Assess and Adapt: Understanding the Science of Safety and Reliability (June 3, 2014)

AHA – Chicago
June 3, 2014
Onboarding Webinar 5
12:00 PM CT

Operator: The following is a recording of the Paul Tedrick Onboarding Webinar 5 call with the American Hospital Association on Tuesday, June 3, 2014 at 12:00 p.m. Central Time. Excuse me, everyone. We now have all of our speakers in conference. 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 the procedure to follow if you would like to ask a question. I would now like to turn the conference over to Ms. Janine Reisinger. Ms. Reisinger, you may begin.

Janine Reisinger: Hi, everyone, and welcome to the fifth webinar of the Onboarding Series. We're excited to have you with us on today's call which is focused on understanding the science of safety and reliability. Before we begin today's presentation, just a quick reminder that today's call is a webinar, so please be sure to log in to the webinar link in order to see the slides. A copy of the slides and the recording will be posted on the project website later this week. Today's presenter is Dr. Lisa Lubomski, an Assistant Professor in the Quality and Safety Research Group Department of Anesthesiology and Critical Care Medicine and the Johns Hopkins University School of Medicine. She has over 25 years of experience in clinical outcomes and health services research. Without further ado, it's my pleasure to introduce Dr. Lubomski.

Lisa Lubomski: Thanks, Janine, and thanks, everyone, for joining the call today. It's a real pleasure to be here with you. And so, Janine— thanks, Janine. So, on today's call we're going to talk about some things that are pretty central to the work that you're going to be doing in this project, as well as any other quality improvement of patient safety efforts that you might undertake at your institution. So, we're going to hopefully define the need for creating reliability, describe the comprehensive unit-based safety program, or (0:02:04 indiscernible)—I'm sorry, I work on a project, it's CUSP—as an intervention that improves the reliability of health care delivery and patient outcomes. And then finally, I hope that you'll understand and be able to discuss the why and how of the first step of the comprehensive unit-based safety program, which is understanding the science of safety. Could I have the next slide please?

So, I think it's apparent to all of us on the call today that health care can be a very dangerous proposition for our patients who come to us seeking care. I think of it, it's often very easy for us to lose sight of, just as a threat that can be posed by exposure to the health care system, especially in the hospital. So what this slide here really shows is if you look at the top, there are fewer than one deaths per 100,000 encounters in nuclear power, railroads, and airlines. There's one death in less than 100,000 to more than 1,000 encounters—I'm sorry, I can't read, can I? So, driving and chemical manufacturing are safer than encounters in the health care system. And if you look at this last piece of the slide here, health care has the dubious distinction of being up there with bungee jumping and mountain climbing with respect to the number of deaths there are per encounter with the system. So, it's not without its risks, although I think that sometimes the risks are not standing up to those of us in health care delivery. Can I have the next slide?

So, when we think about it a little further, we wonder how can this be when we can see that there have been advances in medicine that have led to incredible outcomes, improvements in childhood cancers. When I was in graduate school and when AIDS was first discovered and labeled as an entity, AIDS was a death sentence. And now, we all know due to improvements in medication and care, it's a chronic disease. And the life expectancy of my grandparents and my parents was not as great as the life expectancy that I enjoy. So, we've made great advances that have really made considerable and substantial improvements in the health care population. But when you stop to think about that, aside from that, we also leave sponges inside patients' bodies after operations. So there's kind of a conflict here between the great advances that we've made and the distance that we still have to go to make care safer. Could I have the next slide?

So, when we think about defects in the health care system, depending upon which day do you look at, approximately 7 percent of patients will have a medical error that involves a medication. On average, every patient who's admitted to an intensive care unit has or suffers an adverse event. Between 44,000 and 99,000 people die in hospitals each year as a result of errors in the delivery of care. We know that over half a million patients develop catheter-associated UTIs and that they result in approximately 13,000 deaths each year. When we put that in the bigger picture, nearly 100,000 patients die in our hospitals from healthcare-associated infections, and the cost of those HAIs is about $28 billion per year. And when we think about CLABSI, there's an estimated 30,000 to 62,000 deaths from central line-associated bloodstream infections per year. So, those encounters that patients have in our hospitals, in our ICUs, on our medical and surgical wards, are not without exposure to risk on their part. Could I have the next slide, please, Janine?

So, how do we solve these problems and what do we do? And there's many of you on the call. Now, there are many solutions that have been proposed to this problem. There's CUSP, there's the IHI Model for Improvement, Six Sigma, (0:06:37 indiscernible) lean and the Toyota production system. There are considerable ways to attack this problem and it can be difficult to know exactly what to do and how to start. Janine, could I have the next slide?

They all sort of center at one level around improving safety culture. And we all hear about improving safety culture and how important it is that we do that in our institution. But I want to point out to you that safety culture is not— the need to improve safety culture, that is, is not unique to health care. This headline from The Baltimore Sun from 2003, it's focusing on the results of the congressional inquiries into the Columbia accident. And one of the things that they said that they found after they did their investigation was the safety culture at NASA was partially to blame for the occurrence of that event and the failure of the NASA and its engineers and other employees to fix the problem with o-rings that we now know led to the loss of the Space Shuttle Columbia. So I think that what that shows us can be rather humbling when we think that we're not alone, and we have so much to learn, and there are many other groups that can learn from us, but in addition, we can learn from many other groups as well. Could I have the next slide please?

So this slide, what do we mean when we say ‘safety culture'? This slide shows the percent agreement to which a variety of providers across intensive care units, labor and delivery units, and surgery, or the OR, agree that their teamwork in— that the teamwork in their clinical area is above average. On this slide here, the gold bars represent nurses or CRNAs rating the collaborative environment dispositions. And the question is asking is that teamwork above average. And the red bars indicate where physicians are rating the teamwork that they have with their nursing or CRNA colleagues. And as you can see when you look at this slide, there's a big disconnect across a variety of care areas with respect to the extent to which nurses or CRNAs agree with physicians about the teamwork that is evidenced by their colleagues. Can I have the next slide, please?

So, we know that when we fail to have a culture that works on teamwork that that results in errors in the delivery of care, and also results in poor communication that influences those errors and also influences the teamwork, and the collegiality, and the communication within our units. So, as we used to think about it, all of those things will undoubtedly affect your team's ability to implement those goals of the CAUTI project. And those goals are here on this slide. What we'd like to see is to have a reduction in average CAUTI rates in each participating unit by 25 percent. And the steps that your teams are asked to take to achieve that goal is to educate the health care workers in your clinical area about the appropriate management of urinary catheters, including the indication for their placement and their continued use. We want you to prevent the placement of unnecessary urinary catheters and to promptly remove urinary catheters when they are no longer needed for the patient's care. Could I have the next slide, please?

This slide shows a model to improve care that we'll be using in this project. It's a model that was developed at Johns Hopkins and that we've used successfully across a number of clinical problems now: CLABSI, we have a project that is to reduce surgical site infections, ventilator-acquired conditions, the CAUTI project, and some others. And so, on the right-hand bar, or I'm sorry, the left-hand bar here is translating evidence into practice. And what that step of this process really refers to is summarizing the evidence in a checklist or in a policy or a procedure. We know that many guidelines can be quite long and difficult to sift through, and so Dr. Saint and others have summarized the evidence for the goals of the CAUTI project so that your team does not have to. Importantly though, we know that your team needs to identify local barriers to the implementations of those guidelines. We do not think that—if we thought that creating a checklist or a policy and procedures would instantly result in the reduction of CAUTI rates because it would immediately be taken up, supported, and used by all of the caregivers in your area, we wouldn't have much of a project. So, we know that in many places in health care that's simply not the case, and that implementation of the guidelines and of the work that you need to do to reduce CAUTI, it has barriers both large and small within your clinical area. And the identification of those barriers that are specific to your clinical area is key. You're going to measure performance with the data that you'll be collecting. We need to know where we start and we need to know where we end, because that's really the only way that we can gauge the effectiveness that our methods are having. And finally, it's important to ensure that all patients get the evidence by engaging, educating, executing, and evaluating. How that all works is it works in tandem with the comprehensive unit-based safety program, because what CUSP allows teams to do is it provides you with a framework, tools, and ways of thinking and working that talk about the adaptive or the teamwork aspect of putting the CAUTI bundle into place. And what we're doing there is making sure that your team has the help it needs to be successful in this endeavor as you do this work. On today's call, we're really going to talk about the number one there in red that says ‘educating staff on the science of safety,' but you can see CUSP is a five-step process. Could I have the next slide?

So how do the CUSP and CAUTI interventions dovetail here? And as you can see, you have your care removal intervention and your placement intervention (0:13:54 indiscernible) culture next to CUSP. And what this says is if you think back to the slides that we just previously saw, I don't know if you realized, there was a little cyclical sort of an arrow at the bottom of the slide. And CUSP and implementing the CAUTI interventions and the CUSP interventions and tools is a hand-to-hand process that supports each other and supports the ability of your team to put all this in place, and to work to create a culture within your unit if you don't already have one that improves teamwork and communication, that values that input from all of the team members, and that results in improved outcomes for your patients. Could I have the next slide, please?

So what is CUSP? It's the comprehensive unit-based safety program. And as I said, it's an intervention to improve teamwork and safety culture, and also to learn from mistakes. And there's a URL here at the bottom of this slide that will refer you back to the CUSP toolkit on the AHRQ website to a variety of projects now, beginning with the national On the CUSP: Stop BSI project. HRET, professionals at Johns Hopkins and at other places around the country have been working on improving CUSP, tightening it up. There are some excellent video presentations that were developed that are available to you on that website that you can use to train your team as well as yourself on the steps of CUSP. And I encourage you to bookmark this URL on your computer. Could I have the next slide, please?

So we know from all of the work that we've done in those various arenas that CUSP results in significant improvements for the teams that adopt it and successfully put it in place. We know that there's improved engagement between staff and the senior leadership within hospitals. We know also that there's improved communication among the members of the health care team. It helps in the development of shares mental models in the providers who work in clinical areas where CUSP has been rolled out. And as we think about using the same mental model and learning to think in very similar ways, and approach problems, it's stuff that is really key to improving patient care, but can be a tough nut to crack, and CUSP can help you to do that. Your team will improve its knowledge and awareness of potential hazards and barriers to the safety of patients, and perhaps also team members in your clinical area. And finally, it helps to develop a collaborative focus on systems of care. It is a systems-based project or program, and teaches us to look at how the way the care is organized affects and influences the occurrence of errors. Could I have the next slide, please?

So, here we are. This is the symbol that AHRQ uses for the CUSP program. And as you can see, the little piece of the puzzle there that's moved down at the bottom is understanding the science of safety, and that's what we're going to talk about today. Could I have the next slide, please?

So the science of safety is really built on three premises. The first is that every system is perfectly designed to achieve its end result. So when we think about how things happen in health care and why things happen in health care, when we stop and we look at the way that our systems of care are organized, we realize that that organization and that way that those systems are put together really either hinders or helps the occurrence of adverse events and poor patient outcomes. There's the principles of safe design, which I'll talk about in a few minutes, are key, and they need to be applied to both technical work. And technical work here is the work that we know how to do. So if you think about a couple slides ago I showed you the objectives of the CAUTI project and I showed you the steps that your team needs to take to put that in place, which is the care and removal intervention and the placement intervention for the urinary catheters that are placed in patients in your clinical area. And that's technical work. It's work that we know how to do. We know that if we do those things as the guidelines suggest, we will reduce the occurrence of CAUTIs in our patients. But how do we get there? We get there by improving teamwork, by improving communication, and by changing the values, attitudes, and behaviors of the clinicians who work in our areas, that increases the chances and improves their compliance, if you will, with the technical work that we know we need to do. And finally, that teams make wise decisions when there is diverse and independent input, and I'll talk more about that in a few slides. Could I have the next slide, please, Janine?

So this slide here is taken from the work of Charles Vincent, and it shows you as a nice little funnel diagram what systems— what we mean specifically when we start talking about system factors. And you can see here that systems range from everything from the way that your corporate structure is organized to the way your corporate structure interacts with all of the levels below it, and well as how those levels interact back. Regional factors such as you may have specific state, county, or municipal laws and regulations that govern the way that things must be done, or how you report. Whether there are a lot of hospitals in your area or whether there are few hospitals in your area, another important factor that influences how care is delivered. They are critical. There's factors of your work environment. Do you work in a brand new hospital with nice spacious rooms where there's plenty of room for equipment that the patients may need as a result of the provision of their care? Or do you work in an older facility where things might have been retrofitted, but where the rooms are small and cramped, and where it's difficult to put all of the equipment into a room? Or I even know in some hospitals because of the age of the hospital and the pipes, et cetera, that bring water, for instance, up into patient rooms, that sometimes we ask our— we use bottled water because the water may not be safe. So work environment. Team factors, factors of the individual providers, training, education, the factors that influence the tasks that we're asked to do, and finally, down to patient characteristics such as health literacy, acuity So all of these things, all of these factors affect the way that the care is organized, but they also affect our response to that organization, and these are the things that we need to learn to see and to respond to as we seek to make care. Could I have the next slide, please?

So, this is the famous Swiss cheese diagram that you may have seen before. It comes from the work of James Reason who's one of the great speakers in the area of how system factors relate to the occurrence of errors across a variety of industries, not just health care. And as you can see here, we can think of these pieces of Swiss cheese as being the elements of the care process, some of which are exactly as we would want them to do, and some which may have holes in them. And those holes represent here the negative aspects of the system factors and the way the care is organized, that if allowed to line up perfectly as being shown in this slide, lead to the occurrence of perhaps an error or a near-miss. And we can see here that on the far right-hand side we have the hazards and on the far left-hand side we have the losses. And when those hazards are aligned and are able to overcome whatever, if it's a workaround, if it's a policy, a procedure, then bad things can happen. Could I have the next slide, please?

So, one of the ways that we work against this is by applying the three principles of safe design when we're putting together and structuring our care processes. So the first is to standardize when you can, and especially for key processes, to create independent checks, again for key processes, and very importantly, to learn when things go wrong. So we're very good at recovering when things go wrong, but we're not always that good at learning about why events occurred and what we can do to prevent the future occurrence of negative things that happen in our environment. Could I have the next slide, please, Janine?

So this slide says ‘eliminate steps,' and it's a way of standardizing if you think about it, and it's also a way of learning when things go wrong. So, I don't what the age range is of providers on the call. Certainly when I first got my first ATM card, this is the kind of an ATM that I used. And you can see there on the right-hand side that there's that slot that you put your ATM card in so that you could get your money, or make a deposit, or whatever it was that you were there to do. Well, one of the things that— the way that they used to work was that you'd put your card in and it would stay there for the duration of your transaction. And then when your transaction was done, the machine would release your card and push it back out of that little slot. And if you think about it now when you go, you take your card, you either swipe it or if you're using something like this you put it in the slot and you pull it back out immediately so that the card is really not leaving your hand. And one of the reasons that the ATMs we use now are like that is because this particular design resulted in many people leaving their ATM cards behind after they had completed their transaction so that their ATM cards were lost. And as a result of that, it actually— what was supposed to be a benefit to the banking industry of (0:25:17 indiscernible) transactions actually starts to become fairly expensive because of the expense of people who had lost their ATM cards needed to get new ATM cards, new PINs, and all of the issues that went along with that. So, by eliminating that step of having to remember to take the card out, the banking industry learned from the mistakes that it had made in the design of the ATM machine, and we, the customers of the banking system, learned from our mistake of leaving our ATM card in the machine, and now we're forced to use it in a way that prevents that from happening. Could I have the next slide, please?

The next— as I said, it's standardizing. And this picture represents the line cart at the Johns Hopkins hospital. I think this is the MICU, but I'm not sure. One of the things that Peter Pronovost and colleagues found when they first started to do the work that resulted in the CLABSI bundle was the checklist tells you what you need in the way of supplies to place the central line. What they found though as they were trying to understand what was taking place in their clinical environment was that the supplies that they needed to put that central line in were not all located in the same area within the unit. So if they needed a full-length drape, and they needed a mask, and they needed a cap, et cetera, they might have to go to a number of places to get all of those supplies. And as a result, not likely doing this in any way, but realizing that they had to make a choice about whether to place the central line that was needed or whether to run around and try to find all of the equipment they needed and use up what they perceive to be precious time, that they weren't always using all of the equipment that was called for. So at Hopkins they created this cart, and in each of these drawers of the cart are the various supplies that are needed by the care team. You can see this person standing here in the garb that we would use when we're placing the central line. All of that equipment is now in that cart, as well as the other equipment that you need, the line itself, et cetera. One of the interesting things that they found about this was though that they created a cart, which is great, but they failed to identify who would be responsible for checking that cart periodically to make sure that all of the supplies that were supposed to be stored in it were in fact available. So it was kind of one of those (0:28:07 indiscernible) one step forward, two steps back. But eventually, they got it right, to the point now where I now that there are many hospitals in the United States that don't use a cart, they have kits where everything you need is in a kit. So it's really a nice kind of a one-stop shopping, if you will, experience where you have everything you need and you don't even have to remember the drawers, et cetera. So, standardizing is a very key way of making sure that we have what we need and that we know how to proceed with the task at hand. Could I have the next slide, please?

So the third piece is creating independent checks. And this is, as we know, a seatbelt, and I ask you to think about what happens when you get in your car and you go to drive, and you don't have your seatbelt on? We all know that there's that annoying ding and alarm that reminds us that we need to be putting our seatbelt on. Well when seatbelts were first introduced to the American public, the perception of the automakers and the National Transportation Safety Board was that people would use them, that the value of a seatbelt would be obvious on its face. And in fact, as we know, people didn't, and as we know, people still don't, although the number of people who use seatbelts has certainly increased as we created that independent check and made it more and more difficult to work around the alarm that we get when we don't put our seatbelt on. Could I have the next slide, please?

Janine Reisinger: I'll go back, sorry.

Lisa Lubomski: That's okay. Okay, so this is another way of— as we think about creating independent checks, so these are the evidence-based behaviors that we summarized, that we know are from the guidelines for how to prevent a catheter line-assosciated bloodstream infection when placing the central line. You can show me the next slide, please, Janine.

So, if we've thought about creating independent checks and the CLABSI insertion checklist was developed, it's important to understand whether the clinician— and it should say ‘clinicians,' because in most ICUs, et cetera, I have experienced lines being placed, it's usually two people. So, did they wash their hands? Was the procedure place properly sterilized based on the recommendations of the manufacturer of whatever— if it's chlorhexidine, whatever swabs they're using to sterilize the site. And was the entire patient's draped in a sterile fashion? During the procedure, were sterile gloves, mask, and a sterile gown used? Was a sterile field maintained? Did all of the personnel that assisted with the procedure follow the above precautions? And if they did not, and this is (0:31:24 indiscernible) a key part of the CLABSI bundle, where we started to do this work both on our own and then with HRET and our partners at MHA, we had a lot of people tell us that they used the CLABSI bundle. And then we asked them if the nurses or others on their unit were empowered to stop line placement if there was a violation, and very frequently we heard ‘no.' And one of the things that we know about this work is that if staff are not empowered to stop procedures if violation occurs, then they're not actually using the CLABSI bundle because that is a very key piece of that work. And as you do CAUTI, I think that there are very similar aspects to that work that kind of parallel this in a sense that on a daily basis we need to be asking whether the catheter is needed any longer, and are we actually taking that step to ask whether the catheter is needed, and making sure that we're advocating for our patient so that those lines come out when they're no longer needed by the patient or the care team. Could I have the next slide, please?

So also key to doing this work is (0:32:37 inaudible). Second-order problem solving, which takes it to the next step, this is fixing the system factors that allowed the problem to occur. I don't have to tell you that we in health care are very, very good at first-order problem solving. When our patients need something and it's not where we expect to find it, if it's not in our stores, for instance, we're very good at borrowing from other units, or perhaps even borrowing from other patients to get the things that we need. But we don't often go  that next step after we solve the immediate problem to saying well why is it that, for instance if it's linen, and all of the linen has been used previously, and you go to get clean linen and it's not there, why is it the case that there isn't an adequate supply of linen? Why is it that when we go to place a central line and there's a piece of equipment missing from the central line cart, how does that happen? And so, we need to take that extra step of learning when things go wrong. And you'll learn as you do this work to review incidents that occur on your unit, whether it's CAUTIs, whether it's other items that might be indicated by the members of your care team and your unit staff, to understand what the barriers are to implementing work that we need to do here, and what can we do to solve them. And what can we do to solve them using— considering system factors and how care is organized, so that we're not just having a workaround doing that first-order problem solving, but that indeed we have moved on to second-order problem solving, trying to really do our best to make sure that when the next patient needs clean linen, the clean linen will be there, not that we'll have to do a workaround because we know where all the stashes are kept. Could I have the next slide, please?

So, as I said, it's important to keep in mind the principles of safe design apply to both technical and teamwork. Could I have the next slide, please?

So, one of the challenges of creating that teamwork and communication that works really well is how we communicate with each other, as well as where we communicate with each other. This slide comes from the work of Elizabeth Dayton. If you haven't read it, I really do encourage you to read it. I think it really provides a really nice framework and understanding for where the pitfalls are in conversations across a variety of areas. And it doesn't just apply to health care. I think it's applicable to just about every area of life. But as we see here, this illustrates provider A and provider B both sending and receiving a message, and perhaps sending as well. So provider A here is the sender, and he or she has orders perhaps that they want to give, or a discussion about a patient's care. And as you can see by the sort of eye-shaped enclosure around provider A, so provider A sends the message. And provider A thinks that he or she— they're sending the message that they want to send and they believe that the words that they've chosen will be understood by provider B in exactly the way that they anticipate that they anticipate that they will be. But as you can see, there's sort of a channel here that our communication is going through, and it's influenced by a lot of things. The context in which providers A and B find themselves, background noise that may exist in the area. And it's not just the noise of noise that we hear, but it's also say the noise of interruptions, or the noise of multitasking, of the noise of the thousand other thoughts that we have in our heads about the things that we need to do on any given day. There's also our context of what is our training. We know that the scope of practice for physicians and nurses is different and we know basically that that's true across a variety of health care providers that work in our very sophisticated medical health care system these days. And we know that our communication, both the sending and the receiving, is influenced by that scope of practice, it's influenced by our education, our skill level, and the tasks that we generally do. So, always important as we're seeking to improve teamwork and communication to, first of all, ensure that we're speaking as clearly as we can, and when we're receiving messages to maybe check back and read back to ensure that we— to let the sender know that this is the thing that we received, is this really what you meant, so that we can provide clarifications and perhaps more information if needed to ensure that our communication is clear and conveys exactly what we want it to. Could I have the next slide?

So, one of the other key principals here is that teams make wise decisions when there is diverse and independent input. What that means for all intents and purposes is that very first line there, the wisdom of crowds. So as I said, we know that providers have different scopes of practice, they see the world in different ways by virtue of the jobs that we do, et cetera, so it's important then that we include involvement from clinicians at all levels of the organization when we seek to improve our care processes. Because it allows us to be open to and responsive to the variety of stakeholders that exist their context, the way that they think about things, and the way that their tasks are aligned. We need to alternate between convergent and divergent thinking, and we do that in health care a lot. We want to say what does everyone think and what will be our policy, procedure, and practice before we make our policies, and procedures, and practices. So, are we going to converge or are we going to diverge? Are we going to have a very limited scope of thinking this is the way we've always done it, or are we going to think about what the input from all members of the care team are to ensure that we've taken that into account and that it's reflected in the care that we provide? And finally, there's something that comes from the work of Ronald Heifetz that's talking about (0:39:38 indiscernible) from the dance floor to the balcony level. Sometimes we need to be on the dance floor when we're in the middle of everything and we can see what's going on, but we also as deciders, as team members, as people who are helping to make our policies and procedures, need to go to the balcony level to think about those system challenges. And it's really only as we step back from that, perhaps if you let me use the term chaos of the floor where we're providing care, to the systems-level thinking that we can come up with, processes, procedures, policies, checklists, et cetera, that reflect on the reality of patient care,  but from a systems-level analysis. Could I have the next slide, please?

So, the next thing— what we encourage you to do is to educate both yourself and your staff on the science of patient safety. You remember many slides ago there was that URL that will take you to a series of videos that have been created that take us through the steps of CUSP and the discussion of CUSP in some detail. Your CUSP team together should watch those videos and come to an understanding of what– as you do this work. I'm not necessarily saying you should look at them all at once because I think that no one has time for that, there are a lot of them. But it's important that over time as you do this work that you do educate yourself about CUSP. And that first step, science of safety, there's like a– it's about 22-minute video of Peter Pronovost talking about the science of safety, but really nicely also. The website provides the different modules, if you will, of that 22-minute video broken down into much smaller snippets that may be on a provider basis an easier tool to use to train. You could perhaps use the video to train on in a big staff meeting, or perhaps during a lunch and learn you could use the little snippets to move through the science of safety piece by piece to make sure that your team is getting that information, and that you're really also being able to have, I hope, a robust discussion about what that means and what it means on your unit.

This is an adaptive activity and training that is usually done prior to putting the technical work of the CAUTI project in place. And the reason for that is that it really does allow us to use— to develop and begin to use system lenses as we think about putting that technical work in place. You can complete the safety survey which would be the HSOPS is the Hospital Survey on Patient Safety to measure safety culture, which will help identify departments that may be at risk and that really need the science of safety based on their HSOPS scores as they move toward improving their culture. We encourage you to train your unit safety team, to develop action plans, and finally, have a partnership with senior executives in your institution, because we know that none of this work can be done without input from senior executives, and also without the knowledge, the access to resources that they bring with them. And also involving them on your team helps them to learn about what it means to make care safer. And given where they are in the hierarchical or administrative structure of your hospital, it helps to serve as a conduit also for this information, this way of thinking, and also the news about the work that's being done by your team, that it trickles up from your clinical area to the C-suite so that even up to the board level knows the work that's being done and the success that your team is having with this work. Could I have the next slide, please?

So, when we put CUSP in place as we've done across a variety of settings, we know that culture is local. So it's important that you learn from CUSP. CUSP is not something that you learn how to do overnight. It's not a very crystal-clear process and it can be a bit of a challenge, but a good challenge, to put it in place. We know that culture is local, so we suggest that when you start to think about CUSP, that you implement it in a few units, and perhaps that's a few units in your hospital where CAUTIs might be a particular problem if you have them. And then work on it. Get your processes down. Develop a team that uses CUSP (0:44:58 indiscernible) and understands its value. And then adapt and spread it out to other clinical areas in your hospital. As I said, given the thoughts about wisdom of crowds, it's crucial to include frontline staff on your recruitment team. We believe, based on the work that we've done, that improvement is not something that should be just done by managers, but that the most successful projects involve frontline staff because it gives them the opportunity to share what they know, and what they've learned about the care area, and the thoughts they have about how to make care safer. But it also lets them see the value of doing this work, because as frontline staff are engaged and involved, they begin to be able to see why this work is so important. It's not a linear process. In fact, CUSP is quite iterative, and that slide that I showed you with that cyclical arrow is really referring to fact that we may work on something, have problems perhaps, have issues, have to stop, identify the barriers, work on the solution, and then move forward. So we're always moving back and forth sort of between the technical work and the adaptive work of putting that technical work into place, as well as if we're implementing teamwork tools that work. So always working back and forth, focusing on both things, and trying over time to create lasting change. And it does take time to improve culture on the unit. For those of you who may be actively involved in, either now or in the past, in efforts to try to improve teamwork and safety culture, you know what I'm talking about. It takes a lot of work. Our cultures don't evolve overnight and they aren't cured overnight. CUSP, as we know, needs to be coupled with a clinical focus. As I said, CUSP can seem kind of esoteric. It's not something that people automatically grasp. But we also know that it's difficult to improve culture in and of itself. Having a clinical focus helps to provide a vehicle, if you will, for putting that culture change in place, and for allowing teams to see how by improving culture, teamwork, communication, we start to have success in improving our outcomes, how the two are hand in hand and both important. CUSP by itself I can tell you has been viewed as soft by many people. And so by pairing it with a clinical focus, it gives— as I say, that focus really helps us to realize that it may not be a hard edge, but improving teamwork and communication needs that, if you will, softer focus. And finally, we believe it is a vehicle for clinical change that can be used to and applied to solve the solution of any clinical problem that exists in your unit. Obviously, you and your staff need to take the time to learn how to implement CUSP successfully. But many units that have successfully implemented CUSP have been amazing results in improvements in teamwork and communication, and ultimately, in outcomes for our patients who come to us seeking care. Can I have the next slide, please?

So, when we think about this, we think about the principles of science of safety. It says important to accept that we will make mistakes. Health care is delivered by human beings and human beings are fallible. So as long as we need to keep in mind that fact and realize hat we will make mistakes. And so by developing system-focused organizations and policies and procedures, we both— excuse me, my allergies are kind of (0:49:28 indiscernible) right now. We accept that we'll make mistakes. We develop our processes so that we try to minimize the extent to which there's a loophole that will allow mistakes to occur. And we remove some of the blame and shame, or I hope all of the blame and shame, actually, that prevents us from making real system-focused change. We encourage people to speak up if you have concerns and to listen when others do. And that's a big piece of that wisdom of crowds is realizing that if you have a concern, it's important that our clinical areas allow us to speak up when we see something wrong, or when we have a question about something because we don't understand it or we think that it may result in harm. But then again, when others come to us with those similar issues, we need to understand and have the respect to listen to them as well. We need to create clear goals for our project, for our work, and as we do that, that requires that we ask questions early. From the start we should be asking questions about what the results of our processes will be, what are the results of our current processes, what do we need to change to make care safer. And finally, remembering that we need to standardize, create independent checks, and learn from mistakes as we seek to make care safer. Could I have the next slide?

So safety then is a property of systems. And I know I haven't had a chance to go into that fully here, but I think that when you listen to Peter Pronovost and others talk about this, it will become clear and I hope that you will do that. That we need lenses to see the system, and by doing the science of safety training, we begin to develop those lenses. And by learning to think about our problems in a systems kind of a way, the more that we use those lenses, the better they develop and the more flexible they become. We need to provide a safe space to allow others to voice what they see. That refers back to that kind of one of the nice (0:51:48 indiscernible) we have these days everywhere it seems is see it, say it. So we need to encourage people to know that if they have a problem, and issue, or a concern that they want to speak up about and that it's important to have them speak up about, that they have the freedom and the comfort to speak up without fear of retribution, or being yelled at, or any of the other negative things that sometimes are responses to members of our care team when they voice their concerns. CUSP is a structured approach that helps us to put those three first pieces in place and also to learn from mistakes and improve our safety culture. And again, educating on the science of safety is the first step of the Comprehensive Unit-based Safety Program. Could I have the next slide, please?

Finally, safety is a function of a system, and every system is designed to achieve its anticipated results. Another way of saying that, frequently you'll hear Peter Pronovost say is that every system is designed to achieve the results it gets. So if you don't like the results that you're getting in your clinical area, you need to start looking at the way your systems are organized. Again, those three principles of safe design, they apply to both teamwork and technical work, and that teams make wise decisions when there's diverse and independent input. Could I have the next slide?

So as we come to an end, what I'd like to have you do is I would like your action items from this call are first to have all your CUSP CAUTI team view the Science of Improving Patient Safety video. And I encourage you to do that in a meeting where you have adequate time to view the video, it's about 22 minutes, and talk about the information that's provided in that video. You also need to train all of the folks who work in your clinical area on the science of safety, and also think about how you will train new people who come to your clinical area. If you're an academic medical center or a center that has residents, how will your new residents that are going to come on at the end of this month be trained on the science of safety? New employees, same question. So, put together a roster for those on your unit who need to view the science of safety video so that you can make sure that everyone has viewed it. And then develop a plain that will allow all of your staff to view the Science of Improving Patient Safety Video. What technologies do you have available for staff to view them? Some places have DVD players, computers, like your intranet or the internet, other good places– ways that you can make this video accessible to your team. So, what do you have available and how can you use it? And then identify times that it might be easiest for you to get to your team to have them view it. So staff meetings, admin hours, like I said, lunch and learn. There are a lot of different ways that you can educate your staff. And I think if you especially think about what your clinical educators, nurse educators do, you have lots of ways that you train them on your unit about really important initiatives that they need to know about. I know one thing that we've done for some of our projects, something that we've encouraged, we'll go buy like $10 gift cards to Starbucks or something like that and have a raffle during the training session to try to encourage people to come, and then raffle off that Starbucks gift card at the end of the session so that we're providing some incentive, if you will, for the team to be there. However you do it, I hope that you will that this first next important step of educating both yourself and your team on the science of improving patient safety. And now, Chelsea, if there are any, we can open up the floor for questions.

Operator: Yes, ma'am. At this time, we will open the floor for questions. If you would like to ask a question, please press the ‘star' key followed by the ‘1' key on your touchtone phone now. Questions will be taken in the order in which they are received. If at any time you would like to remove yourself from the questioning queue, just press ‘star 2.' Please try to limit your questions to one at a time. Again, to ask a question, please press ‘star 1.' We're currently holding for questions.

Lisa Lubomski: As we're waiting for questions, I have another thing that I'd like to mention. Many of you may work in institutions that had teams that worked in the On the CUSP: Stop BSI initiative, and those units, I hope, still have the CUSP teams in place that they used to do that work. So one of the things that you might want to do is determine whether there's a CUSP team that already exists in your hospital and tap into the wisdom that they have from the work that they've done and hopefully are continuing to do with the CUSP process to understand how you can implement it on your unit to do the CAUTI work, and also how it can help you to overcome potential barriers that you may have as you seek to put this work in place.

Operator: Again if you'd like to ask a question, please press the ‘star' key followed by the ‘1' key.

Janine Reisinger: This is Janine. As well, if you do have questions at a later date, you can also email them into us. I put the email address in the discussion area. So you can email questions to onthecuspstophai@aha.org and we'll make sure they get to Dr. Lubomski.

Lisa Lubomski: Thanks, Janine. And also, I'd like to tell you that in the onthecuspstophai.org website, there are a lot of resources that are available to you, both for CUSP and for other aspects of this work that I encourage you to take a look and see what's there to help you as you put this real important work in place.

Operator: We're still holding for questions.

Lisa Lubomski: I guess if there are no questions— oh, sorry.

Janine Reisinger: No, go ahead, Lisa.

Lisa Lubomski: I was going to say, if there are no questions, I want to be respectful of everyone's time. We can end the call. And I know that Janine has something that she'd like to share with you before we do so.

Janine Reisinger: Great, thank you. Well, first I'd like to thank Dr. Lubomski for her presentation today. It's been very useful and important information on the science of safety, so thank you very much. And just a reminder before we end, please join us for the final onboarding webinar that's on June 18, and it's focusing on the emergency department improvement intervention. While this call is tailored for the EDs, all hospital unit teams are welcome to attend. Guest speakers include Marlene Bokholdt of the Emergency Nurses Association, Dr. Mohamad Fakih from St. John Hospital, Dr. Jeremiah Schuur from Brigham and Women's Department of Emergency Medicine, and Neil Pathak from HRET. Also, please remember to fill out an evaluation of today's presentation. The link is posted in the discussion area and we really do appreciate your feedback so we can continue to improve our onboarding series, and we thank you again for your presentation— for your participation in today's call. If there are no other questions, we wish everyone a happy and productive day.

Lisa Lubomski: Thanks, everyone, for joining us, and thank you for your work to make care safer for your patients.

Operator: Thank you. Ladies and gentlemen, this concludes today's teleconference. You may now disconnect.