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On the CUSP: How to implement a comprehensive unit-based safety program


A groundswell of research and regulations followed the Institute of Medicine’s landmark 1999 report, To Err is Human: Building a Safer Health System. Leaders, clinicians, educators, researchers, and health payers continue to explore the possible causes of medical errors and preventable harm. A major challenge has been gaining insight into how teams, individuals, and unit cultures influence employees’ productivity and the delivery of high-quality care.

The Comprehensive Unit-based Safety Program (CUSP) provides a structure to support significant care improvements. This innovative program partners frontline staff, physicians, unit managers, and executive leaders to tackle patient hazards. A study of CUSP across Michigan intensive care units (ICUs) found it brought unprecedented reductions in central line–associated bloodstream infections (CLABSIs) as well as improved unit safety-climate scores. Similar results have been replicated in ICUs and organizations across the United States and abroad. Peter Pronovost, MD, PhD, brought CUSP to Johns Hopkins Hospital in 2001.

How CUSP works

CUSP is a five-step intervention. At its foundation is the work of unit-based teams guided by the wisdom of frontline caregivers to support early identification of system defects while empowering unit staff to identify risk-reduction strategies. The unique partnership between frontline staff and senior leaders is mutually beneficial: Staff benefit from the executive’s high-level decision-making, experience, and access to resources; the executive benefits from staff members’ invaluable insight into patient care.

The following scenario below shows how the impetus to create a CUSP might arise: Nurses on a 30-bed inpatient general medical unit that admits patients from multiple subspecialty services are frustrated over ineffective teamwork and poor communication. They express their feelings to Sallie, the nurse manager, telling her these problems are impeding their ability to provide safe care. They also state that their workloads seem to have increased.

Sallie holds a meeting with staff nurses, who say they don’t feel empowered to take steps to improve these problems. Recent unit safety-culture scores from a valid and reliable safety-culture survey validate their concerns. The scores show that staff think their safety concerns are being ignored and that nurses and physicians don’t work as a well-coordinated team.

Sallie takes these concerns to the hospital’s director of patient safety, who recommends starting a CUSP team on her unit. To get a sense of what CUSP entails, Sallie attends a CUSP team meeting on another unit. She comes away impressed with the safety work being done, team members’ relationships with the assigned executive, and staff’s engagement in the program. Heeding the hospital director’s advice, she forms a CUSP team on her unit by following a step-by-step implementation guide.

In the months leading up to CUSP implementation, much work must be done to ensure the program and team will succeed. Called pre-CUSP, this work can take weeks or even months to complete. While Sallie is eager to get the team started, she recognizes the importance of establishing a strong foundation for the program.

Pre-CUSP step 1: Assemble a core team

First, Sallie must assemble a core unit-safety team to implement, manage, and sustain the program. The core team should include a unit-based champion, nurse manager, physician champion, safety or quality officer, infection preventionist, and any other role relevant to that particular unit (such as a point-of-care pharmacist, respiratory therapist, or physical therapist). Sallie must ensure the team is multidisciplinary, includes professionals of different levels of training and experience, and allows members to join at any phase of the program.

Sallie selects Jamal as the unit-based champion. Jamal has been a nurse on the unit for 3 years, is respected by all staff members, has asked for more responsibility, and has shown an interest in problem-solving. Sallie realizes that giving him dedicated nonclinical time each week to work as the CUSP champion may increase the chance for success. Ideally, he should have about 4 hours each week to create a strong and sustainable program. When staffing demands prohibit providing this time, Sallie works with Jamal to ensure his additional duties don’t compromise patient care.

Sallie then approaches Lee, a physician who frequently admits patients to her unit, in the hope of recruiting her as the team’s physician champion. Respected by her peers, Lee is collaborative and an excellent communicator with good relationships with the unit staff. She recently helped the unit solve a patient-flow issue.

Pre-CUSP step 2: Choose an executive champion

The next task of the CUSP team is to work with hospital leaders to choose an executive champion. This executive should be a member of the senior leadership team who is able to meet with the CUSP team on the unit 1 hour each month and is approachable and comfortable with conversations on sensitive topics. This executive should receive an overview of CUSP and meet with unit leaders and the unit-based champion to get to know the unit.

Hospital leaders select Heon-Jae as the executive champion for Sallie’s unit. The hospital’s chief operating officer, he is highly skilled in communication.

Pre-CUSP step 3: Evaluate the safety culture

Evaluating the unit’s safety culture comes next. Understanding the context in which CUSP will be implemented is an important precursor to starting the program. The unit’s safety culture should be assessed rigorously using a valid, reliable instrument. Safety-culture questionnaires elicit frontline providers’ attitudes about various domains that link to safety.

Sallie measures her unit’s safety culture before implementing the first step of CUSP, and she uses the same instrument for periodic culture reassessments (recommended every 12 to 18 months). The hospital already measures safety culture every 18 months using a valid instrument. Her unit has had an excellent overall response rate (83%) from nurses, physicians, residents, case managers, social workers, technicians, housekeepers, and clerks.

Pre-CUSP step 4: Gather unit-based data

The last pre-CUSP step is to gather unit-based information for the initial meeting with the executive champion. The data should include the most recent safety-culture assessment results, bed size, staffing ratios, incident reports, patient-satisfaction scores, patient complaints, sentinel events, and available rates of preventable harm, such as CLABSIs, catheter-associated urinary tract infections (CAUTIs), venous thromboembolism (VTE), and ventilator-associated events.

Jamal works with Sallie to assemble this information. This is a general medical unit, so data are available for CLABSI, CAUTI, VTE, incident reports, patient satisfaction scores, patient complaints, bed size, staffing ratios, and safety-culture assessment scores. Jamal, Sallie, and Heon-Jae review this information before the unit’s first CUSP team meeting.

CUSP step 1: Educate staff on the science of safety

Because all team members must work from a shared attitude on safety, all unit staff receive science-of-safety training. Learning objectives are to:

  • understand that safety is a property of the system
  • acknowledge the basic principles of safe design—standardized work, independent checks (checklists) for key processes, and learning from mistakes
  • recognize that the principles of safe design apply to technical and team work
  • understand that teams make wise decisions when they receive diverse, independent input.

Sallie is overwhelmed as she tries to find training time for all the staff nurses, and she struggles during periods of high acuity and staffing challenges. Jamal identifies creative ways to gather the team to view online modules on safety training through the Agency for Healthcare Research and Quality website. He sends other team members the website link and instructs them to watch the brief video before the first team meeting next month. (Science-of-safety training is available at

CUSP step 2: Have staff members identify safety defects

Once staff members understand the science of safety and the principles of safe design, they are asked to identify defects that put patients at risk for harm. Various sources can be used to identify defects, including incident reports, liability claims, and sentinel events. Another important information source is the staff safety assessment, which asks all team members to respond to two statements:

  • Please describe how you think the next patient in your unit or clinical area will be harmed.
  • Please describe what you think can be done to prevent or minimize this harm.

Jamal asks each team member to complete this two-item assessment immediately after the science-of-safety training. He combines this data with the unit-based data he gathered during pre-CUSP step 4.

CUSP step 3: Partner with the executive champion

Heon-Jae, the senior executive, opens lines of communication, works to improve frontline providers’ attitudes about leadership, educates leaders about clinical issues and safety hazards, provides staff resources to mitigate hazards, and holds staff accountable for reducing patient risks. When he and the unit team hold their first formal meeting, they review the results of the staff safety assessment, set priorities for their work, and identify strategies to address the defects.

Before that kickoff meeting, Heon-Jae, Sallie, and Jamal gather to review survey results and unit-specific information. Heon-Jae is enthusiastic to start “fixing” the unit’s problems. Jamal reminds him that an important part of CUSP is involving staff in the process to prioritize the work, investigate defects, and find solutions. This is best accomplished in the first meeting.

First CUSP unit meeting

Some unit staff members attend the first meeting reluctantly, expecting the standard top-down approach. But they quickly realize the CUSP initiative is different: Leaders aren’t telling them what’s wrong or what they need to do to change. Instead, they’re asking staff nurses to describe the defects that worry them the most. To identify priority areas, Heon-Jae asks nurses what defects keep them up at night. The nurses identify several opportunities for improvement and choose the following as the issues they’d most like to improve over the next few months:

  • inconsistent communication with clinical services
  • nurses’ lack of participation in rounds.

The CUSP team and unit staff also find quick fixes for some longstanding problems. For instance, many staff members have been worried that one of the mounted TVs might fall and injure patients, visitors, or staff. So far, their requests to reinforce the TV have failed, but Heon-Jae makes a phone call, and repairs are made that afternoon.

Also, three near-misses have occurred over the past month due to confusion between oxycodone and Oxycontin, a timed-release formulation of oxycodone. These two drugs have been stored next to each other in the automated dispensing cabinet. After the CUSP meeting, the point-of-care pharmacist who attended the meeting promptly moves the drugs into separate drawers to prevent more errors. Also, the housekeeper present at the meeting describes a shortage of supplies to clean isolation rooms; Sallie agrees to increase the stock of these supplies by the end of the day.

CUSP step 4: Learn from defects

Group participation in investigating and addressing unit defects is an important component of CUSP. Staff are encouraged to learn from at least one defect per month. Some defects, such as those mentioned above, can be solved quickly. Others are more complex and require advanced tools to understand the systemic factors that contributed to them. (See the box below.)

Investigating defects

When investigating a defect that has occurred on the unit, staff examine:

    • what happened
    • why it happened
    • what they can do to reduce risk
    • how to determine that the risk was actually reduced.

A practical tool to guide team members through the process of learning from defects is available at

To illustrate a problem involving interdisciplinary communication, Jamal shares an event in which a patient suffered harm from a communication failure between nurses and physicians. Completing the learning-from-defects tool helped them understand the root causes and implement interventions to address them.

CUSP Step 5: Implement teamwork tools

To support the specific needs of unit-based teams, various tools are available to improve communication, clarify team members’ roles, and build skills to improve interprofessional team performance. For example, the daily goals tool provides a structured format to communicate a patient’s daily goals of care with the entire care team.

Jamal and Lee introduce the daily goals tool to the team. They customize the checklist to reflect the clinical needs of their patient population. Together, nurses and physicians develop a plan to ensure the patient’s nurse is included on rounds every morning. The nurse’s role includes initial patient presentation and outstanding concerns identified since the last rounding. Goals of care are recorded on a form that stays at the patient’s bedside, and are explained to the patient and family. The form is used during staff handoffs to ensure all care providers understand the care goals. (For teamwork tools, visit

Everyone gains

CUSP has led to improvements in safety culture and reductions in preventable harm. While it may look like a linear process with a beginning and an end, it’s cyclical. Each step is important to the success of the program and can be repeated periodically to address the dynamic, ever-changing healthcare environment.

Everyone gains from CUSP: Frontline staff are empowered to identify and learn from defects. Nurses can improve their quality-care and patient-safety skills and demonstrate leadership on their unit. Executives receive unique and meaningful insight into their organization’s operations. And patients get better care.

Selected references

Colla JB, Bracken AC, Kinney LM, Weeks WB. Measuring patient safety climate: a review of surveys. Qual Saf Health Care. 2005;14(5):364-6.

Holzmueller CG, Timmel J, Kent PS, Schulick RD, Pronovost PJ. Implementing a team-based daily goals sheet in a non-ICU setting. Jt Comm J Qual Patient Saf. 2009;35(7):384-8, 341.

Lin DM, Weeks K, Bauer L, et al. Eradicating central-line associated bloodstream infections statewide: the Hawaii experience. Am J Med Qual. 2012;27(2):124-9.

Marsteller JA, Sexton JB, Hsu YJ, et al. A multicenter, phased, cluster-randomized controlled trial to reduce central line-associated bloodstream infections in intensive care units. Crit Care Med. 2012;40(11):2933-9.

Pronovost PJ, Holzmueller CG, Martinez E, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf. 2006;32(2):102-8.

Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-32.

Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med. 2011;39(5):934-9.

Lori Paine is director of patient safety at The Johns Hopkins Hospital and Johns Hopkins Armstrong Institute for Patient Safety and Quality in Baltimore, Maryland. Melinda D. Sawyer is assistant director of patient safety at The Johns Hopkins Hospital and Johns Hopkins Armstrong Institute for Patient Safety and Quality.

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