FOCUS ON INFECTION PREVENTION Pennsylvania: On the CUSP of Measuring Infection Prevention Culture James Davis, BSN, RN, CCRN, CIC INTRODUCTION safety by everyone in every group at every Senior Infection Prevention Analyst level of an organization. It refers to the Pennsylvania Patient Safety Authority The Comprehensive Unit-based Safety Program (CUSP) is a structured, strategic extent to which individuals and groups framework with the intent of improving will commit to personal responsibility the culture of patient safety.1 The CUSP for safety [and] strive to actively learn, ABSTRACT methodology is flexible as it can be adapt and modify (both individual and applied to many patient safety issues. For organizational) behavior based on lessons The Comprehensive Unit-based Safety the purpose of this article, Pennsylvania learned from mistakes.”4 Safety climate is Program (CUSP) works to establish a Patient Safety Authority analysts have defined as “the temporal state measure safety climate through the establishment chosen to focus on cohort 2 of the On of safety culture, subject to commonali- of a unit-based culture of safety. The the CUSP: Stop Blood Stream Infection ties among individual perceptions of the second progress report on the national (BSI) project in Pennsylvania. The second organization. [Safety climate] is therefore On the CUSP: Stop Blood Stream Infec- progress report on the national On the situationally based, refers to the perceived tion project states that the pre- and CUSP: Stop BSI project exhibits results state of safety at a particular place at a post-CUSP implementation safety cul- from the pre- and post-CUSP implementa- particular time, is relatively unstable, ture survey showed little change upon tion Hospital Survey on Patient Safety and subject to change depending on the comparison. Instead, CUSP’s success (HSOPS). HSOPS was administered as features of the current environment or has been measured by a surrogate part of the project and showed little change prevailing conditions.”4 Climate refers to outcome (infection rate). When central pre- and postimplementation.2 Inter- environmental influence on culture, and venous catheters are in use, safe cul- ested in whether CUSP implementation culture is the behavior of the individual ture is evident in direct measurement improved safety culture in participating within the climate. CUSP’s intent is to of compliance with best practices, as Pennsylvania critical care units, Authority have the clinicians learn from mistakes, well as in device utilization ratio (DUR). analysts queried National Healthcare Safety thereby improving the culture of safety.1 The implementation of CUSP in cohort Network (NHSN) event data reported by The CUSP manual states that “culture 2 in Pennsylvania units has resulted in Pennsylvania hospitals in order to deter- is a major focus [of CUSP] because it improved compliance with best prac- mine compliance with best practices related represents a set of shared attitudes, values, tices and an 8% decrease in DUR from to CUSP implementation. Authority goals, practices, and behaviors that make baseline. (Pa Patient Saf Advis 2012 analysts found an increase in best-practice one unit distinct from another.”1 Fur- Mar;9[1]:23-6.) compliance possibly related to improved thermore, Bandura observed that “what safety culture in the CUSP group. people [clinicians] think, believe, and feel affects how they [clinicians] behave.”5 BACKGROUND Although the CUSP project may not have The intensive care unit project of the been able to statistically prove—as mea- Michigan Health and Hospital Associa- sured by the questionnaire—that a culture tion’s Keystone Center for Patient Safety of safety had been caused by CUSP, the and Quality (MHA Keystone Center) CUSP group did demonstrate a reduction achieved impressive results with clinical in central line-associated bloodstream interventions that mainly focused on infection (CLABSI) rates after CUSP central venous catheter (CVC) care. The was implemented, which may allude to MHA Keystone Center project recom- the presence of improved safety culture. mended evidence-based procedures for If CUSP methodology has influenced CVC insertion and daily goal sheets. how participants think, believe, and feel The MHA Keystone Center study also about safety culture, participant behavior implemented a comprehensive program toward compliance with best practices (CUSP) that sought to improve the related to CVC care would change. Can culture of safety in the units where data measurement of compliance with best- was collected.3 Zhang et al. have defined practice data reflect the prevalence of safety culture as “the enduring value and safety culture? priority placed on worker and public Vol. 9, No. 1—March 2012 Pennsylvania Patient Safety Advisory Page 23 ©2012 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION METHODS should be understood that each phase of cohort 2 units outperformed non-CUSP The Authority collects responses to com- CVC life would possess its own unique units in percent compliant with best pliance questions in custom data fields climate based solely on the culture of the practices both pre- and post-CUSP imple- through NHSN that can be used to gauge individuals involved in a CVC phase. mentation. Note the decrease in “blank” compliance in Pennsylvania hospitals. Noting the distinct differences between and “unknown” responses and the Cohort 2 of the On the CUSP: Stop BSI insertion and maintenance phases, Tables difference between the “no” and “yes” project was instituted by the Hospital and 1 and 2 speak to the culture associated fields post-implementation in the CUSP Health System Association of Pennsylvania with insertion. The ability to determine group, indicating better surveillance (HAP), the Health Research and Educa- CVC necessity (see Table 3) would be of compliance metrics, possibly due to tional Trust (HRET), the Johns Hopkins indicative of a quality-based system for CUSP climate. Furthermore, the CUSP University Quality and Safety Research tracking and surveillance of the line intervention took demonstrated high- Group, and MHA Keystone Center. post-insertion, transcending into the performers (as noted by preimplementa- Cohort 2 was chosen for analysis related maintenance phase of CVC culture. Cul- tion percentages) and pushed compliance to the availability of a complete pre- and ture (behavioral choices) associated with even higher. post-CUSP implementation data set that compliance with best practices would then Table 4 refers to the DUR of non-CUSP was inclusive of the Authority’s custom be measured by the answers associated units and DUR of CUSP cohort 2. data fields. The Authority’s data pull from with each compliance question. To fully Central line-days divided by patient-days NHSN was conducted on September 20, evaluate CUSP’s impact through a tradi- equals DUR. When considering the lower 2011. Baseline, or preimplementation, tional outcome metric, Authority analysts DUR in the CUSP group and the results data query started September 2008 and also examined the pre- and postimplemen- represented in Table 3, it would appear continued through August 2009. CUSP tation device utilization ratios (DUR) of anecdotally that removal of unneeded cohort 2 data query started in September each group. CVCs is a high priority in the CUSP 2009, and the data through June 2011 group. If compliance with best-practice was analyzed. September 2009 marks the RESULTS culture (removal of unnecessary CVCs) beginning of the postimplementation Tables 1, 2, and 3 show the responses to is in fact due to CUSP, there should be period. The tables break out baseline (pre- the individual questions that target com- a significant difference of differences in September 2009) and postimplementation pliance with best practices. Overall, CUSP proportions between the groups. (post-September 2009) data for both groups despite the non-CUSP group hav- ing had no direct intervention related to Table 1. Maximal Barriers on Insertion official CUSP participation in cohort 2. NON-CUSP CUSP COHORT 2 The best-practice compliance question Post- Post- fields included in the analysis are part of Baseline Implementation Baseline Implementation the NHSN CLABSI event report. The Yes 58.6% 67.2% 81.4% 91.5% responses to the questions have been No 1.7% 1.3% 0.7% 0.6% normalized and reflected as percentages Unknown 39.4% 31.1% 17.9% 7.9% for comparison between non-CUSP criti- Blank 0.3% 0.5% 0.0% 0.0% cal care units and CUSP cohort 2 critical care units. CVC insertion is a quick procedure Table 2. Chlorhexidine Prep Preinsertion performed by a group of providers that NON-CUSP CUSP COHORT 2 adhere to the culture of their practice. Post- Post- Maintenance of the line occurs over many Baseline Implementation Baseline Implementation hours to months and involves a host Yes 57.2% 64.8% 80.0% 84.8% of individuals (e.g., nurses, physicians, No 3.6% 2.7% 0.0% 0.6% caregivers, patients, families), all of whom have a culture in regard to causing or Unknown 38.3% 31.0% 17.9% 7.9% preventing the development of CLABSI.6 Contra- 0.6% 0.9% 2.1% 6.7% Therefore, given the distinct differences indicated between insertion and maintenance, it Blank 0.3% 0.6% 0.0% 0.0% Page 24 Pennsylvania Patient Safety Advisory Vol. 9, No. 1—March 2012 ©2012 Pennsylvania Patient Safety Authority The DUR for the CUSP hospitals CUSP manual through the statement: fail to comply with best practices based decreased from 34.4% to 31.1% (before “culture and quality improvement need to on process signals, allowing the experts CUSP implementation versus after imple- be linked.”1 If clinical change is evident to be informed of potential issues ahead mentation), which is a decrease of and positive, safety culture would be of time instead of waiting for an infec- 3.3 percentage points. Some of this reinforced; therefore, one should observe tion rate increase in order to investigate decrease may not have been due directly positive compliance (behavior) and better system defects. to CUSP, but may have in part been outcome rates would follow. Benner has At the unit level, compliance data should general cultural changes that were also observed that experts behave with the be collected at regular intervals. Systems experienced at non-CUSP hospitals. To future in mind, and that they consider can be designed to use snapshot data estimate this impact, analysts found that likely possibilities based on current data.8 depicted in SPC format of carefully chosen in non-CUSP hospitals, in the exact same Kunkel and Nagasawa note that “present best-practice metrics in order to gauge time period, the DUR decreased from circumstances provide information about safety culture. In addition, systems can 38.3% to 37.8%, which is a decrease of probable future events based on past be designed to make it extremely difficult only a half of a percentage point. There- experiences, and thus serve as signals for for those who function within them to fore, subtracting the general decrease of present behavior.”9 misstep; however, if someone does mis- 0.5 percentage points from the raw The challenge for those who wish to step, others within the system may then, 3.3 percentage points yields an estimated improve compliance will be to set the because of established climate, discourage impact of CUSP of 2.8 percentage points. circumstance (climate) that delivers cur- behavior that is not part of a safe climate. Analysts formally tested this 2.8% and rent data to bedside experts about their If there is widespread cultural deviance found it to be statistically significant using behaviors (culture) in regard to best or normalization of deviance, one would the Gaussian method described by practice in order to achieve desired future expect to see compliance data signals. Wallis.7 The decrease of 2.8 percentage events (outcome). CLABSI prevention is When the data signals for a particular points in DUR represents an 8% decrease at a unique juncture; many facilities can metric, action can be taken in order to in DUR from the baseline level of 34.4%. report CLABSI rates at or approaching correct the culture associated with the zero for individual units. How can one defect, normalizing compliance. Wiem- DISCUSSION have situational awareness, deliver current ken noted that “through adequate data The relationship between clinical change data, and intervene when the metric of collection and critical analysis of control (compliance with best practices) and monitoring outcome (infection rates) fails charts, the infection preventionist can culture is noted in the second CUSP prog- to be sensitive enough to address cultural detect aberrant data early, which allows ress report as “clinical changes require drift? If compliance with best practices for prompt intervention and mitigation of and reinforce changes in safety culture.”2 is monitored by way of methods like sta- any poor outcomes.”10 The importance of linking culture and tistical process control (SPC), infection Following similar methodology, Harpel quality improvement is stressed in the preventionists can identify behaviors that et al. decreased the incidence of CLABSI by redesigning the traditional intravenous Table 3. Daily Review of Central Venous Catheter Necessity team into a vascular resource team (VRT) whose duties included weekly audits of NON-CUSP CUSP COHORT 2 best practices related to CVC mainte- Post- Post- nance.11 Bedside nurses were educated Baseline Implementation Baseline Implementation by the VRT in central line maintenance Yes 53.4% 57.6% 72.1% 79.3% techniques. In addition, bedside nurses No 8.0% 7.4% 8.6% 12.2% and managers were provided with regular Unknown 38.3% 34.3% 19.3% 8.5% feedback on compliance audit data. When Blank 0.3% 0.7% 0.0% 0.0% best-practice compliance defects signaled via SPC, the infection preventionist and Table 4. Device Utilization Ratio (DUR) NON-CUSP CUSP COHORT 2 Baseline Post-Implementation Baseline Post-Implementation DUR (95% CI) 0.383 (0.382-0.384) 0.378 (0.377-0.379) 0.344 (0.341-0.346) 0.311 (0.309-0.313) Vol. 9, No. 1—March 2012 Pennsylvania Patient Safety Advisory Page 25 ©2012 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION VRT would investigate issues and mentor Aligning CUSP methodology, current of best practices. In the current climate of staff nurses in performing high-quality, evidence-based guidelines, and dedicated infection prevention, outcome has been evidence-based vascular access care. Harpel administrative support helps to set the the traditional measurement of success. et al. found that “compliance with central foundation of an effective program. Proactive intervention using process line dressing changes rose from 68% to Foundations, however, need to be built control data as telemetry of culture— more than 90%.” The authors also wrote: upon for the structure to be useful. rather than the traditional method of “This collaborative approach between the When epidemiological and compliance reacting to outcome (infection) rates—can bedside nurses and the vascular resource measurement are tracked through SPC, possibly hold the key to less CLABSI. team [which allowed for the optimum bal- it is possible to have current telemetry of Streed states that “outcome measurement ance of resources] led to a hospital-wide culture, which will enable activities for is at best a surrogate indicator of process reduction in CLABSI.” The VRT is an clinical change providing for actionable adherence, and that effective process example of a system that was created to defect mitigation. Continuous mapping control leads to predictable outcomes.”12 identify behavior, nourish a climate that of behavioral data from compliance telem- Outcomes need to be predictable in order supports competence, encourage cultural etry allows for balanced resources, thereby to know the risk to the patient in the compliance with best practices, and influencing and supporting the climate of designed systems. The future of infection achieve reductions in CLABSI. best future practice and effectively deflect- prevention will rely on the prevention- ing CLABSI from patients. According to ist’s ability to measure processes, predict Streed, “elimination of HAIs [healthcare- outcomes, and control processes with CONCLUSION acquired infections] requires this constant appropriate interventions that focus on System Framework investment of resources in terms of improving the culture of compliance. CUSP is a valuable framework providing enquiry, action, vigilance, and ownership strategies to increase sustainability.”12 ACKNOWLEDGMENTS a climate for the development of cultures Edward Finley, BS, Pennsylvania Patient Safety that are centered in, and supportive of, Authority, contributed to data acquisition and compliance with best practices, which is Rely on Outcome Metrics or validity in this article. Jonathan R. Treadwell, essential for the well-being of all patients. Process Control? PhD, ECRI Institute, consulted on and contributed CUSP is the centerpiece of a patient Control of process, or lack thereof, leads to statistical testing in this article. safety foundation that is essential for an to an outcome. There is value in the mon- effective infection prevention program. itoring of data points aimed at evaluation NOTES 1. Johns Hopkins Quality and Safety in the ICU. N Engl J Med 2006 Dec english-usage/staff/sean/resources/ Research Group, Michigan Health and 28;355(26):2725-32. comparing-x2-tests.pdf. Hospital Association Keystone Center 4. Zhang H, Wiegmann DA, von Thaden 8. Benner P. From novice to expert, excellence for Patient Safety and Quality. On the TL, et al. Safety culture: a concept in and power in clinical nursing practice. Menlo CUSP: stop BSI. Comprehensive unit- chaos? Proceedings of the 46th Annual Meet- Park (CA): Addison-Wesley Publishing based safety program manual. Agency ing of the Human Factors and Ergonomics Company; 1984:104. for Healthcare Research and Quality Society; 2002 Santa Monica (CA). Also 9. Kunkel JH, Nagasawa RH. A behavioral (AHRQ). 2009 Apr. Also available: available: http://www.humanfactors. model of man: propositions and impli- http://www.onthecuspstophai.org/ illinois.edu/Reports&PapersPDFs/ cations. Am Sociol Rev 1973 Oct;38(5): wp-content/uploads/BSImanualsTools/ humfac02/zhawiegvonshamithf02.pdf. 530-43. CUSPimplementation/CUSP_Manual.doc. 5. Bandura A. Social foundations of thought 10. Wiemken T. Statistical process control. 2. Health Research and Educational Trust, and action: a social cognitive theory. Engle- Chapter 6. In: APIC text of infection control Johns Hopkins University Quality and wood Cliffs (NJ): Prentice Hall; 1986:25. and epidemiology, 3rd edition. Washington Safety Research Group, Michigan Health 6. Davis J. Central-line-associated blood- (DC): Association for Professionals in and Hospital Association Keystone stream infection: comprehensive, Infection Control and Epidemiology; Center for Patient Safety and Quality. data-driven prevention. Pa Patient Saf 2009:6.1-6.10. Eliminating CLABSI: a national patient Advis [online] 2011 Sep [cited 2011 11. Harpel J, Reilly T, Hendler C, et al. safety imperative. second progress report Nov 23]. Available from Internet: http:// Transforming a team: a key to reducing on the national on the CUSP: stop BSI patientsafetyauthority.org/ central line-associated bloodstream infec- project [online]. 2011 Sep [cited 2011 ADVISORIES/AdvisoryLibrary/2011/ tions. Abstract at: SHEA Fifth Decennial Nov 2]. Available from Internet: sep8(3)/Pages/100.aspx. Conference on Healthcare-Associated http://www.ahrq.gov/qual/clabsiupdate/ 7. Wallis S. Comparing x2 tests for separa- Infections; 2010. Abstract No. 458. clabsiupdate.pdf. bility: interval estimation for the dif- 12. Streed SA. Metrics and management: 3. Provost P, Needham D, Berenholtz S, ference between a pair of differences two unresolved problems on the path- et al. An intervention to decrease between two proportions [online]. way to health care-associated infection catheter-related bloodstream infections 2011 Aug [cited 2012 Jan 5]. Available elimination. Am J Infect Control 2011 from Internet: http://www.ucl.ac.uk/ Oct;39(8):678-84. 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