ICU Monthly Team Checkup Tool

CARDIOVASCULAR SURGICAL TRANSLATIONAL STUDY (CSTS)

Hospital______

Unit______

Month______Year______Data Not Collected for this period.

SCIENCE OF SAFETY TRAINING 1. Since you began participating in the project, what portion of your staff have viewed a science of safety video or presentation?

Please Circle: your own the Peter Pronovost version

None/few □ Under ½ □ ½ □ Over ½ □ Almost All/All □

2. Is the Science of Safety video or presentation now part of new staff orientation for your unit? (This new staff orientation should include all providers such as physicians, nurses, and respiratory therapists.)

Yes □ No □

STAFF SAFETY ASSESSMENT 3. Did you survey staff about how the next patient might be harmed (two question survey)? (It is important to note that the Staff Safety Assessment should be administered at the start of the project and as needed thereafter.)

Yes □ No □ No, but we used a different method to assess how the next patient might be harmed □

3a. If you checked Yes for having administered the Staff Safety Assessment, were safety issues grouped and prioritized?

Yes □ No □

Please answer the following questions with respect to the last month only: IMPLEMENTATION OF CUSP TOOLS 4) Please indicate the CUSP activities in which your team participated last month by checking all that apply.

No Planning Pilot Implemented stage testing a) Morning Briefing □ □ □ □ b) Daily Goals □ □ □ □ c) Observing Rounds (i.e., A fly on the wall) □ □ □ □ d) Culture Checkup Tool □ □ □ □ e) Shadowing Tool □ □ □ □ f) Barrier Identification and Mitigation Tool □ □ □ □ g) Learning from Defects □ □ □ □ h) Structured Communication tools, e.g., □ □ □ □ SBAR, DESC, ALEEN

5. Last month, how many times did your CUSP team meet?

(Please enter #.)

IMPLEMENTATION OF CLABSI REDUCTION STEPS 6. What portion of the time do staff on the unit consistently use the following?

Never/Rarely Under ½ ½ the Over ½ Almost the time time the time All/All a) Appropriate hand hygiene □ □ □ □ □ b) Use of chlorhexidine in a back □ □ □ □ □ and forth motion for skin preparation c) Full-barrier precautions during □ □ □ □ □ the insertion (maintaining a sterile field) d) Avoiding the femoral site for □ □ □ □ □ placement e) Removing unnecessary lines □ □ □ □ □ f) Monitoring of line insertion by a second provider who is not □ □ □ □ □ placing the line g) Violation of line insertion protocol □ □ □ □ □ h) Halting line insertion if protocol □ □ □ □ □ is violated i) Use of a line maintenance protocol □ □ □ □ □

8. If there was an infection in the last month, was a full investigation of causes conducted?

Yes □ No □

IMPLEMENTATION OF SSI REDUCTION STEPS

(section to be added later)

IMPLEMENTATION OF VAP REDUCTION STEPS

(section to be added later)

SENIOR EXECUTIVE PARTNERSHIP 9. Last month, how often did your senior executive meet with your CUSP team regarding this ICU CUSP project? (Please enter #.)

10. Please indicate the type of data shared with your senior executive partner last

month by checking all that apply:

Yes No a. ICU SSI infection rates □ □ b. ICU CLABSI infection rates □ □ c. ICU VAP infection rates □ □ d. Findings from the Staff Safety Assessment □ □ e. Data from the Hospital Survey of Patient Safety for ICU □ □ staff f. Other quality improvement/patient safety initiatives □ □ g. Learning from defects stories □ □

11. Last month, how often did your senior executive review your unit’s ICU performance

data (please enter #)? DATA REVIEW AND SHARING 14. Last month, did your CUSP team have a chance to present your unit's performance data (on CLABSI, SSI, VAP, barriers faced or audit/process data) to either of the following entities? (Check all that apply.)

Ye No s a. Senior hospital/health system leadership □ □ b. Senior hospital/health system board of □ □ directors?

15. How often did your CUSP team review ICU performance data last month? (Please enter #.)

16. How often did your CUSP team share your performance results broadly with ICU staff last month? (Please enter #.)

Nursing Physicians___

17. In the last month, did the team identify a patient safety defect?

Yes □ No □

17a. If yes, did the team work through a process to learn from the defect?

Yes □ No □

17b. If yes, did the team share findings with others?

17b1. Yes, it was shared within the unit □ No □

17b2. Yes, it was shared outside the unit □ No □ BARRIERS TO PROGRESS 18. Last month, did any of the following slow your CUSP team's progress? (Check all that apply.)

Under ½ ½ the Over ½ Almost Never/Rarely the time time the time All/All a) Insufficient knowledge of □ □ □ □ □ evidence supporting interventions b) Lack of team member □ □ □ □ □ consensus regarding goals c) Not enough time □ □ □ □ □ d) Lack of quality improvement □ □ □ □ □ skills e) Not enough buy-in from □ □ □ □ □ physician staff members in your area f) Not enough buy-in from □ □ □ □ □ nursing staff in your area g) Not enough buy-in from □ □ □ □ □ other staff in your area h) Staff Turnover on unit □ □ □ □ □ i)Turnover on CUSP team □ □ □ □ □ j) Confusion about how to □ □ □ □ □ proceed with CUSP activities k) Burden of data collection □ □ □ □ □ l) Not enough leadership □ □ □ □ □ support from executives m) Not enough leadership □ □ □ □ □ support from physicians n) Not enough leadership □ □ □ □ □ support from nurses o) Insufficient □ □ □ □ □ autonomy/authority p) Competing priorities or □ □ □ □ □ distractions (e.g., new EMR, accreditation visit,) q) Inability of team members □ □ □ □ □ to work together