Everyone by now knows about Peter Pronovost’s famous checklist for reducing CLABSI’s (catheter-related bloodstream infections). Pronovost and colleagues worked with the Michigan Health and Hospital Association (MHA) Keystone Project on a multifaceted ICU patient safety/quality improvement collaborative. In 2006 they published their results on the impact on CLABSI’s (Pronovost 2006), demonstrating a dramatic reduction in the occurrence of CLABSI’s in the 18 months following the implementation. Last year they showed that the dramatic improvement was sustained for 36 months (Pronovost 2010).
But the MHA Keystone ICU project was about far more than CLABSI’s. It was a comprehensive program aimed at improving patient safety, engendering a culture of safety, and improving communication between providers. The two evidence-based initiatives included were the CLABSI project and one to reduce ventilator-associated pneumonia (VAP). Now the MHA Keystone ICU project has published more results, again demonstrating striking success. The first paper (Lipitz-Snyderman 2011) demonstrated a roughly 20% improvement in adjusted hospital mortality rates in the study group compared to a control group. The second paper (Berenholtz 2011) reported on the VAP outcomes. There was a 71% reduction in VAP rates that was sustained for at least 30 months post-intervention.
Since the MHA Keystone ICU project involved multiple interventions, the dramatic improvements cannot be attributed to one specific intervention. However, we think one of the secrets to success is the CUSP (Comprehensive Unit-Based Safety Program) approach. In our own experience the patient safety and quality improvement projects that are most successful are those done in relatively small settings where the key participants all know each other and work closely together as affinity groups. Contrast the striking successes of the MHA Keystone ICU project to the relative lack of success of a large scale organizational intervention on patient safety at several UK hospitals (Benning 2011a, Benning 2011b). In the UK project there seemed to be a disconnect between the frontline staff and the group overseeing the project.
For good descriptions of the CUSP model, see Pronovost 2006b and Timmel 2010. The CUSP model is also nicely described in Peter Pronovost’s book “Safe Patients, Smart Hospitals” (see our July 6, 2010 Patient Safety Tip of the Week “Book Reviews: Pronovost and Gawande”).
Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ 340:doi:10.1136/bmj.c309 (Published 4 February 2010)
Lipitz-Snyderman A, Steinwachs D, Needham DM, et al. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ 2011; 342:doi:10.1136/bmj.d219 (Published 31 January 2011)
Berenholtz SM, Pham JC, Thompson DA, et al. Collaborative Cohort Study of an Intervention to Reduce Ventilator-Associated Pneumonia in the Intensive Care Unit. Infect Control Hosp Epidemiol 2011; 32(4): 0000 published online February 17, 2011
Benning A, Ghaleb M, Suokas A, et al. Large scale organisational intervention to improve patient safety in four UK hospitals: mixed method evaluation. BMJ 2011; 342: doi:10.1136/bmj.d195 (Published 3 February 2011)
Benning A, Dixon-Woods M, Nwulu U, et al. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ 2011; 342: doi:10.1136/bmj.d199 (Published 3 February 2011)
Timmel J, Kent PS, Holzmueller CG, et al. Impact of the Comprehensive Unit-Based Safety Program (CUSP) on Safety Culture in a Surgical Inpatient Unit.
Joint Commission Journal on Quality and Patient Safety 2010; 36(6): 252-260
Pronovost PJ, King J, Holzmueller CG, et al. A Web-based Tool for the Comprehensive Unit-based Safety Program (CUSP). Joint Commission Journal on Quality and Patient Safety 2006; 32(3): 119-129
Pronovost P, Vohr E. Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out. Hudson Street Press 2010