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What keeps you up at night?

Natasha Tompkins and her colleagues were asked in a unit staff meeting, “What is the next way a patient will be harmed in your unit? What safety concerns keep you up at night?”

These aren’t questions Natasha, CNA, clinical education and Emergency Department technician at Northern Light AR Gould Hospital, has been asked before. Together, the Emergency Department frontline team—made up of CNAs, RNs, physicians, and others—came up with a list of about 30 things they believed could leave our patients open to harm while in our care.   

“The top priority on our list was how we function in code situations,” Natasha explains, referring to a code system used to alert staff to various emergencies in a hospital. Specifically, Natasha and the team were concerned about the crash carts—self-contained, mobile units that contain nearly all the materials and medications necessary to respond to a code.
“If we were responding to an emergency outside of the Emergency Department and taking our crash cart, other staff coming to help didn’t know where anything was located in our crash cart,” adds Jill Codrey, RN, Emergency Department manager. Likewise, other units in the hospital had their own carts with different contents located in different spots. Jill says simply, “It was a safety concern—it can delay care.”

These questions were the first steps of a new patient safety program piloted at AR Gould Hospital along with Northern Light Sebasticook Valley Hospital in November 2018 called the Comprehensive Unit-based Safety Program (CUSP). Originally developed at Johns Hopkins Hospital, the CUSP approach emphasizes improving safety culture through a continuous process of reporting and learning from errors, improving teamwork, and engaging staff at all levels in safety efforts.

“As a system, we didn't have a standardized way to really develop safety programs. Each member organization was doing their own thing,” explains Daryl Boucher, RN, EdD, vice president of Nursing and Patient Care Services and an executive sponsor of the CUSP program. “As a system, we began to talk about national best models and we found the Johns Hopkins model for CUSP as the best.”

The unique aspect of CUSP is that the program gives users an easy toolkit to follow which includes how to introduce CUSP, how to lay the foundation, how to find the defects within your organization, and how to prioritize those defects. Daryl points out that the leadership had their own ideas of safety improvement projects, “But because it’s frontline driven, they were identifying different projects that bubbled to the surface as the most important.”

The involvement from frontline staff doesn’t end at identifying the safety risk. The CUSP program guides participants through implementing change using a CUSP champion, in this case Christine Quirion, RN, in the Emergency Department. Natasha says that the CUSP team figuratively dismantled the contents of the hospitals’ crash carts and rebuilt them. “Our frontline staff are the hands-on ones, right? So, it was really important that they were involved in the process.”

A signature of any good CUSP project is its positive reach throughout an organization and “spin-off” projects that closely complement the original objective. “Our project started small—we thought we were just going to revamp our crash carts and do some education,” recalls Jill with a smile. “However, our project grew immensely. We developed a trauma alert, then we ended up building a trauma cart. We implemented a new documentation for all our trauma patients and that affected a lot of departments including lab, radiology, pharmacy, and others.” The team has also streamlined medications in the carts and implemented an identification system for staff to wear job role labels in a code situation that specifies their role (Who's on compressions? Who's the recorder? Who's the medication nurse?).

Daryl is a true believer in CUSP. He says when an organization rolls out the program it just becomes the culture of the organization. “You implement this project and next thing you know, it's just forever. That's the nice thing about this program and why we chose it—it’s much easier to sustain than many of the other programs.”

Cherri Fitzpatrick, BSHA, MLT(ASCP), CPHQ, associate vice president of Compliance, Risk, and Quality, is also an executive sponsor of the CUSP program, like Daryl, and notices word is getting out about the success of CUSP, “Other units and member organizations are saying, ‘When is our turn? When can we sign up? When can we do this?’ and that’s not something I’ve seen before.”

Natasha says that her team has seen very positive results from their crash cart project, and it was encouraging to staff to see its success. “We get multiple codes—sometimes it's one a month, sometimes it's six a month—and after our project, we've heard the frontline staff say, ‘Wow, that was a lot easier.”

There were naysayers when CUSP was first rolled out, Daryl told us. Some thought CUSP was just the flavor of the month. “What we discovered is that staff began to see CUSP as a tool to get stuff done. In fact, it became a verb, ‘Let's CUSP this…’ when something came up, because they felt like they had good leadership support. When we say CUSP, we know it's a big deal and so people put energy into it.”
To learn more about CUSP and using it in your organization, contact Emily Burdin, Northern Light Health director of Patient Safety or visit our Patient Safety portal at