Transcript Project Report - Lean Sigma - Massachusetts Coalition for the

Staff Safety Assessment
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Learning Objectives
• To understand Step 2 of CUSP:Identify
Defects
• To understand how to Implement the Staff
Safety Assessment
• To understand ways to use results of the
Staff Safety Assessment
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Goals
• To identify defects
• To leverage the wisdom of the front line worker
• To prepare a list of improvement opportunities that
has face validity and provides a focus for CUSP
activities.
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On the CUSP: Stop BSI
CUSP
CLABSI
1.
Educate staff on science of safety
1. Remove Unnecessary Lines
2.
Identify defects
2. Wash Hands Prior to Procedure
3.
Assign executive to adopt unit
3. Use Maximal Barrier Precautions
4.
Learn from one defect per quarter
4. Clean Skin with Chlorhexidine
5.
Implement teamwork tools
5. Avoid Femoral Lines
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The CUSP Team
The smaller group that spreads the
intervention
to the rest of the unit
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Education and engagement activities
on the unit
• BSI: Providing Evidence, Modeling the line
placement steps; stopping insertions that violate
protocol; having one-on-one talks where
necessary;
• Facilitating CUSP Activities
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Comprehensive Unit-based Safety
Program (CUSP)
1.
Educate staff on science of safety
(www.safercare.net)
2.
Identify defects
3.
Assign executive to adopt unit
4.
Learn from one defect per quarter
5.
We are here
Implement teamwork tools
You are here!!!
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Identify Defects
• Review error reports, liability claims, sentinel events
or M and M conference
• Ask staff how the next patient will be harmed
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Identifying Defects
What DO you know?
What SHOULD you know?
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Transparency
Making project and progress visible
to everyone
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How are We Going to Harm the Next
Patient?
One way to make harm visible-- get staff
thinking about safety and how to improve it
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Step 2: Staff Identify Defects
Frontline caregivers are the eyes and ears of patient safety
• Identify clinical or operational problems that negatively
impact patient safety (have or could)
• Use the Staff Safety Assessment form (Part of CUSP manual)
– How will the next patient will be harmed in our unit
– What can be done to minimize patient harm or prevent this safety hazard
• ICU managers and team review suggestions, set the agenda
for discussion with executive partner
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Appendix C
STAFF SAFETY ASSESSMENT – CUSP
Purpose of this form: The purpose of this form is to tap into your knowledge and experiences
at the frontlines of patient care to find out what risks are present on your unit that have or could
jeopardize patient safety.
Who should complete this form: All health care providers.
How to complete this form: Provide as much detail as possible when answering the 2
questions. Drop off your completed safety assessment form in the location designated by the
CUSP improvement team with your job category, date and unit in the top box (name is
optional).
When to complete this form: Assessing safety should be considered an iterative process with
no defined end (like a moving bicycle wheel). Thus, it can be filled out by any health care
provider at any time. At the very least, all health care providers should complete this form
semiannually.
Name (optional):
Job Category:
Date:
Unit:
Please describe how you think the next patient in your unit/clinical area will be harmed.
Please describe what you think can be done to prevent or minimize this harm.
Thank you for helping improve safety in your workplace!
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Step 2: Staff Identify Defects
• What Team Leaders need to do:
• Hand out a Staff Safety Assessment form to all staff, clinical
and non-clinical, in the unit
• Establish a collection box or envelope
• Identify and group common defects (such as communication,
medications, patient falls, supplies, etc.)
• Summarize as frequencies (i.e., what percent of responses
were for communication)
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Prioritize Defects
• List all defects
• Discuss with staff what are the three greatest risks
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Step 2: Staff Identify Defects
• Report the identified defects to staff, executive
partner
• ICU managers and CUSP team prioritize defects
identified by the potential level of risk to the patient
• Select one to work on with support of Executive
• Step 2 should be ongoing
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Appendix D
SAFETY ISSUES WORKSHEET FOR SENIOR EXECUTIVE PARTNERSHIP - CUSP
Date of Safety Rounds:
Unit:
Attendees:
1.
2.
3.
4.
5.
6.
7.
8.
9.
(use back of form for additional attendees)
Identified Issue
Potential/Recommended
Solution
Resources
Needed
Not
Needed
1.
2.
3.
4.
5.
6.
7.
8.
9.
Copy form if more than 9 safety issues are identified.
Please return this form to your project leader
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Appendix E
STATUS OF SAFETY ISSUES – CUSP
Unit: ___________________________________________
Date
Safety Issue
New and Ongoing
Contact
Status
Goal
Date
Safety Issue
Completed
Contact
Status
Goal
Please return this form to your project leader
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CUSP Team activitieskeeping on track
• Team meetings (recommend monthly)
• Review of data
(monthly)
• Meet w/ Exec Partner (monthly or more)
• Executive review of data (monthly)
• Presentations to hospital colleagues
–
(leadership, frontline staff, board)
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On The CUSP
Stop BSI
Assemble a CUSP team,
Partner with a senior executive;
Baseline Data
Exposure Survey and Technology Survey
Adaptive (CUSP)
Technical CLABSI
CVC Insertion
CVC Line
Cart
1. Contents
inventory
Evidence based BSI
prevention (hands,
site, skin prep,
barrier, removal)
1. Presentation
of evidence
2. CLABSI
factsheet
3. Insertion
checklist
CVC Management
Science of
Safety
Training
Staff Identify
Defects
Senior
Executive
Partnership
1. Daily goals
Implement Tools for
Teamwork and
Communication
LFD toolkit
2. Dressing
change
3. Vascular
access manual/
policy protocol
Learning
from
Defects
1. Science of
safety
presentation
3. Attendance
sheet
1. Staff safety
assessment
form
2. Indentifying
hazards
presentation
Briefings
1. Daily goals
2. Shadowing
3. AM briefing
4. Call list
6. Team check up
tool
4. Vascular
access quiz
5. Vascular
access manual/
policy
6.Annotated
bibliography
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Comprehensive Unit-based Safety
Program (CUSP)
1.
Educate staff on science of safety
(www.safercare.net)
2.
Identify defects
3.
Assign executive to adopt unit
4.
Learn from one defect per quarter
5.
We are here
Implement teamwork tools
You are here!!!
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What Should you do NOW?
CLABSI: Collect & Submit Baseline & Monthly BSI data
CUSP Preparation: Assemble team/Schedule meetings
CUSP Implementation
1) Science of Safety Training for all staff
2) Identify Defects: How will patients be harmed?
www.safercare.net
www.onthecuspstopbsi.org
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References
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Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence into
practice: A model for large scale knowledge translation. BMJ. 2008;
337:a1714.
•
Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease
catheter-related bloodstream infections in the ICU. NEJM. 2006; 355(26):27252732.
•
Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in
intensive care units in michigan. J Crit Care. 2008; 23(2):207-221.
•
Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a
comprehensive unit-based safety program. J Pat Safety. 2005; 1(1):33-40.
•
Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: A
model for safety improvement. Jt Comm J Qual Saf. 2004; 30(2):59-68.
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