When was the last time you were invited to a meeting to talk about your “bombs”? Most often, failures are not something that you want to talk about. Teams participating in the Comprehensive Unit-based Safety Program (CUSP) have found that they learn more from their mistakes, and while celebrating their successes, they are also focusing on what they can learn from their bombs. With CUSP, teams learn to recognize the importance of culture in safe care and patient outcomes, and are provided tools to improve their culture.
CUSP is one of two options supported by the Provincial Surgery Advisory Committee and the British Columbia Patient Safety and Quality Council (BCPSQC) to improve surgical care: CUSP builds capacity to address safety issues by combining clinical best practices and the science of safety; and The Productive Operating Theatre (TPOT) is a continuous improvement program to improve patient outcomes and operating theatre performance that focus on the front-line team driving improvements using elements of lean. Currently, three health regions - Fraser Health, Island Health (Vancouver Island Health Authority) and the Provincial Health Services Authority (PHSA) - have embraced the CUSP program. Vancouver Coastal Health has opted to proceed with the TPOT program, whilst Interior Health, well along in implementing Lean methodology, has decided to continue along that path.
Currently, there are fourteen teams at eight sites in BC using CUSP. In April 2014, a team of patient safety experts from Johns Hopkins Center for Innovation provided train-the-trainer sessions so that teams could help other teams learn more about implementing CUSP on their units.
CUSP is a five-step program designed to improve a unit’s workplace culture by empowering staff to see their role in providing safe care. The first step in the CUSP program is the science of safety, which introduces teams to principles that promote safe care for the patient. It helps teams to develop a lens focusing on the system factors that can negatively impact patient care. CUSP looks at the activities that go on within a unit and within the patient’s journey, and demonstrates how to recognize some of the things that can cause patient harm. “The science of safety helps empower people and highlight how much the care they provide can impact the care of the patient”, says Geoff Schierbeck, Quality Leader Surgery, BCPSQC. “It gives staff the responsibility and awareness to recognize when they need to do something differently.”
The second step involves staff identifying defects impeding work flow. A frequently used tool is to ask two questions: How will the next patient be harmed, and how can we prevent this harm from happening? Harm can be anything ranging from untimely provision of medications, to inefficient methods of delivering care. “Harm can be whatever you define it to be,” says Schierbeck. “Constructive conversations result in looking at how we can prevent harm by using the resources we have available.”
The third step is Executive partnership. What makes the CUSP approach unique is that executives sit in partnership with the teams, and anyone on the unit can attend CUSP meetings. Teams chose what problems and questions to work on, not necessarily items that Executive want them to work on. Lingering problems get dealt with so that staff and management can focus on bigger issues that need to be addressed, such as staff turnover, sick time and cancellations. Teams are empowered to make changes, and having frontline staff involved has helped with engagement and sustainability.
Schierbeck says that getting physicians on board has been challenging in the past. The CUSP program has created physician engagement without calling it that. “CUSP gives physicians a voice and avenue to pursue improvements. When they come to the meeting with a problem, we ask them for the solution,” adds Schierbeck. “It provides a forum to talk about improvement, and frames the conversation. Physicians now have a process to do something about the issues they face.”
The fourth step is to learn from defects, or what CUSP calls collective sense-making. All of the issues to be addressed are grouped into closely-knit themes, such as efficiency, safety, equipment issues, etc. “Small things that create inefficiencies can be dealt with quickly, such as having marking pens in the operating room that actually work,” says Schierbeck. “We look at what is causing delays and then take care of them -- what happened, why it happened, what we can do to reduce it from happening again and how do we know if the risk has been reduced. This approach provides good feedback in current time. Results are measured through data collection, which is done by unit staff to make it more sustainable.”
The final step is tools to improve. Sites are encouraged to measure their culture to get a perspective of next steps. Data is broken down for teams on what their culture looks like at a unit level. Sites own their culture data, and observations are done on non-technical skills in the operating room, looking at how well the team communicates and hierarchy issues, empowering the team to speak up if a problem or potential problems are recognized. Tools to improve communications are then identified, such as briefings, debriefings, CUS words, critical language and others.
“Many studies say that good culture leads to good results,” says Schierbeck. “Before CUSP, we really did not know how to improve our culture. Instead of having culture sessions where we talk about improving our culture, CUSP has helped us embed culture into our everyday practice. Using simulations to illustrate certain activities or ideas that you can implement to help with teamwork and communication has made people accountable. Everyone on the floor is part of the culture. If an issue arises and you do not step up and say something, you are empowering the type of culture that can be detrimental to the patient and outcomes.”