The CUSP Method
Causality Between Safety Culture and Infection Prevention
Establishing causality between safety culture and infection prevention has been examined by investigators, including Braun, et al.( 2021), who identified 13 papers that addressed the relationship between safety culture and IP & C processes, such as HAI prevention bundles, hand hygiene, and infection control structure. They found 20 papers that addressed the relationship between safety culture and HAIs, with most of the studies looking at CLABSIs, CAUTIs, VAPs, or SSIs either exclusively or as a combined outcome. They also found 22 articles that measured both IP & C processes and HAIs to address the relationship with safety culture, with most studies measuring process compliance with HAI prevention bundles, hand hygiene adherence or adherence to policy and guidelines.
As Braun, et al.( 2021) observe,“ The 55 articles reviewed varied considerably regarding purpose, design, safety culture measurement tools and respondent, and outcome( IP & C process and / or HAI) measurement, although several were based on the CUSP model. This heterogeneity contributes to the previously described challenges to linking safety culture, IP & C processes and outcomes. Nevertheless, most of the QI and research articles that measured safety culture and statistically analyzed the associations concluded that safety culture was positively associated with IP & C processes and negatively associated with HAIs. Thus, our findings are generally consistent with other reviews supporting the notion that an association exists.”
There are two competing take-aways from their findings, the authors say. On the one hand, study authors reported that culture did change, even if not measured in a quantifiable way. They said that they saw or felt a culture change which was integral to the effectiveness of the improvement effort. As Braun, et al.( 2021) explain,“ It is quite possible that culture did improve in certain domains because of the increased attention of leadership, extra resources, incentives, and momentum to drive change. Awareness and attitudes about the preventability of HAIs likely changed through education, and a sense of teamwork likely improved through the shared experience of working toward a common, measurable goal. This notion is highly consistent with the multi-faceted CUSP approach to improvement initiatives.”
On the other hand, Braun, et al.( 2021) say that some research studies with the strongest methodologies( such as large numbers of sites, multiple outcomes, and longitudinal design) did not find an association between safety culture, IP & C process, and HAIs. For example, Meddings, et al.( 2017) suggest that improvements in HAIs occurred by means other than improving safety culture, such as a strong emphasis on standardizing technical components of care, and that changing safety culture may not be critical to improvement. Alternatively, they also suggest that safety culture may have improved and been instrumental in improving outcomes but could have been inadequately measured. In response, others have argued that the conclusions drawn by Meddings were unrelated to the instrument and inadequately supported by the methods and analyses.
As Meddings, et al.( 2017) confirm,“ Contrary to our hypothesis, there was no significant association between safety culture as assessed by the HSOPS with CLABSI or CAUTI outcomes when either measured at baseline or in follow-up, in two national collaboratives that were successful in reducing these infections. An important implication of this result is that it is possible to reduce CLABSI and CAUTI rates without improving safety culture, through improvements in technical components of care such as standardizing procedures involving catheter insertion, maintenance and removal. This interpretation would prompt reconsideration and prioritization of technical and safety culture components of interventions in future studies,
The CUSP Method
The Comprehensive Unit-based Safety Program( CUSP) is a method that can help clinical teams make care safer by combining improved teamwork, clinical best practices, and the science of safety, according to the Agency for Healthcare Research and Quality( AHRQ). The Core CUSP toolkit provided by AHRQ gives clinical teams the training resources and tools to apply the CUSP method and build their capacity to address safety issues.
An infection reduction project of the Michigan Health and Hospital Association Keystone Center for Patient Safety proved that CUSP was successful in improving the safety culture. In 2003, the Michigan
The Core CUSP toolkit available here
Keystone Center launched an AHRQ-funded project to reduce central line-associated bloodstream infections in select Michigan intensive care units. The project was extremely successful, and the participating Michigan ICUs continue to sustain central line-associated bloodstream infections, or CLABSI, rates of zero percent, even today. In 2008, AHRQ funded national projects to apply the CUSP model to reduce infections nationwide.
The CUSP model supports all eight steps of the popular change model by John Kotter, which are:
Step 1: Create a sense of urgency Step 2: Create a guiding coalition Step 3: Develop a shared vision Step 4: Communicate that vision Step 5: Empower others to act Step 6: Generate short-term wins Step 7: Consolidate gains and produce more change Step 8: Anchor new approaches in culture
CUSP integrates with and supports a broad range of quality and safety improvement models. As teams use CUSP and its tools, they should look at resources already in place and enhance the projects by combining them in efficient and effective ways. As the AHRQ notes,“ CUSP is an investment in time, energy, and dedication that brings both tangible and intangible benefits. When CUSP tools become integrated into routine daily and weekly workflows, the process of improving safety will become a recognized complement to the process of care delivery itself. CUSP implementation can lead to improved safety and improved staff satisfaction and retention.”
CUSP aligns with and supports a wide range of safety tools and approaches to quality improvement models in the field such as TeamSTEPPS ®, Six Sigma, The Institute for Healthcare Improvement Model for Improvement, Plan-Do-Study-Act or PSDA Cycles, Root Cause Analysis, Failure Mode Effect Analysis, and Just Culture. For example, The TeamSTEPPS model includes these steps:
Step 1: Create a change team Step 2: Define the problem Step 3: Define the aims Step 4: Design an intervention Step 5: Develop a plan for testing the effectiveness Step 6: Develop an implementation plan Step 7: Develop a plan for sustained improvement Step 8: Develop a communication plan
18 • www. healthcarehygienemagazine. com • mar-apr 2025