In 2010, Pat Murray, CEO of Peterson Regional Medical Center in Kerrville, Texas, came back from a Texas Hospital Association meeting intrigued by what he had heard about a program to prevent deadly central-line associated bloodstream infections. Murray met with his senior team, including chief nursing officer Kaeli Dressler, then asked Theresa Hickman, an intensive care unit nurse educator, to lead the program's implementation because of her prior experience with it. Since starting the program, known as CUSP (Comprehensive Unit-based Safety Program), Peterson has gone 32 months without a CLABSI. Peterson is now spreading CUSP to all hospital departments and all employees.


Like Murray, you know that safety culture plays a critical role in mitigating harm, but you may wonder what tools are at your disposal to transform your institution's culture to make dramatic improvements in patient safety. The Agency for Health Research and Quality recently released the CUSP Toolkit, a science-based "change package" that helps hospital teams to identify safety problems, and provides them with proven tools to tackle these problems.

The concept behind CUSP was developed by Peter Pronovost, M.D., at Johns Hopkins Hospital with funding from AHRQ to prevent health care-associated infections in hospital intensive care units. In 2004, AHRQ funded a statewide demonstration in more than 125 Michigan ICUs using the CUSP patient safety methodology combined with evidence-based technical interventions.

AHRQ contracted with the Health Research & Educational Trust of the American Hospital Association in 2008 to implement CUSP nationally. HRET has worked with the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality and the Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality to apply CUSP to other hospital units and safety problems nationwide.

Results from CUSP Implementation

More than 1,100 hospital teams in adult ICUs in 46 states and territories participated in the national implementation project. Using CUSP, these hospital teams have reduced the rate of CLABSI by 40 percent. So far, the project has prevented more than 2,000 CLABSIs, saved more than 500 lives and avoided more than $34 million in health care expenses.

Though the CLABSI prevention bundle has been available to hospitals for some years, CUSP is different from other patient safety tools: It makes the science of safety relevant to clinicians by putting it in the context of a hospital environment and improving the overall culture of safety in a hospital unit. The technical intervention is readily accepted due to the culture change that CUSP promotes. CUSP offers effective strategies where care is delivered — at the unit level.

Interviews with hospital leaders from CUSP teams have identified CUSP as the methodology that has changed the culture in their units and is fostering a new way of thinking — that health care–associated infections are not an unfortunate consequence of care, but are preventable. The CUSP model teaches leaders and teams to embrace four Es: engagement (harm to patients is preventable), education (teaching the CUSP model and evidence-based practice), execution (applying CUSP and the technical intervention) and evaluation (measurement and learning from defects). New toolkit modules similar to CUSP are being developed to help make surgery safer and to reduce catheter-associated urinary tract infections and ventilator-associated pneumonia.

About the Toolkit


The CUSP Toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses and other clinical team members work together. It builds the capacity to address safety issues by combining clinical best practices and the science of safety. Created by clinicians for clinicians, the toolkit is modular and modifiable to meet individual unit needs. The teaching tools and resources support change at the unit level, with step-by-step instructor guides, slides and presentation materials, implementation tools such as checklists, and videos that simulate desired behaviors.

The CUSP Toolkit features patient safety resources to help improve teamwork and communication and to identify defects through sense-making, a deliberate process of reflection on failures and near misses. It contains nine modules with a description of the CUSP framework; instructions on how to assemble a team to improve a safety problem; background to help clinicians understand the science behind safety efforts; training to help front-line staff understand how to identify problems and take action; team and communication training to help team members work together better, including empowering staff to speak up when others take unsafe actions; guidance on how to apply CUSP; and tips on how to spread the CUSP process to other units of a facility.

Role of Senior Leaders


The senior executive's participation and engagement in this quality improvement initiative is vital to the success of the project. The "Engage the Senior Executive" module of the CUSP Toolkit focuses on the role and responsibilities of the senior executive within the CUSP team.

Engaging a senior executive to partner with a unit will bridge the gap between senior managers and front-line providers and will facilitate a system-level perspective on quality and safety challenges that exist at the unit level. Senior leaders who have been most effective in using CUSP to reduce HAIs and improve safety culture have invested the time to understand the key components of CUSP and have taken the CUSP component of senior leaders' engagement seriously. Review the CUSP Toolkit with other members of your leadership team; it is available at Pay particular attention to the module "Engage the Senior Executive."

The CUSP model has proven its worth in preventing HAIs, and hospitals are using CUSP successfully to address other patient safety concerns, such as falls and pressure ulcers. The CUSP Toolkit is an important resource to empower unit teams, when it is supported by engaged leadership, to improve safety culture and thereby save lives and resources.

Deborah Bohr, M.P.H., is a senior director of special projects at the Health Research & Educational Trust.