New Patient Safety Improvement Toolkit Builds on Clinical Best Practices, Science of Safety


Hospitals taking part in a national project funded by the Agency for Healthcare Research and Quality (AHRQ) recently reported some exciting results: Rates of potentially deadly central line-associated bloodstream infections (CLABSI) had dropped by 40 percent.


By Carolyn M. Clancy, MD

Hospitals taking part in a national project funded by the Agency for Healthcare Research and Quality (AHRQ) recently reported some exciting results: Rates of potentially deadly central line-associated bloodstream infections (CLABSI) had dropped by 40 percent. As any clinician working to reduce infections knows, improvements of this magnitude dont occur on their own. 

By following the Comprehensive Unit-based Safety Program, or CUSP, hospital teams at more than 1,100 adult intensive care units (ICUs) achieved and sustained these outcomes. The drop in CLABSIs is also estimated to have prevented more than 2,000 CLABSIs, saved more than 500 lives, and avoided more than $34 million in healthcare costs.

Now, with the four-year project coming to a close and as work to prevent other healthcare-associated infections (HAIs)  ramps up, AHRQ and our key project partners from the American Hospital Association and Johns Hopkins Medicine are eager to spread the word about CUSP. Beyond its demonstrated benefits for CLABSI, CUSP can and should be used by infection control staff, nurses, physicians, hospital executives, and allied health professionals to achieve similar results for a wide range of patient safety improvement efforts.     

The CUSP Toolkit
To help clinicians and healthcare organizations realize this goal, AHRQ has developed a CUSP toolkit ( that includes training tools and resources to be used at the unit level. It is based on CUSPs use of clinical best practices and incorporates an understanding of the science of safety, improved safety culture, and a strong focus on teamwork. 

Created by clinicians for clinicians, the toolkit is divided into seven core educational modules, which can be modified to meet the needs of individual units. Each module includes facilitator notes, slides, videos linked from the slides, and tools. Videos feature interviews with clinicians who have used CUSP to achieve specific patient safety goals. The modules help clinicians:

Learn About CUSP: The introductory module provides a brief history of the CUSP model and shows how CUSP can support other quality and safety tools.  It also discusses the effects of errors and patient harm and demonstrates how to apply the toolkit in a clinical environment.

Assemble the Team: This module addresses concepts that address the importance of teamwork and team composition. A variety of strategies are presented to help build an effective CUSP team, define roles and responsibilities of team members, and identify characteristics of successful teams and barriers to team performance.

Engage the Senior Executive: This module focuses on the role of the responsibilities of the senior executive within the CUSP team. Engaging a senior executive partner with a unit helps to bridge the gap between senior management and frontline providers and facilitate a system-level perspective on quality and safety challenges that exist at the unit level.

Understand the Science of Safety: Understanding system design and safe design principles are important concepts in improving patient safety.  This module helps clinicians analyze patient safety as a science, with the goal of providing patient-centered care on their hospital unit.

Identify Defects Through Sensemaking: Sensemaking refers to a systematic approach to patient safety event reporting. CUSP and Sensemaking use similar tools that help clinicians systematically identify defects or failures and develop plans to prevent harm from occurring.   This module helps clinicians identify recurring defects at the unit level and apply CUSP and sensemaking tools to reduce the potential for patient harm.

Implement Teamwork and Communications: Communicating effectively and working as team members are proven elements in preventing and reducing errors. This module emphasizes their importance yet acknowledges that working conditions typical in many healthcare organizations can create communications barriers. By isolating and identifying the relevant tools from CUSP and TeamSTEPPS®, a teamwork system designed by AHRQ and the Department of Defense for healthcare professionals, clinicians can learn to improve communications and teamwork across the unit. 

Apply CUSP: The final module in the toolkit examines the principles of Just Culture, which emphasize shared accountability and attitudes toward risk and human behavior.  It also reviews the elements of the CUSP toolkit, highlighting key principles of each.

A Focus on Nursing
CUSP recognizes that nurse managers are often the leader of their units, and in that role, can profoundly influence the units culture and ability to embrace change. To illustrate how nurse managers can work with their unit staff to initiate new policies that achieve quality improvement goals, the CUSP toolkit includes a separate module targeted to nurse managers.

This module includes a video that examines how Abbey, a nurse manager, and her team approach the issue of lowering the rate of patient falls and near falls on the hospitals geriatric unit.  Abbey and the team discuss several potential interventions, including:

Educating patients and their families about fall prevention
Taping an outline of the patients walker in the area where it should be kept
Making sure that the nurses call button is within easy reach of the patient
Entering information about a patients fall risk into the electronic health record (EHR)  

Discussions among staff also reveal why certain interventions already in place on the unit, such as information entered into the patients EHRs, have not reduced the units fall rates. (Answer: The data in the EHR wasnt routinely checked or updated by staff).

Brief video segments then examine how the nurse manager and staff working together can better prioritize, implement, and monitor each of the interventions. Interactions between the nurse manager and staff members illustrate how the nurse manager enhances the performance of the team through mentoring, encouraging professional development, and representing the unit staff within the hospital. 

AHRQ is currently developing additional CUSP modules to help prevent ventilator-associated pneumonia, surgical site infections, and obstetrical complications and to help engage patients and families in the patient safety process.

Teamwork in Developing CUSP
The creation of the CUSP toolkit reflects an ongoing commitment by AHRQ to generating evidence-based improvements through a teamwork approach. AHRQ helped generate the evidence base for CUSP through its funding of the pioneering work of Peter Pronovost, MD, PhD, vice president for patient safety and quality at Johns Hopkins Medicine. He was motivated to make fundamental improvements in patient safety following the tragic death of an 18-month-old patient at Johns Hopkins Hospital in 2001.   

CUSP to reduce CLABSI was successfully implemented in more than 100 Michigan ICUs between 2003 and 2005; a study published in the New England Journal of Medicine in 2006 found that dramatic drops in CLABSI were sustained for 18 months.  A subsequent analysis showed that these reductions were sustained for up to two years. Following the Michigan ICU results, the use of CUSP to reduce CLABSI was expanded to 10 states, and then nationwide by AHRQ through a contract to the American Hospital Associations Health Research and Educational Trust.

AHRQ is currently developing additional CUSP modules to help prevent ventilator-associated pneumonia, surgical site infections, and obstetrical complications and to help engage patients and families in the patient safety process.

With the positive results of the national implementation of CUSP for CLABSI now in the public domain, AHRQ is eager to translate the wisdom of this patient safety improvement protocol even further. 

The CUSP toolkit combines the evidence-based research on the science of safety with a practical understanding of the unique cultures in which clinicians practice. As reducing patient safety events becomes a greater financial imperative to healthcare organizations, the CUSP toolkit can help clinicians target their pressing patient safety improvement challenges and undertake them with confidence and commitment. 

Carolyn M. Clancy, MD, is director of the Agency for Healthcare Research and Quality (AHRQ) in Rockville, Md.


  1. Agency for Healthcare Research and Quality.  AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent.  Sept. 10, 2012.  Available at:

  2. Agency for Healthcare Research and Quality.  CUSP Toolkit.  Available at:

  3. Agency for Healthcare Research and Quality.  CUSP Toolkit.  The Role of the Nurse Manager.  Available at:
4. AHRQ Patient Safety Network.  Pronovost P, Vohr E.  Safe Patients, Smart Hospitals: How One Doctors Checklist Can Help Us Change Health Care From the Inside Out. Hudson Street Press; 2010. 

  5. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU.  N Engl J Med. 2006 Dec 28;355(26) 2725-32.

6. Lipitz-Synderman A, Needham DM, Colantuoni E, et al. The ability of intensive care units to maintain zero central line-associated bloodstream infections. Arch Intern Med. 2011 May 9; 171(9):856-8.


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