www.ahrq.gov/
Text Size:  Select for smaller font Select for medium font Select for larger font  Print this page

CUSP Toolkit

Apply CUSP

Contents

Slide 1. Cover Slide
Slide 2. Learning Objectives
Slide 3. Introduction to Just Culture Principles
Slide 4. Understand Just Culture
Slide 5. Just Culture
Slide 6. Understanding Risk and Human Behavior
Slide 7. Managing Error and Risk
Slide 8. Systems and Behaviors Work Together To Improve Outcomes
Slide 9. Accountability
Slide 10. Engineering System Design to Support Behavior Choices
Slide 11. Leadership Team's Role in Applying Just Culture Principles
Slide 12. Debrief on Accountability
Slide 13. CUSP Toolkit Modules
Slide 14. CUSP Toolkit Review
Slide 15. Assemble the Team
Slide 16. Keys to Assembling the Team
Slide 17. Engage the Senior Executive
Slide 18. Keys to Engaging the Senior Executive
Slide 19. Understand the Science of Safety
Slide 20. Keys to Understanding the Science of Safety
Slide 21. Identify Defects Through Sensemaking
Slide 22. Keys to Identifying Defects Through Sensemaking
Slide 23. Implement Teamwork and Communication
Slide 24. The Keys to Effective Communication
Slide 25. Summary
Slide 26. References

Slide 1. Cover Slide

The 'Apply CUSP' module of the Comprehensive Unit-based Safety Program (CUSP) Toolkit. The CUSP toolkit is a modular approach to patient safety, and modules presented in this toolkit are inter-connected and are aimed at improving patient safety.

Image: CUSP Toolkit logo.

Return to Contents

Slide 2. Learning Objectives

Text Description is below the image.
  • Introduce Just Culture principles.
  • Learn how Just Culture principles can augment CUSP.
  • Review key steps of the CUSP Toolkit.

Return to Contents

Slide 3. Introduction to Just Culture Principles

Introduction to Just Culture Principles.

Return to Contents

Slide 4. Understand Just Culture

Image: Video icon.

Vignette still.
Click to play.

Return to Contents

Slide 5. Just Culture1

Text Description is below the image. Image: A patient in a hospital bed surrounded by the health care team.
  • A system that:
    • Holds itself accountable.
    • Holds staff members accountable.
    • Has staff members that hold themselves accountable.

Return to Contents

Slide 6. Understanding Risk and Human Behavior1

Text Description is below the image.

  1. Human Error:
    • Inadvertently completing the wrong action; slip, lapse, mistake.
  2. At-Risk Behavior:
    • Choosing to behave in a way that increases risk where risk is not recognized, or is mistakenly believed to be justified.
  3. Reckless Behavior:
    • Choosing to consciously disregard a substantial and unjustifiable risk.

Return to Contents

Slide 7. Managing Error and Risk1

The three behaviors are human error, at-risk behavior and reckless behavior. Human error is the product of our current system design and behavioral choices. It is managed through changes in choices, processes, procedures, training, design and the environment. Consolation is the appropriate response to human error. At-risk behavior is a choice made while believing that the risk is insignificant or justified. This behavior is best managed through removing incentives for at-risk behaviors, creating incentives for healthy behaviors, and increasing situational awareness. Coaching is the best response to at-risk behavior. Reckless behavior is the conscious disregard of substantial and unjustifiable risk. It is managed through remedial and punitive actions. Punishment is the appropriate response to reckless behavior.

  • Human Error

    Product of our current system design and behavioral choices.

    Manage through changes in:

    • Choices.
    • Processes.
    • Procedures.
    • Training.
    • Design.
    • Environment.

    Console

  • At-Risk Behavior

    A choice: risk believed insignificant or justified.

    Manage through:

    • Removal of incentives for at-risk behaviors.
    • Creation of incentives for healthy behaviors.
    • Situational awareness.

    Coach

  • Reckless Behavior

    Conscious disregard of substantial and unjustifiable risk.

    Manage through:

    • Remedial action.
    • Punitive action.

    Punish

Return to Contents

Slide 8. Systems and Behaviors Work Together To Improve Outcomes1

Both system design and behavioral choices have an effect on patient safety. Learning systems, like mission, values, and expectations, affect system design and in turn, behavioral choices. These inputs also influence the accountability and justice of the environment to bring about improved outcomes.
  • System Design.
  • Mission, Values, and Expectations.
  • Behavioral Choices.
  • Improved Outcomes.
  • Learning Systems.
  • Accountability and Justice.

Return to Contents

Slide 9. Accountability

Video icon.

Vignette still.
Click to play.

Return to Contents

Slide 10. Engineering System Design to Support Behavior Choices1

Text Description is below the image.
  • Punitive Culture: Transparency is impossible.
  • Blame-Free Culture: No accountability.
  • Just Culture: Optimally supports a system of safety.

Slide 11. Leadership Team's Role in Applying Just Culture Principles

Text Description is below the image. Image: Two senior executives standing next to each other.
  • Have a procedure in place for employees to follow.
  • Ensure employees are properly trained.
  • Offer positive reinforcement at the monthly Learning from Defects meeting.

Return to Contents

Slide 12. Debrief on Accountability

Video icon.

Image: Vignette still.

Return to Contents

Slide 13. CUSP Toolkit Modules

Text Description is below the image.
  • Learn About CUSP.
  • Assemble the Team.
  • Engage the Senior Executive.
  • Understand the Science of Safety.
  • Identify Defects Through Sensemaking.
  • Implement Teamwork and Communication.
  • Apply CUSP.

Return to Contents

Slide 14. CUSP Toolkit Review

CUSP Toolkit Review.

Return to Contents

Slide 15. Assemble the Team

Text Description is below the image. Image: Team members standing together.
  • Address the importance of the CUSP team.
  • Develop a strategy to build a successful team.
  • Identify characteristics of successful teams and barriers to team performance as identified in TeamSTEPPS.
  • Define roles and responsibilities of CUSP team.

Return to Contents

Slide 16. Keys to Assembling the Team

Text Description is below the image.
  • Understands that patient safety culture is local.
  • Composed of engaged frontline providers who take ownership of patient safety.
  • Includes staff members who have different levels of experience.
  • Tailored to include members based on clinical intervention.
  • Meets regularly (weekly or at least monthly).
  • Has adequate resources.

Return to Contents

Slide 17. Engage the Senior Executive

Text Description is below the image. Image: Two senior executives standing together.
  • Identify characteristics to search for when recruiting the senior executive.
  • Describe the responsibilities of the senior executive.
  • Explain the role of the senior executive in addressing technical and adaptive work.
  • Explain how to engage the senior executive and develop shared accountability for the work.

Return to Contents

Slide 18. Keys to Engaging the Senior Executive

Text Description is below the image. Image: A provider and a senior executive standing next to each other.
  • Acknowledge the senior executive's perspective ("What's in it for me?").
  • Increase the visibility of your senior executive.
  • Ensure a senior executive is assigned to each CUSP team and participates regularly in meetings.
  • List identified safety issues in the Safety Issues Worksheet for Senior Executive Partnership or a tracking log.

Return to Contents

Slide 19. Understand the Science of Safety

Text Description is below the image. Image: Team members examining an x-ray image.
  • Describe the historical and contemporary context of the science of safety.
  • Explain how system design affects system results.
  • List the principles of safe design and identify how they apply to technical work and team work.
  • Indicate how teams make wise decisions when there is diverse and independent input.

Return to Contents

Slide 20. Keys to Understanding the Science of Safety

Text Description is below the image. Image: Team members in a conference room watching a video.
  • Develop a plan so all staff on your unit view the Understand the Science of Safety video.
  • Video screening should be mandatory for all unit staff.
  • Create a list of who has watched the video.
  • Describe the three principles of safe design:
    1. Standardize.
    2. Create independent checks.
    3. Learn from defects.

Slide 21. Identify Defects Through Sensemaking

Text Description is below the image. Image: Team members discussing a patient's fall after slipping on water left on a hallway floor.
  • Introduce CUSP and Sensemaking tools to identify defects or errors.
  • Discuss the relationship between CUSP and Sensemaking.
  • Show how to apply CUSP and Sensemaking tools.
  • Discuss how to share findings.

Return to Contents

Slide 22. Keys to Identifying Defects Through Sensemaking

Text Description is below the image.
  • CUSP and Sensemaking share several common themes.
  • CUSP and Sensemaking tools help teams identify defects and identify ways to deter them from occurring in the future.
  • The team should:
    • Share summaries of defects within the organization.
    • Engage staff in conversations to enhance Learning from Defects.

Return to Contents

Slide 23. Implement Teamwork and Communication2

The communication that takes place between two people risks exposure to many roadblocks between its transmission from one individual to another. First, the message is encoded, or created, by the sender, who then transmits the message to the receiver, who then must decode, or process, the message. While the message is being transmitted, it may be exposed to barriers that may muddy the context and clarity of the message as it is sent and received.
  • Recognize the importance of effective communication.
  • Identify barriers to communication.
  • Describe the connections between communication and medical error.
  • Identify and apply effective communication strategies from CUSP and TeamSTEPPS®.

Return to Contents

Slide 24. The Keys to Effective Communication3

Text Description is below the image. Image: TeamSTEPPS logo and penguin.

  • Complete.
  • Clear.
  • Brief.
  • Timely.

Return to Contents

Slide 25. Summary

Text Description is below the image.
  • A Just Culture is a system that holds itself accountable, holds staff members accountable, and has staff members who hold themselves accountable.
  • A Just Culture environment is ruled by both transparency and accountability and supports improved outcomes by emphasizing both robust systems and appropriate behaviors.
  • Use the Just Culture principles along with the CUSP principles involved when assembling the team, engaging the senior executive, identifying defects through Sensemaking, and employing teamwork and communication.

Slide 26. References

Text Description is below the image.
  1. Griffith, S. Just Culture. Plano, TX: Outcome Engineering; 2011.
  2. (Adapted from) Dayton E, Henricksen K. Communication failure: basic components, contributing factors and the call for structure. Joint Commission Journal 2007;33(1):36.
  3. Agency for Healthcare Research and Quality. TeamSTEPPS Fundamentals Course: Module 6 Communication. http://teamstepps.ahrq.gov/abouttoolsmaterials.htm Accessed August 18, 2011.

Return to Contents
Return to Index

Current as of August 2012


Internet Citation:

Apply CUSP. Text Version of Slide Presentation. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/cusptoolkit/7applycusp/slapplycusp.htm


 

AHRQAdvancing Excellence in Health Care