Unit-Based Safety Program Improves Safety Culture, Reduces Medication Errors and Length of Stay

Problem Addressed

• Role of poor communication: Many sentinel events in health care stem from failures in communication, which is a pertinent element of culture.⁴
• Failure of executives to recognize and make safety issues a priority: Perceptions of safety vary widely between health care executives and frontline workers; one evaluation found that executives consistently rate the degree of teamwork and the safety climate within organizations much more highly than do frontline workers.⁵ As a result, executives may not be aware that additional tools and resources are needed to improve safety. By unifying perceptions and promoting teamwork, comprehensive safety programs may change organizational culture and help ensure that executives and on-the-floor teams work more closely together to improve safety.
• Poorly designed work systems: Evidence has demonstrated that the systems in which frontline staff work are often poorly designed and can lead to medical errors and patient harm.³ Implementing an improvement tool is one mechanism to redesign a system or process of work that will improve safety and quality of care. Tools are practical, feasible, easily implemented by frontline workers, and become a permanent part of daily practice.

Pertinent Quality Measures

Description of the Innovative Activity

• Staff education on the basic science of safety: Unit staff receive education on the basic science of safety to help them understand the following: (1) that safety performance is determined by the system in which care is delivered, and, as a result, safety improvement efforts should center on improving systems rather than blaming individuals; (2) that basic strategies for safe design include standardizing work processes, creating independent checks for key processes, and learning when things go wrong; (3) that the principles of safe design apply to both technical issues and teamwork; and (4) that teams make wise decisions when there is diverse and independent input (i.e., health care is a “team sport” that should not be played with a “man down”).
• Identification of hazards: Teams use many sources to identify potential hazards, including incident reporting systems, liability claims, sentinel events, and morbidity and mortality conferences. One of the most effective and efficient methods used by the teams is to ask staff how the next patient will be harmed on their unit. This question is intended to tap into the knowledge of the people who work on the front lines of care (and therefore know which systems do and do not work), to encourage these individuals to think about ways to fix broken systems on their units and to develop interventions to do so, and to evaluate the impact of these interventions.
• Partnering of unit with a hospital executive⁶: A hospital executive is assigned to work with frontline staff on the unit to prioritize safety improvement efforts and provide resources to support these efforts. The overall goal of this partnership is to improve culture at the organization level. In addition, by interacting with frontline staff, the executive increases his or her understanding of what is needed to effectively, efficiently, and safely care for patients.
• Learn from defects (LFD) tool⁷: The LFD tool provides lenses through which staff can see, learn, and investigate defects (or factors) that contribute to harm or the potential for harm. The LFD tool guides the user through an indepth investigation of one event, in which they design, implement, and evaluate an intervention to mitigate or prevent a future similar event. The LFD tool helps to answer four questions: What happened? Why did it happen? What was done to reduce risk? How do we know that the risk was actually reduced? (This last question has historically received far too little attention.) Each team is asked to learn from one defect per month. To document learning, staff write a brief summary answering the four questions and share it throughout the organization.
• Tools to improve teamwork, communication, and the culture of safety: Rather than provide substantial didactic training in teamwork, teams implement any of a variety of tools that are intended to support the practice of teamwork in a safe space. These include the following:
  • Morning briefing⁸: Every morning at shift change and before rounds, physicians and nurses meet to discuss admissions, discharges (including where to start rounds to facilitate discharges), and events that occurred during the night that may pose risks during the day. This briefing is intended to improve communication, teamwork, and the efficiency of unit management.
  • Daily goals checklist⁹: This checklist is completed on each patient during rounds by the health care team to clarify the care plan for the day. The checklist includes the consideration of potential safety risks for the patient. For example, if the patient has a central venous line, consideration is given as to whether it can be removed to reduce the risk of potential infection.
  • Culture checkup¹⁰: This tool is used to structure group discussions within a unit around its culture assessment results and to help the team identify and work on any component (e.g., poor collaboration between physicians and nurses) that has weakened the culture. The culture checkup sparks an open dialogue about the culture of safety, providing a safe venue in which to discuss and resolve problems. (See below for more details on the culture assessment results.)
  • Shadowing another profession¹¹: This tool allows individual staff members to observe and better understand the roles and responsibilities of other clinical or nonclinical health care disciplines. Teamwork is more efficient and effective when team members are familiar with each other’s role and tasks and when they understand the barriers others face relative to communication and/or collaboration.
  • Operating room (OR) briefing¹²: The OR briefing is a preoperative dialogue among team members that includes first names and roles, an inventory of equipment and other essential needs, and a plan to guard against potential safety risks.
  • OR debriefing¹³: An OR debriefing occurs after a procedure to reflect on factors that contributed to, mitigated, or prevented an adverse event or inefficiency during the procedure. Some ongoing debate exists about the cost-benefit ratio of debriefings, particularly in certain situations (e.g., cases that are completed without an adverse event or inefficiency).
  • eCUSP⁴: eCUSP is a Web-based project management tool that follows the six-step version of CUSP. It is used to manage data collected through the process of identifying safety concerns, developing interventions to rectify potential hazards, and evaluating whether the intervention worked.
• Ongoing measurement, feedback, and improvement: Safety culture was assessed using the Safety Attitudes Survey derived from aviation’s Safety Climate Survey.^14,15 Results from the baseline and ongoing safety culture assessments, sentinel events, and incident reports are shared periodically with the improvement teams and senior executives to stimulate discussion on how culture may pose a risk to safety and how these risks can be reduced.

References/Related Articles

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Results

• Improved culture of safety: Results from the safety climate survey show that the percent of staff reporting a positive safety climate increased from 35 to 52 percent in one ICU and from 35 to 68 percent in the other.¹
• Reduced LOS: CUSP was associated with a reduction in ICU LOS, from 2 days to 1 day on one unit, and from 3 days to 2.3 days on the other unit.¹
• Fewer medication errors: Before implementing the medication reconciliation process that was a part of CUSP, 94 percent of medication orders in one ICU contained errors, whereas 40 percent of charts in the other ICU contained a medication error at transfer.¹ After the intervention, these errors fell to zero on both units.¹
• Reduced nursing turnover: Nursing turnover rates decreased from 9 to 2 percent on one unit and from 8 to 2 percent on the other.¹
• Hospital-wide rollout and continued success: Given the success of CUSP in the two surgical ICUs, this program was rolled out to other units and clinical areas throughout the Johns Hopkins Hospital. Unpublished data show that Safety Attitudes Questionnaire scores on these units have improved since implementation; for example, scores on one unit increased from 35 to 68 percent. 

• Improvements in safety culture: Culture was assessed using pre- and post-implementation teamwork climate scale scores, with either of the following being used as an indicator of improvement: 60 percent or greater consensus that good teamwork exists and/or a 10-point or higher increase in climate scores. (The teamwork climate scale was used because teamwork is recognized as a significant contributor in the safe delivery of health care.) The data show that teamwork climate scores improved significantly across a diverse cohort of ICUs during the year after CUSP implementation. In 2004 (prior to implementation of CUSP), 17 percent of participating ICUs had a 60 percent or higher consensus among staff that good teamwork existed. By 2005 (after implementation), 46 percent of ICUs had reached the 60 percent or higher figure, and/or achieved a 10-point improvement in its teamwork climate score.²

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Formation of project team: Each unit formed an improvement team consisting of at least a physician, nurse, and the hospital executive. Ideally, teams are multidisciplinary in nature and include as many clinical disciplines as possible that work on the unit. Thus, respiratory therapists, pharmacists, and other staff members were encouraged to join the teams in both ICUs.
• Obtaining resources: Teams met with individuals who manage the budget (e.g., a nurse manager, unit director, and/or department chair) to introduce the program and secure resources to implement the project.
• Partnering units with a hospital executive: Teams worked with the hospital executive assigned to the unit to schedule an initial meeting with the improvement team, along with monthly meetings during which the executive conducts rounds on the unit.
• Assessing baseline safety culture: Baseline assessments of safety culture were conducted on each of the units.
• Pilot testing, refinement, and rollout: The program was pilot tested in two ICUs. After the pilot test, the program was refined (including a consolidation in the number of program steps) and rolled out throughout the hospital.

Resources Used and Skills Needed

• Staffing: At a minimum, a physician and nurse are needed from each participating unit to serve on the improvement team and implement the program. These individuals must dedicate 4 to 8 hours per week to CUSP.
• Costs: Cost estimates will depend on the resources available for the unit. At Johns Hopkins, the minimum staff time per unit is 4 to 8 hours/week from the safety nurse, 2 hours/week from a coach working in the hospital’s safety and quality department who is trained in CUSP, and 1 hour/month from the hospital executive.

Funding Sources

Agency for Healthcare Research and Quality; Johns Hopkins Hospital

Tools and Other Resources

Getting Started with This Innovation

• Select units with low culture scores (if  known) or an elevated risk for preventable patient harm, and with a unit leader who will champion the program. 
• Administer the Safety Attitudes Questionnaire (SAQ) before implementation to get a sense of perceptions about safety culture and morale. Gather data from appropriate quality improvement surveys and other sources to compare and analyze.
• Hold a CUSP orientation with the senior executive team and the safety team. (A Senior Executive Partnership Orientation Handbook is included with the CUSP manual.) During the orientation, share information about safety attitudes and other pertinent information.
• Schedule monthly meetings at least 6 months in advance. Post meeting dates and times on the bulletin board along with photos of the key project players and contact information, as this will enhance communication and increase the comfort level of interactions.
• Have project leaders brief staff on the value of the senior executive partnership. Help staff prepare to discuss issues with their assigned senior executive and collect safety concerns from those who will not  be there during senior executive rounds. 
• Consider streamlining the number and length of the various learning modules and tools. The original CUSP program featured eight modules, but this figure was reduced to six after pilot testing.
• Allocate adequate time for staff to become familiar with and implement program tools and principles. Four to eight hours of dedicated training time per week are needed for the first several weeks of the program.  

Sustaining This Innovation

• Conduct morning meetings to reinforce the culture of safety and problem-solving. 
• Periodically administer the CUSP safety culture reassessment tool and the SAQ to track changes in morale and perceptions about safety. 
• Provide frequent unit-specific feedback reports to staff and the senior executive on length of stay, medication errors, and other outcome measures of importance.
• Encourage senior executives, physicians, and nurses to "shadow" each other for a total of at least 4 hours, over one or multiple sessions. Ongoing senior executive and staff dialogue is critical to incorporating lessons learned into the daily routine and spreading the program to other units.
• Use tools such as the daily goals checklist to establish what needs to done for each patient.
• Use the Healing After Harm tool to help all people involved with a medical error or mishap recover and grow from the experience.

Additional Considerations and Lessons