.

And so, this is an example of the fact that we had to kind of pair that cultural component. We had to instill that cultural component along with asking people to make sure that they are following the proper technical interventions, and that one without the other really would not work very well. It was never an option in our minds to allow people to go ahead and have a central line inserted if they were not following all those proper components. So here, I am just sort of highlighting the fact that we did try to make sure we always paired this work together, so there was always the cultural component that was addressed through the implementation of the Comprehensive Unit-based Safety Program along with the technical piece of what are those evidence-based practices for making sure that we follow the proper steps for insertion of the line.

In Michigan, this work has been sustained. Our results for CLABSI have really been sustained at a median of zero for about 7 years, so it's really been something that we are very proud of, and our teams are very diligent about making sure they continue to keep their eye on the ball and to implement these aspects of the work. As you can see on this slide, when we did this work, we made sure that we monitored results of their cultural of safety survey. We implemented the safety attitude questionnaire originally in the Michigan Keystone ICU collaborative. And this slide is really showing an example of where we were at the beginning. So we had 87 percent of our team in the range of needing improvement on their safety climate. Several years later, we were at 47 percent so we have seen some significant improvements in this area.

This slide is showing you kind of how bringing the cultural component in making that improvement in culture has had any impact on our outcomes. So what you are seeing here is that as you progress toward the right of this slide, these are the teams that had the highest scores in their safety climate. Those were the units that were associated with the lowest rate of blood stream infections. In particular, the question that was very predictive of that improvement was whether or not caregivers feel comfortable speaking up if they perceive a problem with patient care. And this really goes back to that piece that we asked teams as part of the CUSP process: "Would your most junior nurse feel comfortable speaking up and stopping the line insertion if there was a senior position that had not washed their hands or didn't have the proper barriers in place before they inserted it?" So that's really asking that question, “Do you feel you have that culture in place where somebody is comfortable challenging their most senior staff, senior physicians, about whether or not they’re following all of those proper safety components?

Actually, I think this is a duplicate slide so I apologize for that.

If we go on to looking at the teamwork climate and annual nurse turnover, when we began the original early Michigan work, we asked some of our teams that were able to, to capture a subset of data that really looked at their nurse turnover rates. And we did this by looking at how or what we compared was how nurses rated their teamwork climate and how physicians rated their teamwork climate. So the red bars on this graph are indicative of how physicians rated teamwork; the yellow bars are indicative of how nurses rated teamwork. And so the slide is really oriented to show the increase along how nurses rated teamwork. So again, towards the right-hand side of this slide, you'll see the area where the hospitals nurses rated teamwork higher, actually had a lower turnover in their staff, and that's really consistent with what we talk about as part of the Comprehensive Unit-based Safety Program is really actually bringing the joy back to people’s work and allowing everyone the opportunity to be able to say "I went into this profession for a reason: I want to help people, I want to provide the safest care that I can, and I want to work in an environment where that is supported and I feel that I can do that every day." We see that in those units where they have been successful at achieving that kind of a climate, they actually also have the result of having a much lower rate of turnover amongst their nursing staff, which I think is something I think we all struggle with in these days in this climate.

This is just a quote we wanted to throw in here: "The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man.” You are all that are on this call today being asked perhaps in your minds to do something unreasonable, so we want you to think about that in the context of this quote that, yes, we’re asking you to do something different. It's a challenge, but if we accept the status quo and are not willing to take on this challenge, then we’re really not going to make progress in this area.

So I want to go ahead and turn over the call now to Chris Goeshel who is from Johns Hopkins University. She is the director of the Strategic Development and Research Initiatives at the Armstrong Institute. She is our resident expert on the Comprehensive Unit-based Safety Program, and I'm going to go ahead and turn it over to you, Chris.

Chris Goeshel: Great. Thank you, everyone. It’s an honor to be with you, and it’s delightful to see how many of you dialed in today. Just to let you know within the context of this call, I’m going to spend about 15 to 20 minutes talking about the specifics of the Comprehensive Unit-based Safety Program, and I’m going to tell you at the outset that in the many, many States with many, many areas of improvement where we’ve implemented the CUSP program, it takes a while before the light bulb goes on. So don't anticipate that because you've heard this today or you have the slides that you're going to be able to run out and implement CUSP without having any questions. In our experience, it takes some time. Part of what we do and before I get into the steps of CUSP, I want to share with you, part of what we've learned in this work and what we know is that effective interventions often have discrete activities focused on what we call the four Es. And the Es are engagement: How do you get people on board, understanding the importance of the work that you're going to ask them to do? And Chris alluded to how we did that in Michigan in some of her slides, but some of the tools of engagement that are quite successful include both stories and solid data. The second E is to really educate the staff or the folks that you expect to be involved in the work on what the evidence is for the change you are asking them to make. We now talk about this as having a clear theory of change. If you're asking me to change my behavior, why are you asking, where is the evidence for what you were asking me. The third E is execution, and there are a number of tools within the CUSP framework that help you execute or implement the changes that you’re going after. But some of the primary considerations for execution are embedded in the science of safety, and those include standardizing, creating independent checks, learning when things go wrong, and, in the case of blood stream infections, making sure that we empower anyone in the room, not just nurses, this slide says empower nurses to stop takeoff, but we've learned over time that anyone in the room at the time that a central line is being inserted needs to be empowered to stop the line if and when there's a breach in technique. And the final E it is to evaluate. When we began the work in Michigan well over 8 years ago, one of the things that was radically different in this work than in some other quality improvement or collaborative projects that many hospitals had participated in, is that we insisted, and at the time I was in Michigan, not at Hopkins but partnering with Hopkins, we insisted that we use standardized measures, that data were collected on a regular basis and submitted and that they were analyzed scientifically so that we weren’t dealing with hypotheses about whether the project had worked or not in the absence of clear scientifically sound data that said a change had occurred. And evaluation includes that data and feedback and then also the information about looking at infections as defects.

This next slide real quickly talks about some key questions that we have found over time help folks get involved. We want to be able to get senior leaders, team leaders, and staff engaged, but the techniques that we use vary because the roles and responsibilities for reducing infections vary depending upon whether you are a frontline caregiver or a senior leader, and yet all groups have some accountabilities for this work. The same thing with education, execution and evaluation, clear accountabilities but they vary by your role.

The next slide is intended to depict what we see. And this is a very early slide. I always smile when I see some of these early slides, but this slide really depicts what Chris talked about in terms of the two components of change. And the two components, as we see them, include the Comprehensive Unit-based Safety Program that's an intervention to help us improve safety culture and know whether we are learning from mistakes, and then an intervention that’s focused on translating research evidence into practice, and -- in the instance that were talking about today for CLABSI and CAUTI -- the process of translating the evidence was very similar. The things we need to do are radically different because, of course, those particular infections are very different. But at the end of the day, when we look at whether we've improved, we want to understand how often we are harming patients and whether outcomes are improving. We want to know whether we are learning from mistakes and whether our culture has improved.

What exactly is CUSP? It's been fascinating as someone who has been using CUSP almost since it was developed to see that many people think CUSP is the project to reduce blood stream infections, and it's not. Many people think CUSP is the project to reduce urinary tract infections, and it's not. What CUSP is is a baseline unit-level safety program that in our experience allows organizations, not just hospitals, but organizations with engagement from the boardroom to the bedside to narrow the gap between common practice in that institution and the practice that is demonstrated as best practice in the empirical evidence. It allows you to learn from mistakes and improve culture, which ultimately allows you to embrace technical changes and improve outcomes. So “On the CUSP Stop BSI,” the big project, the BSI project that has rolled out across the country and is in its final days of formal rollout is part of the HRET activity and includes both the CUSP program and a specific technical BSI protocol. You can see some of the impact of that on the slide that you’re looking at.

If we look at the next slide -- it's a very busy slide -- this is drawn from a British Medical Journal article that we published back in 2008 that allows you to drive down at a very specific level to understand the method for translating research evidence into practice. This is useful because what we've learned is that many teams that implement CUSP to reduce blood stream infections, for example, or to reduce urinary tract infections, want to use CUSP to reduce time to C-section or time to be seen in the emergency department, but they want to understand how to get the technical intervention, and that happens through this TRiP process. We're not going to talk about that specifically today, but it's important for you to know that in this change model that includes CUSP and TRiP, there's a lot more to learn about TRiP and for QIOs in particular where you are tackling many, many improvement arenas, TRiP might also be of interest to you.

So the next slide really restates what Chris talked about in terms of the phenomenal success that was recognized or achieved by those Michigan teams on reducing the blood stream infection rate, improve safety culture in well over 100 intensive care units. If we had an ideal scenario, and acknowledging that we rarely do, we would encourage teams that are starting this work de novo to do some pre-CUSP work, and pre-CUSP work asks you to create a CUSP team. Nurses and physicians and support staff and infection preventionists are part of the team, and it's important to identify a team leader. All of this information is spelled out in more detail in the CUSP manual, which you all have access to. Once you create a CUSP team, it's really useful to measure culture in the unit, and Chris talked about some of those cultural components. Many hospitals across the country are using AHRQ’s Hospital Survey of Patient Safety Culture. There is a similar instrument for long-term care and other settings, but there are also many other culture assessment instruments in the field. And then it's really important to work with your hospital quality leader or management to have a senior executive assigned to the team. And we're going to talk about that senior leader role in just a minute because it's a lot more than just making rounds and patting people on the back and saying, “Go Team.” The steps of CUSP then as we saw earlier are five. And I frequently am reminded to let folks know, as I tried to do when we started, that the steps of CUSP are simple. It doesn't take long to memorize the steps of CUSP. The work of CUSP is some of the most, I'm going to say, difficult and rewarding that most teams will ever do. We're going to walk through briefly what each of these steps entails at its basic level. CUSP, from a Hopkins framework, has to begin with educating staff on the science of safety, and I'll tell you why. The science of safety presents, in very easy-to-understand snippets, information about systems. It allows everyone from physician leaders and board leaders to unit clerks and patient care techs and bedside caregivers to see systems perhaps differently than they ever have before, to understand that we are interlinking parts and to appreciate that systems determine performance in many, many, many cases -- most cases, in fact. The science of safety also explains that there are some strategies that are evidence based that have allowed teams to improve system performance. Standardizing when you can, creating independent checks for key processes, and learning when things go wrong are key concepts in the science of safety. We talked then some, and there's a video on the science of safety that you can share with the individuals and organizations that you work with. But the science of safety video provides additional information on the fact that this science of safety and these strategies apply to both the technical work, the actions we must do based on the evidence to get the best outcome, and teamwork or the behaviors and attitudes and beliefs that are part of the culture on our units. Importantly, science of safety drills home that there's growing evidence to suggest that teams make wise decisions. We all make our best decisions with diverse and independent input, and that's important when we're trying to improve performance, because performance is determined by the team so letting the team have a voice is useful.

The second step of CUSP is to identify defects. A defect in our language is anything that happens that you wouldn't want to have happen again in the arena of delivering care. There's a lot of ways you can gather that information. You can look at sentinel events, liability claims, morbidity and mortality conferences, but in our experience the best way to reinforce engagement and to get everyone involved in the safety work is to administer the staff safety assessment. That assessment has two questions. The first one is "How do you think the next patient will harmed?” And the second one is "Do you have ideas on how we could prevent that harm?" Now think about this for just a minute, the first step, and I said at Hopkins we believe firmly that you have to start with the science of safety. The science of safety gives people new vision, new lenses. The second step of CUSP asks people what they see, so it gives everyone that’s learned about the science of safety a voice that says, “We've added to your vision. Now we want you to tell us what you see.”

The third step of CUSP is to share what we've learned and to prioritize what we’re seeing. So what are the defects? And there are ways that we go through that are very effective. We create and with the CUSP team asked the team to list all the defects that were identified as part of the staff’s safety assessment and to look and prioritize and pick what the group thinks the three greatest risks are and what they should work on next.

If we look at the next slide, we use that information with step three of CUSP, which is the executive partnership. I told you at the beginning, in CUSP, executives are a critical member of the team. They're not just doing walk arounds and patting you on the back and saying “Great job” or doing things that shine a light on your good work but not being part of it. As part of CUSP, executives are expected to meet with the CUSP team at the unit level once a month. The executive sits as a member of the team and looks at the prioritize defects, looks at what staff said when they had vision and they had voice. Now we have partnership. So we say we’re all in this delivery thing together. We're looking at system problems, we are identifying problems, we're going to prioritize the problems, and then we're going to fix the problems. Now, many of the problems that come up are not specific to reducing blood stream infections or reducing urinary tract infections. But quite often, they get at issues that are absolutely crucial to allowing those things to happen. So oftentimes the defects that are surfaced have to do with teamwork, in communication, in system issues that allow us to achieve the clinical outcomes that we are looking for. So step three of CUSP is making sure that you have an executive assigned to your unit, and that they’re a full partner with the team.

The fourth step for CUSP, then, is how are we going to learn from our mistakes? So you’ve got vision, you’ve got voice, you've got a partnership, you’ve prioritized what you want to work on again very, very quickly here so that we can get to Mary Jo Skiba and hear some real examples. Step four of CUSP is asking, given our priorities, looking at one case at a time: What happened, why do we think it happened? Use your system lenses. What ideas do we have that could reduce the risks? How will we know if risks are reduced? So if we look at the prioritized issues that surfaced during the staff safety assessment, you can see that the questions we ask there are very similar to the questions we ask when the inevitable mistakes occur. So in spite of our best efforts, there will always be some bad things happening, but we use the CUSP team and we use this framework to learn, to use our system lenses, to use our vision, to use our voice, to use our partnership to make sure that we are eliminating or mitigating risks to future patients.

Understanding whether and how risks were reduced, again, involves the entire continuum. We don't sit in a room with the manager and the nurse and the respiratory therapist and say "Yep, we created a policy. It's fixed.” We create policies and processes and procedures. We go out and talk to staff to say "Do you know about this policy?" And then we asked the frontline caregivers whether they believe the policy is being used correctly or if they think the risks of harm have truly been reduced. We look in late contributing factors to each of the problems that we identify, and then we develop interventions based on where we think there's the greatest opportunity to impact outcome.

I'm going to go through these next couple of slides, which are a bit more detailed, a little more quickly. The rating process for interventions is pretty clearly spelled out in the CUSP manual, and we encourage CUSP teams to take an example from the CUSP manual or a made-up example, if you will, of a mistake and really practice this learning from defects process. Learning from mistakes, learning from defects has very effective tools, but just like the CUSP process in general, it takes time to understand, and in our experience learning from defects works best when the team is fairly well ingrained in the CUSP process. Most of the staff on the unit and the physicians who work on the unit, the administrators have viewed the science of safety. You’ve conducted the staff safety assessment and have begun to share what staff surfaced as issues and have begun to fix issues. Then when you come to the CUSP team with a mistake that happened, they're more inclined to understand and to spend the time necessary to truly learn from the defects that occur and share what they learn.

Step five of CUSP, the last step, again not easy, implementing teamwork tools. If at the beginning, you are developing system lenses by reviewing the science of safety video, asking the questions, but the second step of CUSP, you're inviting caregivers and staff and people who spend time in the unit to tell you what they see as patient safety risks. After viewing the science of safety, then you partner with an executive to say okay vision, voice, partnership. You’ve committed to learn from the mistakes that occur. The big question is how are you going to do that? What tools are going to help you? So we, at Hopkins, what used to be the Quality and Safety Research Group, now the Armstrong Institute, have developed a number of tools here, and again not going to spend time on any of them, but also going to let you know that we have begun integrating all of the TeamSTEPPS tools. There are a number of tools out there that are part of the Just Culture work, there are tools out there as part of Kotter's work, and this notion of using teamwork tools to improve is very broad. We are not suggesting that there is a finite list that you must use A to achieve B. Rather we are saying, develop positions, use your voice, create your partnership, commit to learning from mistakes, and then use tools to improve and obviously measure what you’ve learned. I'm going to go through these specific tools without spending time on any of them because we want to get to Mary Jo, and my 20 minutes is about up. I ask you to think about where we started in this 20-minute quick overview, and my acknowledgment that CUSP is probably the most powerful tool, implementation method that I have seen in my long career in health care that has allowed a diverse group of teams across the U.S. and in many countries to improve their culture, to improve a broad understanding of the science of safety, to commit to learning from mistakes, to measuring what they’re doing, and to being able to answer questions about whether care is safer and how they know. I will let you know, however, that just as it takes time to understand and implement CUSP, CUSP is a continuous effort. It's an ongoing journey, and with each collaborative that happens, no matter who leads it, there's more to learn, there's more tools being developed so it's constantly in evolution. The concrete steps that we've seen be very successful with teams is that they embed this in the infrastructure of their organization. Adding science of safety education to orientation, committing to learning to one defect a quarter, sharing what those learning lessons are across organizations, sharing stories of how teamwork tools have been used or modified to meet local unit culture are all ways that each team is encouraged to take this work and make it their own. There is a CUSP manual. We think it's incredibly useful, but it's far from perfect, so your feedback on the manual is going to be incredibly valuable over time. The opportunity to brainstorm potential hazards with local teams, to assess composition with respect to CUSP elements and for QIOs since many of the organizations that you are going into will have active CUSP teams. Really feeling out how they've made this work their own, perhaps where they’re struggling, would be incredibly useful. In reviewing the many, many tools that are available for the general public on the HRET Web site, On the CUSP-Stop HAI, toolkits, slide sets, manuals, and project management checklists are all there for your use and modification. A few references for the work that we've done in the past. And my presentation wouldn't be complete with sharing a picture of Josie King who is the inspiration for much of the work that the Armstrong Institute is doing and will continue to do in the name of improving the science, advancing the science of health care delivery. So that as Sorrell King asked shortly after Josie died, "Is care safer than it was when Josie died and how do you know?” A commitment to rigorous measurement, to standardization, to scientifically sound methods of improvement and to acknowledging both our progress and our deficiencies as part of the journey. And with that I'm going to turn this over to Mary Jo Skiba, who is going to give you a wonderful, ground-truth example of CUSP and CAUTI as implemented in her organization. Mary Jo.

Mary Jo Skiba: Thank you very much, Chris. As Chris said, I'm going to give you some information about how we implemented CUSP with our CAUTI project. I was a project lead for our CAUTI program, which we started approximately 4 years ago in association with our State Hospital Association in Michigan with the Keystone Project. Just to give you a background, we are a small hospital in northern Michigan. We have about 146 licensed beds. We had two med-surg units and an eight-bed ICU -- not big but not real small, either. My objective is to share with you how we applied the CUSP interventions, the four Es that Chris just talked about to our CAUTI project, and in the process, maybe help you identify some of the steps to successfully implement your CAUTI or even your CUSP program and then how to use CUSP to maintain that success.

First of all, I do want to talk a little bit about the science of safety education that we did at our respective hospital. We did our science of safety education and our CUSP project prior to starting our CAUTI project. It was a whole project in itself. First of all, we sent out a safety survey to every department and then, based on the results when we got the survey back, we identified which departments were at risk, the lower scores, and then we had mandatory science of safety training, which we did. We took right to the units. We had them watch the Josie King video. We taught them the steps. We had a didactic session and one-on-one with staff. We also distributed, we created orange safety sheets where staff could identify safety defects that they identified on their units and also established a senior executive who somewhat owned the unit to be on the department safety team. They made executive rounds and brought those safety concerns, then, back to the team and in which the team used the science of safety to work on improving those projects, so they got a little bit of experience with the education, the execution, the executive involvement in engaging staff.

So here's how we moved on to our CAUTI project. We knew that when we started the project that we needed a list of items that needed to be worked on. And planning the process is very important. You have to have a plan. I can't emphasize that enough when we started our project. As you look at the slide, these are the actual agenda items that we used for our first several meetings, and you could take this list and plop it right into an agenda and use it yourself, if you so decided to. When we got our project planning, we knew we had to establish and engage our CAUTI team members. We involved frontline staff. Respect the wisdom -- and I remember this term from my CAUTI training. And it kind of keeps in my head all the time. Anytime I create a team, I have to engage my staff members and I have to get frontline staff because they know what's going on. We had a personal care aide on our team, and we also, lower on the slide, had several charge nurses from our med-surg units that were included in our team. We also had a physician champion who could bring the physicians along. This was a family practitioner who did a lot of OB work. He was very engaged in the project and very interested. Staff development, I also have on there, that's in hindsight and I'll talk a little bit about that later on. We didn't have a staff development person on our team to begin with, but we wish we would've and then also to engage an executive leader -- very important -- you need those executive people on your team. They’re the ones that are going to help you move the project along. A lot of these frontline staff members haven't even been on a team before, much less been on a team with an executive leader. It really lends importance to your team, and those executive leaders are the ones that are going to help you remove those barriers. You are going to need resources for some of these big projects. They are going to go to your finance people and give you those resources and help you remove barriers -- very important to have them engaged. Also, in project planning, you are identifying your defects. We reviewed our baseline data, our CAUTI rates. How many infections do we have right now? And, really, that was the whole goal of our project. Yes, we are going to decrease the number of catheters and not put as many in, but our ultimate goal is getting those catheter-associated urinary tract rates down. We looked at that. We also brainstormed safety concerns. We wanted to identify the defects that we already had. Our aides went around the room and asked everybody, “What are your concerns? How are we going to harm patients with catheters?" One of our aides said, "You know, these patients come up from the emergency department. They have catheters in and their perineal hygiene is atrocious. We have to teach people to do perineal cleansing before they put catheters in." One of the RNs on the team said, "You know, every time we get a patient on the floor, it seems like they have a catheter. Why are all these catheters being put in? We've got to decrease the number of catheters." Those are the things you want to brainstorm and just identify. Determine also the scope of your initial project. You don't want to start off on the wrong foot right away by having too big of a scope. We decided we were just going to do our med-surg unit. We are not going to include ER, OR, and ICU, as far as when we are measuring this data. We are just going to do it on med-surg because they all mainly end up there anyway. Look at your policy for urinary cath, review, revise, and consolidate. In essence, that was a defect, too, because we had all kinds of policies: One for insertion, one for cath specimen, one for straight cath, one for indwelling. We took those policies and made them into one. We didn't re-create the wheel either. We took the kit, and we looked at the policy there, which was great, and we made it our own. And that's really important to do. Don't do any more work than you have to do -- great tools out there. We also feel that we needed some project awareness, so we initiated information in the hospital newsletter, fliers, and screensavers. This was an important project. This was a huge safety initiative. We wanted to give it some importance -- this was important to us -- and also to make sure the physicians knew before we start calling them to get those catheters out that we were going to be working on this. Data collection is also very important. You have to identify your data collectors -- who is going to do it? We looked at infection control, would they be the best person? Hmmmm, maybe, but they're not on the unit every day; they're not frontline caregivers. What about quality people? They're back in the offices. They definitely aren't out there. And because we had the charge nurses on our team, it was just a given, they just came and automatically volunteered, "Why don't we collect the data? We're on the unit every day. We see what's going on." It was just a perfect niche, and they became our data collectors. Data forms -- add your qualifiers. Assure your understanding of the project requirements. Do it Monday through Friday, 5 days a week. Follow the plan; that's what the project wants you to do. We started doing it on weekends until we identified, “Hey, wait a minute, we got to do it Monday through Friday.” And then data entry is important, too. Who is going to put it in the Web-based program that we had? We thought this isn't a role that staff nurses need to do so, we let them collect the data by paper, and they gave it to the quality department, and we entered it, which was a lot smoother process. In planning your education, you have to also identify those defects. You’ve got to plan ahead to prevent those roadblocks for nursing as well as physicians, and this slide kind of tells it all. Think about all these issues. Educate on the evidence, very important. We decided to do a twofold approach. We used a didactic or training approach as far as giving them information and then also did a demonstration of insertion competency for the catheter. We provided face-to-face CAUTI in-services to all staff -- all staff -- and I'm not talking just the nurses and the aides. And again, I know I am telling you the scope of the project was just med-surg, but that's just where we collected the data. Hospital wide, even our nurses that worked psych that were sometimes pulled to the med-surg units, they all got the education and they all got the competency training because they are all nurses and they all have the capability to do that. We trained them on the guidelines for prevention. You need to ensure that that research gets into local practice. You have to educate on the evidence, and that's where that piece of it came in. The physician did the physician CME and, as you all know, physicians don't always go to CMEs, so she decided to go to all the department meetings and she gave that education again at all the department meetings trying to engage all the physicians in the process. Then the demonstration of insertion competency. When you develop the education, don't re-create your wheel again. Use other hospitals’ PowerPoint slides. There's multiple CAUTI education toolkits out there. Again, update and revise them to fit your plan. When we developed our education, we didn't have a, which happens a lot of times, is a manager, someone says "Okay you need to educate staff on this." We didn't have a manager go out and develop the education and then give it. We engaged our staff to be the trainers. We trained the trainers because they were the ones that needed to be the experts. They were the ones that needed to engage this path and stop the staff if they were doing wrong and answer the questions when the questions came up. So we created a PowerPoint, and on the slides, I created the talking points for each one of the bullets, and then I pulled the charge nurses who were our trainers into a room and sat them down and gave them these handouts and trained them as far as what they should be telling staff with the evidence that I have learned from the state association conferences. And so everybody was on the same page. Everybody learned the same information. We also did the urinary cath insertion competency. Not all hospitals do that, but we felt that it was very important, especially when you listen to that frontline aide talking about how she felt that it just wasn't being done properly. We were fortunate enough to have a traveling mannequin that we put in a cart, and we wheeled her way down to the units and in some cases, not bedside, but as close to bedside that we could get in the conference room or sometimes on the stairwell platforms because that's the only place we could grab nurses on their way to and from lunch. And we gave them the competency. All aides from ED, OR, women's health, and patient rehab and ICU, they read the policy, they took the quiz and performed the procedure, and they received immediate mediation. Now, prior to this project, back to this, it only took about 20 minutes per person when we did this. And we actually got resources from our executive that allowed us to hire a contract nurse who was very well respected and had worked a lot of the units. She was a retired RN that actually did this. She was very flexible, thank goodness, and she was absolutely wonderful. Again, prior to the project, RNs and EDs specifically would do these catheters, go in have the aides put the catheters, either not pay much attention or not care if the aide did it appropriately as long as the catheter was put in. I can tell you that within the first 2 weeks after this competency was done, we had two different RNs from the emergency room actually stop the aides from putting the caths in. And this is an example of creating that mindset of safety and takeover the insertion process, and they asked that aide to go back to the education department for more education and better competency training. That was just so exciting for us. What we learned also from this is that a lot of these, not only just the aides but the RNs, many of them didn't clean well. The gloving wasn't appropriate, the fields got contaminated, and they didn't know which port to use. Very enlightening when you do this. So what we did when we learned from these defects is that we executed a new plan. We had an improvement plan for the competency. Not only did we have them do it on the mannequin, but now --  and, again, most of the problems were with the aides -- is that we required them to do the competency on a real patient within 2 months of the mannequin, and that had to be supervised by RNs. We found out that our newly hired aides were trained by aides and not by RNs, so that was changed, and we had a yearly aide hands-on demonstration of the competency that we wanted them to do, not just a one-time thing. Other strategies: Caths were flagged with the date of insertion. We made sure they were secured to the legs. We looked at how the specimen was collected for culture, not using the first drained catheter, etc. We used perineal hygiene, especially emphasized that prior to cath, and used a lot of educational posters, john-door posters, and even on the screensavers on the patient units. How did we do? Well, before the project, the first 2 years before we even start the project, we as a small hospital, averaged 3.25 CAUTIs a month. Now in the last year, we've got our CAUTI rates down to 1.7 catheter-associated infections a month. The Partnership for Patient Safety says they want to decrease the number of infections down by half; we've done better than half and we're pretty proud of that, but we just followed the guidelines. And you can see we didn't do it perfect all the time. You can see a lot of spikes there, and we learn from those spikes and why we have the defects in our process, and those defects are a number of CAUTIs that went up. Our competency plan wasn't followed. It wasn't embedded, and that stems back that we didn't have staff development on our initial team. They didn't put it into the schedule. We relied on the managers to remember to go back and do the competency on the staff, and that wasn't the best thing, in our hospital anyway, to do. We had another spike, and we had an increase in the number of catheters when our EMR was implemented. You know, the focus was pulled away. The daily cath patrol wasn't consistent because that's what the charge nurses did, and our prevalence rates went up. So we executed new plans. We now not only do our annual competency with the aides, but we felt that a lot of our infections were not only coming from aides inserting that the RNs in the ED and the OR that were inserting, so now they get an annual competency. We embed this in our competency in orientation and our annual skills evals. We have the report of how many competencies on every agenda item. We do the daily cath patrol. We even added a few things that are also now required by the Joint Commission to evaluate that we are following evidence-based practices. And we give feedback monthly to our staff and our physicians and build cath necessity in our EMR. We considered decreasing the size of the cath, and we recently had ED, because we were seeing a lot more catheters come from the ED, put a checklist down there, and every time an ED nurse considered a catheter over a 3-month period, she had to also document what the indication was for it. I can tell you that that really helped to decrease our number of non-indicated catheters because when you have to actually write it down and measure it, you are much more likely to see things happen and go the right way.

So, CUSP isn't a linear process. You can tell by the way we used it -- and we kind of had our ebbs and flows – you have to fight the battle more than once in order to win it. You have to engage the staff. You have to execute the plan. You have to engage your executive. You have to learn from your defects. And those four Es just keep happening. And don't worry alone.  CUSP is a team sport. Again, you start out with your longer minutes, and after a while you're going to see your highs and low, and it only takes about 30 minutes when you identify a problem to pull a couple of people from that team in the room and work at it. Don't sit there and try to figure it out yourself. And on this last one I saw recently, “Shoot for the moon. Even if you miss, you'll land among the stars.” We've developed a culture within our hospital -- and what Chris said or maybe she didn't, maybe I just remember this from our training -- but culture is how you do things here, and we’ve changed our culture. We don't do CAUTIs anymore. When we have a couple or two or three a month, we really ask questions about it. That never happened before, but it sure does now. So, that being said, that's the end of my presentation so I'm going to hand it back over to the Barb Edson.

Barbara Edson: Terrific, thank you very much. I hope that you all have gained from the conversation today a bit of understanding of the impact of the CUSP-CLABSI work and CUSP itself in Michigan, and then what the CUSP is all about, the CUSP program, and its components and the effective ways in which CUSP puts a framework around this area of culture which, to most of us being in this work, the quality improvement work, when folks mention culture it feels ugly and intangible and it certainly feels that way, I think, for our hospitals at times. But with the framework that's been set forth, giving us the vision but also giving us a bit of a roadmap on how to do that, but allowing for the individuality that we need to go ahead and be successful in our units. And then I think Mary Jo has given us some very practical lessons on how to go ahead and how her unit had approached it and her hospital has approached it and been successful there. So I hope that you have been able to go ahead and gain some valuable information there, and I want to thank every one of you that presented, and I also want to thank Marge and her team with the QIO for understanding that we are all working on this together, and the coordination is really important. I want to go ahead and open the phone lines up, and I know we have a lot of folks on line so I'm a little leery to go ahead and do this without crashing our system, but we could either type in some questions and entertain a few of those for folks. Before we get into that, I'd like to go ahead, Paul, and get the polling questions up. And what we’re going to do here is just ask a couple of questions around a CUSP component and try to get some feedback from you all to find out where you are on these things. Paul, can you go ahead and do that for us?

Mari Franks: Great, Barb, this is Mari Franks, and I'm going to go ahead and do the polling questions, thanks so much. I'm going to go ahead. There are three polling questions, everyone, and I'm going to have about 15 seconds to 30 seconds for everyone to answer, and then I'm going to show the results for that specific question before I move on to the second one. So I'm going to go ahead and have everyone start. Here is your first question. “Have you ever heard of the Comprehensive Unit-based Safety Program before?” Give everyone about 15 seconds (pause). Okay, here are the results, let's see if we can show that. Hopefully everyone is able to see the results. Okay.

Barbara Edson: This is Barb, as Chris said, this call today is to give you a bit more of a taste for it, but certainly as there’s programs out there whether it's through the QIO program or it's through some of the work we're doing at HRET, through the AHRQ work or some of the work that Johns Hopkins is doing, you will see as Jim Battles, our project officer at AHRQ will say, you’ll see things being “CUSP-ized.” You are going to see different initiatives, and if you need help in these areas, certainly there are resources out there to go ahead and help you look at the different components as they’re implemented. But I see that 40 percent or so have heard of it but haven't implemented it. So I want to let you know that there are tools out there. In addition there's going to be some tools that AHRQ will have coming off of CLABSI and will then enhance coming forward in CAUTI and stuff and the rest underneath those contracts to go ahead and help you. And some of those are going to be located on the Web site. There will be modules, learning modules, for folks. Go ahead Mari.

Mari Franks: Sure. The next polling question, "My senior executive regularly attends safety meetings on my unit and can identify the top three safety issues that our safety team is currently working on." So go ahead and give everyone about 20 seconds (pause). All right, I'm going to make the results visible to all here (pause). Give folks about 5 more seconds (pause). And while everyone is voting, I'm getting some questions in the chat. The slides are going to be made available on the onthecuspstophai.org Web site I put it up earlier in the chat box. I will be happy to post that Web site again under the “What's New” section. Again I'll put this in the chat. The slides are going to be available for download later on this afternoon, so thank you for your patience on that. Barb, I'm not sure, can you see the percentages? (pause) So it looks like we have 41 percent saying attends and 50 percent very rarely attends.

Barbara Edson: Terrific, yes I can see that. Thank you very much, Mari. Actually, I am very pleasantly surprised about the response here of attending whenever possible and is aware of our unit’s top three safety issues. That's terrific. I have to wonder, Chris Goeshel and Chris George, if these questions were asked 5 years ago what these response rates would look like.

Chris: Yeah, exactly. This is fascinating and this kind of feedback is so, so helpful because this is something that teams often struggle with which is how the polling questions came up. So the fact that people are having what looks to me to be a little bit more surprising success than what I would have anticipated is really useful, and I think these sorts of questions are just wonderful, immediate feedback. So thank you everyone for voting.

Barbara Edson: Terrific, okay. Next, Mari.

Mari Franks: All right, the third question, "By ensuring that your senior executive is a part of your safety team, meeting monthly with your unit team and holding your unit team accountable for improving risks surrounding a hospital-acquired condition, my unit will be successful in utilizing the executive partnership component." So again this is a bit of a test regarding one of the components of CUSP. I'll give everyone about 15 to 20 seconds (pause). While you are voting, I also saw another question. This call will be recorded and, again, it will also be posted on the same Web site onthecuspstophai. Again, give that about 24 hours for us to receive the recording, but again it will be online on our Web site.

Barbara Edson: So, there's also a question here from Tere Dickson, asking about what advice would you give to the 23 percent where the executive is not engaged? Chris, do you want to go ahead and grab that one?

Chris: Well sure, but I think bunches of people on this call could answer it better than I can. I think that, depending upon the issue, part of it goes back to the four Es slide. So if they’re not engaged, why not? Have they been invited? It's surprising how often when we go back to CEOs and explained what their role is they say, "Oh I didn't know that was my role." They thought their role was to sign the team up for the projects, so making sure that they are invited. Some teams have found it really useful to put the photo of their executive up on the bulletin board. Oftentimes, for the first couple of meetings, the unit manager meets with the executive so that they are comfortable in the space. CEOs and senior leaders are often not accustomed to being on the front lines, and so just like the rest of us, they need some coaching for their role. Those are some key strategies that have been successful, but I suspect that others might have more to add, and we actually have a slide deck on getting your senior executive engaged. So if you have not seen that particular detail, it might be worth taking a look at that.

Mari Franks: Terrific.

Barbara Edson: Terrific.

Mari Franks: Barb, do you want to see the results?

Barbara Edson: I see the results right here, and see that 62 percent of you recognize the components in that sentence above as being some of the interventions that we go ahead and talk about to your senior executive’s role. And you know this is, as Chris just said, they don't understand having worked with senior executives at the State level, I can tell you they don't often understand their role, so showing them the aggregate data coming off some of the collaborative work that we did, when I turn around and I would talk to the senior leaders, they are like "Well, those are good results, Barb, but they are not happening fast enough." And for me to be able to turn around and say, "You know what, you're right, they're not. What do we do? What is our role in doing this?" From my role at working to support the teams at the State level, but really most importantly what are the goals that the senior executives bring to the table and their roles that come around resources and prioritization for organizations. But there's also, as Chris just alluded to, they’re not always comfortable in your space just like you may not be comfortable in theirs. So I think that understanding some of those components and helping down that direction is really, really important. I know that there is a lot of questions on here. I can't read them as I'm talking, but I know there's a lot of questions about where to find some resources.

Mari Franks: There is one question that's been asked twice. I'm not sure if you're the right person to answer it, but their question goes, "Is there a requirement to annually competency test your staff on Foley care?"

Barbara Edson: So, a competency from whom? Not from our perspective from the AHRQ work that's being rolled out if that's what the question is. That’s not something that we’re doing. So, I don’t know if you are referring to Mary Jo’s presentation, whoever asked that question.

Mari Franks: Yeah, to Jennifer Conti. Jennifer if you want to go ahead and type another follow up, I’ll grab it.

Mary Jo Skiba: This is Mary Jo. To my knowledge there’s not a State nor a Joint Commission requirement to do competency testing for urinary caths. It was just something that we decided to do at our hospital.

Barbara Edson: That’s my understanding of it, too, Mary Jo.

Chris: So with that, you guys, it’s been great to get your feedback, I really appreciate that. I’m going to go ahead and open it up to questions for folks, and I don’t know the best way to do this without consulting here with Mari or the team at HRET. How do you want to go ahead and do this? Just go ahead and have them queue up?

Mari Franks: Operator, what do you recommend?

Operator: I think a queue would be the best.

Mari Franks: Terrific.

Operator: I’ll go ahead and tell everyone. At this time, we will open the floor for questions. If you’d like to ask a question, please press the star key followed by the one key on your touchtone phone now. Questions will be taken in the order they are received. If at any time you would like to remove yourself from the questioning queue, please press star, two. And once again to ask a question that’s star, one.

Mari Franks: So we have a followup from Jennifer Conti regarding the earlier question, Barb and Mary Jo. She says "When you spoke about reducing UTIs, it seems like a great idea to competency test staff, but I'm afraid I would not get buy-in if it is not mandated by an accrediting body."

Barbara Edson: This is Barb, and I don't know, Mary Jo, if you want to pipe in, but we mandate an awful lot of stuff, and I understand mandates. And I think that in some instances they are very appropriate, but I also believe that by going ahead within your own organization, you can set what your expectations are, and once those expectations are set and folks are understanding why the expectation is there, I think that's the most important thing for them to understand why the expectation is in front of them, to understand the value in what that expectation is to get folks to go ahead and really value it and buy into the competency portion of it. So I don't know, Mary Jo, if you wanted to add to that.

Mary Jo Skiba: Our team felt very strongly that, especially with our aides because they were very uncomfortable seeing some of the ways this catheter was put in, that we really needed to do a competency that we felt that would have the most impact. And because we had our senior executive on, they helped move this forward and then even took it to the directors. She gave us the resources and believed in the project. It is hard and anything that involves money and adding staff and cost, but sometimes I find that when you show people the evidence, including physicians, you get more buy-in. And the fact that some of these UTIs are not going to be reimbursed when they are hospital associated or they aren’t going to be included as a comorbid condition, so you could be losing that payment, that helps as well. But, that shouldn't be the focus of it, but it certainly doesn't hurt.

Barbara Edson: And I think one of the things with competency, what you hope to gain there is looking at some variability, but there's a whole way to go about that. And if you were to just come in with the competency without looking at some of the cultural pieces around it, we're going to be where we are with some of the mandates that have been put out there. I think about when -- Chris Goeshel pop in here because I know you're in the surgery world here -- but I think about mandating some of the timeouts, and then I go pick up a magazine and I read and I see that we've done all these sentinel event alerts and things like that around timeout procedures, and I see wrong site surgeries at the rates we are seeing.

Chris: Yeah, very quickly, I would tag on to that. I think one of the things that it's not a slide that we included today, but we often include that when we started first doing this work, if you imagined a cross, what we talk about is scientific evidence on one end of the vertical axis, and feasibility on the other end, so there's a gap between what science says we should do and what we can do with the given hours in the day. If you imagine a horizontal axis with regulatory requirements at the top and local wisdom at the bottom, if you are imagining that, oftentimes what happens in organizations is what regulatory agencies say we have to do and what's feasible, what we can manage to fit in, given our local culture, so activity is in that upper right-hand quadrant. Yet, what you just said, Barb, is so important because what we are trying to do with CUSP is move everyone more toward the middle, what we call the sweet spot, closer to scientific evidence and taking into consideration local wisdom. So your example of timeouts in surgery, if someone tells us we have to complete a checklist, we will complete the checklist. If we get people engaged in understanding why competency assessment of certain groups of people for Foley insertion is really important to rates of infection, lengths of stay, comfort, and capacity of our patient’s discharge, if we help people understand why those things are important, it’s much more likely to happen. So it is a balancing act, but our inclination as well is that mandating things is not the answer because we are quite capable of saying we did what we were supposed to do and nothing changes. I would add the whole notion that everyone in the country is doing the SCIP measures, and performance on SCIP measures is uniformly high, and there's not really been a marked decrease in surgical site infections, which makes one wonder whether we are completing the checklist or actually doing the work. So, we can go down another path on that, but you are absolutely right, mandating things is often not the answer.

Barbara Edson: Thank you, Chris. That was helpful. I want to go ahead, and let's check on some of these. I know we’ve got about 14 minutes or so left, and I want to go ahead and tackle some of these questions that folks may have. Operator?

Operator: Once again, if you'd like to ask a question that's star, one on your touchtone phone now.

Mari Franks: So while we’re waiting for questions, Barb, we have another question in the chat box saying, "What is your recommendation for perinatal care? Daily, twice daily, etc.?" Do you have a recommendation for that any of the speakers?

Barbara Edson: What is your recommendation for perinatal? I missed the rest of it.

Mari Franks: That was about it, that was the question. It was from Betty. Betty, if you want to maybe star and ask the question, that would be great, but that was it, she just said what is your recommendation.

Barbara Edson: Not perinatal. Perineal care, sorry.

Mari Franks: That’s okay. That was my error.

Barbara Edson: No, it’s mine, I see it now. I went to the chat box. Do you want to go ahead, and talk about that as someone who has been down the CAUTI realm, Mary Jo?

Mary Jo: I believe our recommendation is just daily perineal care with bathing. I know there is evidence out there that when you do frequent perineal cleansing, you can actually cause irritation and increase the rate of infections, and I'm sorry to say I'm fast looking it up because it's been a while since I actually looked at it but we just do daily cath care.

Barbara Edson: You are on track from where we are coming from the national work. Chris George, did you want to add anything?

Chris George: No, other than that's a good question. Our focus has really been in the national CAUTI project on looking at the appropriate use of catheters and whether or not the catheter is indicated according to the HICPAC guidelines and then, in the context of today's presentation, just thinking about how we can create a culture that's going to support people looking at catheters on a daily basis and making sure that the catheter is truly needed. So that's kind of where we have been focused in the national project.

Barbara Edson: And there's guidelines out there from the CDC and others that go ahead and address that, and most of them speak to exactly what Mary Jo just alluded to, that aggressive cleansing of the perineal area like I learned way back when is probably not a wise thing to do.

Chris George: I just found in the HICPAC guidelines. It says do not clean the perineal urethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene -- i.e., cleansing of the meatal surface during daily bathing or showering -- is appropriate, and that's a 1B recommendation.

Barbara Edson: Okay, terrific, thank you.

Mari Franks: Operator, do we have any questions?

Operator: At this time, I am showing there are no questions.

Barbara Edson: Okay, does anyone else want to go ahead and add anything, Marge? Minette? Chris? Chris? Mary Jo?

Chris Goeshel: This is Goeshel, and I would just say -- reminding people of what we said at the beginning -- this takes time. Don't expect you’re going to have it memorized or be able to go out and implement it with teams in an instant and know that we are absolutely all here to answer questions and to help you on the journey because it is, indeed, a journey. It was great to be on the call today. Thanks.

Marge: And Barb, this is Marge and Minette from CMS, and we’d just like to thank you and everyone who presented and who everyone who attended the call. Thank you so much. We really appreciate you working with us and the QIOs, and the QIO recruiter hospitals are here for outstanding questions if you want to email us.

Barbara Edson: Terrific. And then as far as making slides available, Marge and Minette, we've got a few questions on that. Are you going to post them someplace or are we going to give them to you? How is that going to work?

Marge: If you just email them to us, we can send them to our national QIO coordinator and we can get that out on the listserv.

Barbara Edson: Perfect. We will take care of that upon the conclusion of the call. And then, folks, for additional resources out there I said, I did mention there were manuals and Chris had talked a bit about some slide presentations. There’s a lot right now on onthecuspstophai.org. There are recorded calls that have been made on specific topic areas. There’s slide presentations. And we are in the process right now of getting a toolkit over to AHRQ, as I said, that there was going to be some resources. So that’s pretty similar to TeamSTEPPS, if you are familiar with that, and the fact that it’s got a slide presentation with some facilitator notes as well as some video vignettes that are placed within those presentations to drive home some key points. And those things are going to be available, as I said. That has just transferred over to AHRQ, and we will be building upon that with each of these AHRQ projects that are developed for folks. As we fill out more content, those will be available. I'm thinking that went to them in March. I think they'll probably be available to folks, I would think by May-ish at the latest.

Chris: Other questions or thoughts before we go ahead and end the call? I do want to recommend that you guys fill out the survey that is there. If you could just take a few minutes, we really do appreciate it and it will help us do a better job of serving you all and supporting you in the work in which you do. If you can click on the survey link, that would be great.

Mari Franks: And, Chris George, are you still on the line?

Chris George: Yeah, I was just hoping that you would put up those slides that Chris Goeshel had ended with about kind of what are your next steps for CUSP.

Mari Franks: Okay, let me get that.

Chris George: Talking about going back and thinking about educating staff in the science of safety and having your teams identify defects, I think, is a great place to leave from today's call.

Barbara Edson: Terrific.

Chris: Other folks? So there are some action items there. Look over the CUSP manual with team members. Brainstorm potential hazards with your team. Assessing your composition, your team composition with respect to CUSP elements. And review of pre-implementation checklists, where are you right now in the work that you are trying to go ahead and get accomplished whether it be in CUSP, CLABSI, CAUTI? Where are you? Where you want to be?

Barbara Edson: So with that, if there's no other questions or comments from folks, we can go ahead and end the call. Thank you very much for all of your time today. Again, we really appreciate it, and we wish you the best in the work in which you were doing. Thank you.

Operator: Thank you. This concludes today's conference call. You may now disconnect.