So, as we move into the adaptive work, I want to talk about the program that we use here at Johns Hopkins and many other organizations around the world. In fact, I believe there are well over 1,000 CUSP units, and we have well over 400 CUSP units here at Johns Hopkins. It stands for The Comprehensive Unit-Based Safety Program. And as I mentioned earlier, it's one of the first programs that actually showed that when you implement and give power to frontline staff, that culture changes because you're changing the dynamic from top-down mandates to having people on the frontline do the work to improve. And I think that that was crucial in our success with both CLABSI and many of the other infection reductions or adverse event reductions that we've done, whether they be in adults or pediatrics. And it started out as an eight-step program. And you heard me say, "When we standardize, we want to reduce the number of steps." So, we're down to five steps. And the first is educate the staff on the science of safety. And the science of safety really is quite lengthy, and I'm sure you've heard it before. But really, what it's saying is that we inherit a bunch of risk factors, because we didn't design the workplace that we work in. And oftentimes, they were designed without frontline providers at all. So, there might not be adequate horizontal space in order to keep a sterile field while you're doing a dressing. And it also points out that in order to do a good job, the risk averse industries that we borrow from, they are nuclear power, aviation, the military, is that standardization is incredibly important. We want to standardize based on the evidence. We want to implement that independent check. And then lastly, like any high reliable organization, we want to focus on the defect. Because our goal is to eliminate preventable harm. The second step is identify defects. And we do that in a couple of different ways. They can come from risk management, they can come from our Adverse Event Reporting System. But we also ask our staff with a two-question survey, how do you believe the next patient will be harmed? And what do you think we can do to prevent that harm? The next step is partner with the senior executive. And you heard me say early on that, this is really about reducing hierarchy. Hierarchical structures may have had their day, and there definitely has to be a leader. However, that being said, being able to talk to somebody who's a president of the hospital or the ICU director or the CMO or the CFO is very important. Many of us don't even know the hierarchy of our hospital, we know a few people. What this program does is it pairs us with one of those senior executives. I'm a senior executive myself for the Harriet Lane Pediatric Clinic. And I don't know. I didn't know these people before I get there. I look to see what they have to show me every month. I look at their data. We address the concerns that they have. The nice thing about having a senior executive adopter unit is, they have experience throughout the hospital. So they are often the person that can tell you who you need to talk to when you're looking at change. They also are the person that might be able to see firsthand when additional equipment might be needed or why something doesn't work as well as we anticipated it would have. And it changes that dynamic. So instead of the president being the president or Dr. Pronovost being Dr. Pronovost, he's Peter. Peter Pronovost, the frontline staff. That hierarchy's reduced. Communication is better from top-down and bottom-up. So that the senior executives actually know what's going on on the frontline, so very important. And they can guide you. As I said, through some of the organizational pitfalls that every hospital has, and they can also get you in touch with people that you need to talk to. And again, like high-reliable organizations everywhere, we want to learn from our defects. We don't want it to happen, pay out a bunch of money and then let it happen again. We want to understand why it happened, what happened, and I believe in another module, you went through the learning from defect tool. That tool talks about the system factors responsible. But it also talks about the system factors that limited the negative effects of the adverse event. And our goal in the CUSP program is to learn from at least one defect a quarter. So, you're fixing four things a year. But what we've found is some of our most prolific CUSP teams can fix as many as 18 defects in a month. So there's not only the reduction of risks to your patients and to the staff, it builds autonomy and capacity because you have a bunch of frontline providers that now understand patient safety. They have the lens to see it. And they become problem solvers. And they are probably your next generation of patient safety experts within your organization. And then lastly, we develop tools because teamwork communication has always been an issue with Joint Commission, showing that sentinel events primary cause was communication. Teamwork issues have always been a problem. When you work on an adaptive work, you're trying to build your team. You're getting people to talk to each other. You're getting nurses to speak up. In fact, I'm going to show you the results of our program, that we would have never had the results we had, had our senior executives not supported the nurses ability to speak up, to make changes, and to let the hierarchy know whether it be the Dr. Pronovost or Dr. Edward Miller that a resident wasn't doing what they were supposed to do without any potential harm to their career. They were allowed and actually encouraged to speak up when they saw a problem or if they had a problem with providers. It also meant that we have tools that we use for teaching people to be assertive, teaching people to communicate better, people to direct how their day is going to be, the daily goals form which I talked about, which really is a way to make sure that patients getting everything that they need with the goal of moving them out of the ICU or if you're on the floor getting them moved out of the hospital as quickly as possible. And the focus of CUSP, as I said, this is allowing the frontline staff, and usually the team is composed of a nurse champion, a physician champion, and the frontline staff. And so instead of us, the mandates that we have that are federal and state mandates and quality improvement, their goal is to work on those. But their goal is to identify what needs to be fixed. And it's something that they're accountable to themselves for. So it's something that they do as a team. We don't do it to them, we don't make them. This is something that they want to do. And for every defect that they learned from, we share it broadly so that units aren't always doing the same work. If one unit has the same problem, we can share that within our organization. And we keep that information very close so that they can get as much done as possible. And the other thing is that CUSP been around for such a long time that it's not just for units. We have CUSP teams in sterile processing. We have CUSP teams in housekeeping. How do we improve care delivery here at Johns Hopkins? So, again, it is a program that builds autonomous providers to fix defects within their unit and to allow them to share and learn broadly. Again, this is something that usually people very enjoy and it does build capacity. So, we've seen our capacity building for quality and safety go up significantly here at Johns Hopkins. We have the Armstrong Institute which has well over 100 faculty members, and we have 80 some different staff members that are all working in patient safety and quality. And I still think that we need more. So, no matter how quickly we work, we have never run out of defects. So, there's always something that needs to be fixed. Our vision is really that we want our patients and family treated the same way that we want. We do not accept preventable untenable harm. It's never an option. There's always a way. And if you're learning from your mistakes, hopefully, that mistake doesn't happen so that you aren't having root cause analysis committees come together, make 12 recommendations and implement five, because the last maybe seven of them were too expensive to implement, where there's potential for that adverse event to occur again. The other thing is we don't settle. So, something isn't just good enough. Something has to be good. It has to positively impact our patient population. It has to improve the working conditions for our frontline providers. And it has to decrease the risk to both the frontline staff and to patients and their family. And, it goes on to say that one of the goals is that we're really looking for that safety culture excellence, and the ability to move ourselves forward as a unit. And this is measured using the hospital survey of patient safety or the safety attitudes questionnaire and there's a couple others out there. But really, what we want to see is continued growth to the top percentile, because those are the teams that can anticipate the needs of their other team members. They are the teams that are open to communication, and those are the teams that are more likely to teach you when you say, "Oh, I think that's wrong." And let's say, "You're right," instead of reproaching them, say, "Oh, I guess you didn't know. Let me show you. This is what the literature says." So, it's a group of people that really the vision is that they're there to learn about patient safety and to make a difference. And this is the component that we use for the adaptive work with our program. So, we implemented CUSP CLABSI as well as CUSP with many other programs, and we have CUSP teams, as I said, on well over 400 units. I think the other thing that we want to say is that we have a deep respect for the safety concerns of others. And that one of the things that we do in having this monthly meeting is that we keep things alive and each other resolved. And, we report out at every meeting with the status of what we're fixing until it's fixed. And again, it doesn't drop off, we maintain. So, it's the four E model with the embedded expanse. So, we embed the practice to make sure it doesn't happen again, and then we expand it to units that are still vulnerable. We keep an eye on our systems. So, remember the systems can be team level like, do you have adequate supervision when you're doing a new procedure, or if you're uncomfortable, do you actually seek supervision? The teamwork between different providers, the system factors, departmental factors, unit factors, like is there a protocol that guides my therapy? Do I have adequate lighting to perform what I need to perform in this room? All of those are very important to the quality of care. We see a defect as an opportunity to improve. And I'll say it one more time as any highly reliable organization should, you focus on it so that you can prevent it. Because these opportunities really make for a much stronger organization because we are, as I said, we've never run out of defects but it is rare that a defect reoccurs that we've addressed. And then lastly, the vision goes on to talk about the patient and family members. And through our core vision, we get patient and family feedback about what it's like to be on their floor and what are some of the things that they would find helpful. So there's no longer an exclusion. They can participate in rounds, and often, they are the person that knows the patient best. And we should benefit from their knowledge. So, it is kind of full circle. Eight steps to five where we were only healthcare providers that participated to now we are health care providers and patient and family. And all of that has been able to help us address the adaptive needs. So, in getting ready to close, I wanted to talk to you a little bit about our model to improve. So, we've talked about the CUSP CLABSI program, developing the technical evidence, and then what we had to do to get it to work, how we had to train our physicians, what the CUSP program does for us. And, so really, when you look at this, that whole big slide on the translating evidence into practice, those are the technical work. So, in the middle of reducing preventable harm for us in CLABSI, that was washing your hands, using chlorhexidine, site selection, making sure that you use maximum barrier of precautions. And then finally, that you take out the line as soon as possible.
