For Patient Safety and Quality

JHAH CUSP/CLABSI Team Registration Form

1. Name of hospital Johns Hopkins Aramco Healthcare (JHAH)

INTENSIVE CARE UNITS

2. How many ICU step-down units will be taking the HSOPS survey?

3. Name of each ICU and step-down unit and number of people who spend most of their work time in each ICU unit or step-down unit/work area? (Including nurses, physicians, technicians, support staff, administrators, and others who spend 60% or more of their work time working in this unit/work area) 4. Name of ICU or step-down unit (please Name of department (Critical Care, Number of people who spend 60% or specify) etc.) more of their work time in this unit/work area (this will be the denominator for this unit’s survey response rate)

CUSP/CLABSI PROJECT ADMINISTRATION For each ICU or step-down unit identify the following:

1. Nurse Manager  Supports CUSP process  Assigns project leaders to interventions  Manages resources  Assists in scheduling executive walk  Assures survey results are shared with rounds staff  May serve as the Unit Champion (will need 20% dedicated effort)   ICU/Step-down Unit  Nurse Manager  Email address                   2. Project Leader (Unit Champion)  Encourages unit staff involvement  Educates staff about CUSP  Obtains staff feedback ARMSTRONG

INSTITUTE Manages documentation of CUSP program; either paper-based forms or eCUSP project management tool  ICU/Step-down Unit  Project leader  Email address                  3. Physician Champion  Review and identify problems  Assist in implementation of interventions  Communicates with physician group as needed   ICU/Step-down Unit  Physician Champion  Email address                  4. HSOPS Coordinator   Helping coordinate the survey  Entering data about the work area(s) that administration process, will be completing the survey into the online  Participating in training webinars and survey database, conference call to learn how to use the online  Monitoring the survey response rate survey database, using the online survey database,  Informing clinicians and staff about the  Working with hospital and work area survey items and instructions; assisting them leadership to distribute survey materials and if they have questions about how to complete information, the online survey,  Communicating with other HSOPS Coordinators in the project.   ICU/Step-down Unit  HSOPS Coordinator  Email address                       5. Coach (optional) (usually a person with expertise in the CUSP process)  Mentors executive regarding his/her role  Contact person for questions in improving unit safety  Helps identify resources  Assists where appropriate in setting up  Helps when appropriate in documenting meetings findings and process  Assists in project management role  Trains to use eCUSP project management tool  ICU/Step-down Unit Coach Email address

6. Patient Safety Coordinator/Patient Safety Officer (optional)  May serve as a Senior Executive in some  Verifies surveys are analyzed and results institutions are reviewed in a timely manner  Coordinates executive orientation  Monitors progress  Assures coach is assigned (if CUSP expert  Helps to disseminate results and share available at institution) stories   ICU/Step-down Unit  Patient Safety  Email address Coordinator/PSO                