AHRQ: CUSP – Scaling Up a Safety Framework

May/June 2013

CUSP: Scaling Up a Safety Framework


In the 13 years since the Institute of Medicine (IOM) issued its clarion call exposing major deficiencies in U.S. healthcare (2000), improving patient safety has been a foremost goal within our system. Providers, purchasers, consumers, payers, regulators, and other stakeholders have worked tirelessly together to formulate strategies to reduce needless harms (including needless deaths) resulting from care.

One of the priorities in improving patient safety has been the reduction and eventual eradication of healthcare-associated infections (HAIs). This has been an explicit goal of the Department of Health and Human Services (HHS) for several years. HHS’s National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination (n.d.) demonstrates the Department’s commitment to this goal. HHS and its agencies, including the Agency for Healthcare Research and Quality (AHRQ), have been working closely with states, providers, and relevant associations to promote safe practices in healthcare that will combat HAIs.

As befits an agency devoted to health services research, AHRQ leads research into practical ways that health systems can reduce HAIs and promotes the wide-scale implementation of proven methods for preventing these infections. A cornerstone of these efforts is the development of the Comprehensive Unit-based Safety Program, or CUSP, toolkit. As announced last fall, clinical teams in ICUs across the country used CUSP to reduce rates of potentially deadly central line-associated bloodstream infections (CLABSIs) by 41 percent (AHRQ, 2013a).

Quality improvement professionals understand that progress of this magnitude doesn’t occur on its own. It takes a concerted team effort grounded in science and supported by clinical best practices, all hallmarks of the CUSP framework. Regular readers of this journal may already be familiar with CUSP (Clancy 2011a; Clancy, 2011b), a structured strategic framework for safety improvement that integrates communication, teamwork, and leadership engagement with a checklist of evidence-based practices to create, support, and sustain a culture of patient safety. Yet even for those accustomed to seeing success, the results in CLABSI reduction were gratifying.

Using CUSP, hospital teams at more than 1,000 adult intensive care units (ICUs) not only reduced CLABSIs but also sustained these outcomes over time. Equally important, ICUs that already had low rates of infections were able to reduce their rates even further using CUSP. This initiative is estimated to have prevented more than 2,100 CLABSIs, saved at least 500 lives, and avoided more than $36 million in healthcare costs. In the neonatal ICU environment, the results were even better: an analysis of 100 NICUs in nine states showed a reduction of CLABSI by 58 percent, preventing an estimated 131 infections and up to 41 deaths and avoiding more than $2 million in healthcare costs (AHRQ, 2013b).

Clearly, CUSP works to reduce CLABSI rates in ICUs. But CUSP isn’t just a tool to tackle infections. CUSP has the ability to address any safety problem, and it can be employed in many settings of care to achieve similar results for a wide range of patient safety improvement efforts. Now, our challenge is to take this powerful tool to scale and apply CUSP principles to other areas where there are safety concerns.

A Toolkit to Aid Implementation
To spread the CUSP success as broadly as possible to providers who wish to implement CUSP themselves, AHRQ developed a CUSP toolkit, which includes training tools and resources to be used at the unit level. The toolkit is free and available for anyone to access on AHRQ’s website (www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/).

The toolkit helps clinical teams implement and sustain clinical best practices and incorporates an understanding of the science of safety, improved safety culture, and a strong focus on teamwork. Created by clinicians for clinicians, the toolkit is modular. Each module can be modified to meet the needs of individual units and includes facilitator notes, slides, and videos linked from the slides. Tools are incorporated into each module. Videos demonstrate desired behaviors and some feature interviews with clinicians who have used CUSP to achieve specific patient safety goals.

The modules of the core CUSP toolkit help clinicians:

  • learn about CUSP,
  • assemble the team,
  • engage senior executives,
  • understand the science of safety,
  • identify defects through “sensemaking,”
  • implement teamwork and communications, and
  • apply CUSP.

Each of these aspects is equally important, and the modules work in tandem with each other to present a clear total picture of how to implement CUSP successfully. Two of these modules may be of particular interest to quality improvement professionals.

The first of these is the science of safety. This module focuses on understanding that system design and safe design principles are important in improving patient safety. It helps clinicians analyze patient safety as a science, with the goal of providing patient-centered care on their hospital unit. This is important because the evidence base behind patient safety has improved markedly since the IOM galvanized the modern patient safety and quality improvement movements in the United States (IOM, 2000; IOM, 2001).

Another module of particular interest is the identification of defects through “sensemaking.” This term refers to a systematic approach to addressing patient safety events. CUSP and sensemaking use similar tools that help clinicians systematically identify defects or failures and develop plans to prevent harm. This module can build the capacity within clinical teams to identify defects or safety problems at the unit level and apply research-based tools to fix those issues and keep their patients safer.

Teamwork in Developing CUSP
A third module may also stand out: one that focuses on assembling the team. Teamwork is critically important in employing CUSP successfully. Not coincidentally, from its outset, CUSP itself has been very much a team effort.

AHRQ helped generate the evidence base for CUSP through its funding of the work of Peter Pronovost, MD, PhD, vice president for patient safety and quality at Johns Hopkins Medicine, who studied implementation science and how to deploy proven interventions at the unit level. CUSP then was applied on a large scale in the Keystone Project, which deployed this approach in more than 100 ICUs in Michigan from 2003 to 2005 in partnership with the Michigan Health & Hospital Association. A study of the Michigan project published in 2006 found that dramatic drops in CLABSI were sustained for 18 months (Pronovost et al.); a subsequent analysis showed that these reductions were sustained for up to two years (Lipitz-Synderman, 2011).

Following the Michigan ICU results, the use of CUSP to reduce CLABSI was expanded to 10 states, and then nationwide by AHRQ through a contract to the American Hospital Association’s (AHA’s) Health Research and Educational Trust. The AHRQ CUSP toolkit builds on the experiences and lessons learned from this national project.

CUSP’s principles can be broadly applied to a multitude of patient safety problems. Thus, with the positive results of the national implementation of CUSP for CLABSI now well known, AHRQ is eager to demonstrate the protocol’s benefit in other areas. AHRQ is currently adapting CUSP for application to other safety problems, such as preventing catheter-associated urinary tract infections, improving surgical safety in hospitals and ambulatory settings, and reducing obstetrical complications. The Agency is also developing additional modules on topics such as engaging patients and families in the patient safety process.

The CUSP toolkit combines the latest evidence on the science of safety with a practical understanding of the unique culture in which care is provided to patients. Providing safe, harm-free care has always been providers’ goal. Now, as financial incentives align with this moral imperative, organizations can focus on making the right thing to do the easy thing to do. The CUSP toolkit can help them target patient safety challenges and undertake them with confidence.

Carolyn Clancy is director of the Agency for Healthcare Research and Quality, Rockville, Maryland. She is a general internist and holds an academic appointment at the George Washington School of Medicine in Washington, DC. She may be contacted at carolyn.clancy@ahrq.hhs.gov.

Agency for Healthcare Research and Quality (AHRQ). (2013a, January). Eliminating CLABSI, A national patient safety imperative. Final report on the national On the CUSP: Stop BSI project. Rockville, MD: Author. Available at www.ahrq.gov/professionals/quality-patient-safety/cusp/clabsi-final/index.html.

Agency for Healthcare Research and Quality (AHRQ). (2013b, January). Eliminating CLABSI, A national patient safety imperative: Neonatal CLABSI prevention. A progress report on the national On the CUSP: Stop BSI project, Neonatal CLABSI prevention. Rockville, MD: Author. Available at www.ahrq.gov/professionals/quality-patient-safety/cusp/clabsi-neonatal/index.html.

Agency for Healthcare Research and Quality (AHRQ). CUSP toolkit. AHRQ, Rockville, MD: Author. Available at www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/.

Clancy C. M. (2011a). Eliminating CLABSI: Progress on a national patient safety imperative. Patient Safety & Quality Healthcare, 8(5), 6–7
Clancy, C. M. (2011b). What is your organization’s patient safety culture? Patient Safety & Quality Healthcare, 8(2), 6–9.

Dept. of Health and Human Services. (n.d.). National action plan to prevent healthcare-associated infections: Roadmap to elimination. Available at www.hhs.gov/ash/initiatives/hai/actionplan/index.html.

Institute of Medicine. Committee on Health Care in America. (2000). To err is human: Building a safer healthcare system. L. T. Kohn, J. M. Corrigan, & M. S. Donaldson (Eds.). Washington, DC: National Academies Press.

Institute of Medicine. Committee on Quality Health Care in America. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press.

Lipitz-Synderman, A., Needham, D. M., Colantuoni, E., et al. (2011). The ability of intensive care units to maintain zero central line-associated bloodstream infections. Archives of Internal Medicine, 171, 856-858.

Pronovost, P., Needham, D., Berenholtz, S., et al. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 355, 2725-2732.