On the CUSP of Culture Change
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On the CUSP of Culture Change | Patient Safety, Quality Improvement, CUSP, Comprehensive Unit-Based Safety Program, AHRQ, Agency for Healthcare Research and Quality, Pronovost, CLABSI, James Battles

Dr. James Battles
Making Patient Safety, Quality a Shared Priority

Mistakes happen.

For many years that was the conventional wisdom in healthcare settings, but innovative programming from the Agency for Healthcare Research and Quality (AHRQ) shows mistakes don’t have to happen if everyone is on board to make safety and quality a priority.

Learning More About CUSP

A basic CUSP toolkit is offered on the Agency for Healthcare Research and Quality website. The materials — which include videos, Word documents and Power Point displays — are available to download at no charge at www.ahrq.gov/cusptoolkit.


 WEB: www.ahrq.gov

(and specifically) www.ahrq.gov/cusptoolkit

James Battles, PhD, a social science analyst with AHRQ’s Center for Quality Improvement and Patient Safety, noted the Comprehensive Unit-based Safety Program (CUSP) is an example of how to change the culture to achieve dramatic results.

Battles, who has worked in the field since the mid-1990s, was focused on patient safety even before the landmark Institute of Medicine Report, “To Err is Human,” was released in November 1999. The report became a catalyst for the creation of intervention strategies to avert medical errors. A year after its release, Battles became the first expert hired by AHRQ to focus strictly on patient safety initiatives.

By 2001, AHRQ began funding the work of Peter Pronovost, MD, PhD, FCCM, the renowned patient safety advocate with Johns Hopkins. The roots of CUSP can be found within that early work. In 2003, a large-scale demonstration project for CUSP focused on CLABSIs (central line-associated blood stream infections) was underway.

The unique partnership between AHRQ, the Health Research & Educational Trust (HRET), Johns Hopkins University Quality and Safety Research Group, the Michigan Health & Hospital Association’s Keystone Center for Patient Safety & Quality and more than 1,000 U.S. hospitals yielded dramatic outcomes. Battles said the national program has resulted in a 41 percent decrease in CLABSI rates among participants.

“We’ve prevented nearly 500 deaths and averted nearly $36 million in costs … and that’s a conservative estimate,” Battles noted. Building on that success, other CUSP programs have been launched with similar results. The next, Battles noted, is a new national CUSP program in the area of labor and delivery. The Perinatal Safety Improvement Program is expected to roll out this fall.

CUSP is a strategic intervention that integrates communication, leadership and teamwork to create a culture of safety. The program utilizes evidence-based strategies and includes training tools, standards for consistent measurement, leadership engagement and methods to improve teamwork among physicians, nurses and others impacting the safety and well-being of patients.

“The CUSP model is designed for a unit of care, but that unit of care can be anything. CUSP itself is an intervention strategy, and then the areas where you apply it are the targets of CUSP,” Battles explained. Based on the success seen in demonstration projects, he continued, “We are ‘CUSP-izing’ everything.”

Previously, Battles said, the traditional approach to safety was to measure results … good or bad … and publish the information. “We miraculously thought just providing the information would lead to change.”

What’s different about CUSP is the level of engagement of the entire team … from housekeeping all the way up to the CEO. Battles noted that former U.S. Speaker of the House Tip O’Neill once famously said, “All politics is local.” That same premise applies to patient safety. “It’s going to be at the unit level,” he said of implementing real change. 

Half jokingly, Battles added, “In the past, we’ve anointed someone as the ‘infection control czar,’ and if it didn’t change, you’d take them out and shoot them.” However, that approach hasn’t been particularly effective. Instead, Battles said, “Everybody has to have a shared ownership of risk. If they don’t own that risk and don’t share in the solution, you’re not likely to change.”

To apply CUSP, the team looks at the area of concern, identifies the risks and begins to pinpoint solutions to avert or circumvent those risks. Through CUSP, the staff is educated on the science of safety and given the tools to utilize, such as checklists, to improve teamwork and processes. A senior hospital executive also partners with the unit to improve communications up the food chain so that the leadership is engaged in supporting the culture of safety.

Battles said the ‘unit’ could be anything … an ICU team, a med-surg floor, an ambulatory surgery center, or an entire skilled nursing facility. It could also potentially be broadened to include new methods of care delivery, such as ACOs, but might need to be tweaked a bit.

No matter the setting, using the principles of CUSP allows for a culture change and measurable improvement. “It can be done. That’s the good news … the really good news,” Battles said.

However, he cautioned, CUSP isn’t a magic bullet. “You’ve got to work at it, and you have to work really hard,” he said. “If you’re interested in improving patient care and delivering the best care to your patients, you can make improvements … and rather dramatic ones … but you’ve got to work at it, and everybody has to play.”

He concluded, “The amazing thing is when everybody does get on board and start to see the changes, it’s immensely satisfying because no one ever wants to cause a patient harm.”


Agency for Healthcare Research and Quality, AHRQ, CLABSI, Comprehensive Unit-Based Safety Program, CUSP, James Battles, Patient Safety, Pronovost, Quality Improvement

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