[usPropHeader] Error loading user control: The file '/CMSWebParts/WK.HLRP/LNC/LNCProductHeader.ascx' does not exist.


  1. Slade, Jill MS, RN
  2. Hata, Rose MS, RN, APRN, CCRN, CCNS

Article Content

Improving care delivery quality and patient safety is a growing priority for many facilities in the modern healthcare landscape, and nurse managers play an important role in ensuring the success of new safety measures. Research has shown that the way nurse managers engage RNs in decision making and problem solving has a direct influence on improving care delivery quality and patient safety.1 In addition, frontline RN engagement positively impacts satisfaction rates.2

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

The Comprehensive Unit-Based Safety Program (CUSP) utilizes the clinical experience of frontline RNs to promote a safer patient environment by targeting cultural improvements through data transparency, teamwork, communication, and self-identification of safety issues.3-5 We chronicle the journey of a surgical intensive care unit (SICU) in adopting and utilizing the CUSP staff safety assessment (SSA) tool to improve the culture of patient safety on the unit.


Staff safety assessment

The first step in improving unit culture is assessment. The CUSP requires nurse managers to identify process or system issues that need improvement. The CUSP SSA tool provides the basis for the nurse manager to begin the conversation with staff members about the current safety environment. The results of the assessment create an opportunity for the nurse manager to partner with frontline RNs and other clinicians to develop action plans for identified concerns.


Putting the tool into practice, nurse leaders at a hospital in Hawaii created a performance improvement project to address patient safety issues on the unit that most concerned frontline SICU RNs. They formed a SICU CUSP team consisting of the nurse manager, clinical nurse specialist (CNS), intensivists, and a clinical nurse. Project leaders introduced the tool to the unit through the State of Hawaii's CUSP initiative with Johns Hopkins Hospital (JHH).6


The original SSA tool asks clinicians to provide feedback on two questions: 1. How do you think the next patient on our unit will be harmed? and 2. Describe what you think can be done to prevent or minimize this harm. The SICU CUSP team decided to enhance the tool by adding a question to quantify the perception of unit safety: On a scale of 0 to 10, how safe is our current environment? A score of 0 indicates the unit is "extremely unsafe" and 10 indicates "extremely safe."


In November 2009, the first SSA was offered to all clinicians working on the SICU. This included SICU intensivists, fellows, residents, RNs, respiratory therapists, and pharmacists who had worked on the unit for at least 4 weeks, as recommended by JHH.


Frontline clinician perceptions

Project leaders, including the nurse manager and medical director, analyzed the results of the initial assessment for common safety concern themes. In November 2009, study participants rated their perception of patient safety on the SICU at 4.65 out of 10, on average. (See Figure 1.) A total of 23 clinicians (37%) completed the assessments. Three major categories of patient safety concerns arose: 1. patient acuity and assignments (52%), 2. sedation management (19%), and 3. delay of care due to RN-physician communication (14%).

Figure 1:. November ... - Click to enlarge in new windowFigure 1:. November 2009 staff safety assessment

The SICU CUSP team reviewed the issues and considered suggestions from all staff members. Then, the group discussed promising and feasible potential action plans to address the concerns. Participants from all disciplines reviewed the assessment results and proposed pilot action plans. (See Table 1.) Because the majority of the survey responders were nursing staff members, the team shared the results and action plans at the mandatory nursing skills fair.

Table 1: November 20... - Click to enlarge in new windowTable 1: November 2009 patient safety concern topics and related action plans

Addressing concerns

To address the first identified safety concern of patient acuity and assignment, the nurse manager increased mentorship of the charge nurses. During this timeframe, nurse managers across the organization developed workshops to better equip charge nurses, including those from the SICU. Content of the workshops focused on listening to staff concerns with intent, understanding generational diversity, and coaching clinical RNs on how to resolve issues independently.


An evidence-based practice (EBP) team was formed by the CNS to address sedation management issues. This team attended a statewide EBP workshop, conducted literature reviews, and designed a practice change. The group identified that the SICU lacked delirium assessments, which may have contributed to patients' agitation and sedation management. As recommended by the Society of Critical Care Medicine's pain-agitation-delirium guidelines, the Confusion Assessment Method for the ICU (CAM-ICU) assessment tool was implemented, along with strategies to prevent and manage delirium.7 In addition, the team developed nonpharmacologic nursing management strategies, including the SICU Sleep Program, designed to create an environment conducive to improved sleep, and the Progressive Mobility Program, designed to promote earlier mobilization of ICU patients.8


To build better RN-physician communication about patient goals, the daily goals tool (DGT) was adopted.9,10 The intent of the DGT was standardization of daily ICU multidisciplinary rounds for a clear care plan. To address the unit's safety concern, the SICU team customized the tool and the process by having the clinical nurses read back the care plan, allowing the entire multidisciplinary team to make any needed clarifications.


Each pilot project introduced small changes, allowing frontline clinicians to give feedback, improve the project, and then reassess after implementation. Because only small changes were adopted over time, the performance improvement projects weren't overwhelming to the frontline clinicians. This strategy assisted in the sustainability of culture change on the unit.


Progress checks

To assess if the unit perception of patient safety improved, the team repeated the SSA in June 2010 (7 months after the initial survey). The SSA tool was converted to an electronic version. A total of 28 (44%) clinicians completed the assessments. The average score of the patient safety perception on the SICU increased from 4.65 to 6.75. (See Figure 2.)

Figure 2:. June 2010... - Click to enlarge in new windowFigure 2:. June 2010 staff safety assessment

The SICU CUSP team compared the results of the second assessment with the initial assessment while the unit continued to work on the three original initiatives. The second assessment results showed the following top three concerns: 1. communication (17%); 2. critical-thinking skills (13%); and 3. staff accountability (13%). (See Table 2.) The top three concerns were different than the initial assessment. This change may have been due to addressing the clinicians' initial primary concerns.

Table 2: June 2010 p... - Click to enlarge in new windowTable 2: June 2010 patient safety concern topics and related action plans

As an ongoing assessment, the SSA was conducted again in March 2013. The assessment was offered using a similar methodology to 2010. A total of 56 (89%) clinicians completed the assessments. The 2013 data showed that patient acuity and assignments resurfaced again as the primary safety concern (40%). (See Table 3.) This was most likely due to the focus shifting away from patient acuity and assignments when new initiatives were being addressed in 2010. Trending of these patient safety concerns allowed the unit to readjust action plans while implementing additional projects to address new concerns.

Table 3: March 2013 ... - Click to enlarge in new windowTable 3: March 2013 patient safety concern topics and related action plans

Over time, by addressing safety concerns, the average score of the patient safety perception on the SICU increased from 4.65 to 6.75 in June 2010 and to 7.43 in March 2013. (See Figure 3.) Overall participation by all clinicians also increased from 23 (37%) in 2009, to 28 (44%) in 2010, and 56 (89%) in 2013. Additionally, the total SICU nurses participating in the assessment increased from 22% to 40% and 98%, respectively. (See Figure 4.)

Figure 3:. March 201... - Click to enlarge in new windowFigure 3:. March 2013 staff safety assessment
Figure 4:. Total SIC... - Click to enlarge in new windowFigure 4:. Total SICU RN assessment involvement

Impact on nursing satisfaction

Although there was no intentional focus on improving RN satisfaction scores during this timeframe, the unit's scores improved. RN satisfaction results are broken into subscales, such as decision making, autonomy, professional status, nursing management, professional development, RN-RN interaction, and RN-physician interaction. All subscale data were compared with the National Database of Nursing Quality Indicators(R) (NDNQI(R)) index of RN work satisfaction from all participating hospitals.11


Over the years of the performance improvement project, the hospital utilized various RN satisfaction tools. Each year, as a benchmark, the hospital compared the unit's subscale results with the average subscale scores of other participating hospitals. In 2008, all of the unit's RN satisfaction subscales were below the benchmark. Over the subsequent years of using the SSA on the SICU, the unit saw an increase in the number of subscales outperforming the national benchmark. (See Figure 5.) In 2013, all of the RN satisfaction subscales on the SICU outperformed the national benchmark.

Figure 5:. Percentag... - Click to enlarge in new windowFigure 5:. Percentage of RN satisfaction subscales above the national benchmark*

Between 2013 and 2015, the SSA tool wasn't implemented. The unit noticed a decrease in RN satisfaction scores. Due to the associated results of utilizing the SSA and increased RN satisfaction scores, the unit adopted the SSA as an annual standard assessment tool.



This project aimed to assess frontline clinician perceptions of patient safety on the SICU using the CUSP SSA tool. By implementing the SSA and working together on solutions to close identified gaps, the perception of the unit's safety culture improved. Although initiatives were targeted to address patient safety issues, the nurse manager observed an increase in the unit's RN satisfaction scores. Addressing the frontline clinicians' patient safety concerns generated several initiatives while improving patient safety and increasing RN satisfaction scores.


Nurse managers can gain important insights into the reality of the frontline clinicians' working environment by using the SSA. First, it provided a venue for frontline staff members to voice their concerns and make suggestions about patient safety issues. In addition, collective trending of concerns allowed the SICU to prioritize quality improvement efforts that were meaningful for the unit and patient care. Detailed discussions with all unit nurses promoted full engagement and ownership of patient safety.


Nurse leader tips

Building and maintaining a culture of safety takes considerable time and effort, but yields positive outcomes for patients and RNs. The following are tips for nurse leaders when building a culture of safety:


* Listen: Allow the frontline clinicians to voice their concerns openly and in a safe manner.


* Be ready to take action: Based on suggestions from frontline staff members, appropriate responses and actions are necessary to address safety concerns.


* Communicate constantly: Encourage constant communication and feedback, along with prompt updates.


* Focus on the whole: Ensure that everyone is involved in the discussion.


* Use leverage: When there's resistance to change or adoption of new improvement processes, remind everyone that the intent of the change is to address their concerns.


* Pilot with feedback: To secure successful adoption that's meaningful, pilot projects first.



Empowered and ready

On the SICU, the process of utilizing the SSA tool enhanced frontline clinician engagement and empowered them to be part of solutions to address patient safety concerns. In addition, the SSA provided the nurse manager with a road map to proactively improve the unit's environment. By addressing their concerns, the frontline clinicians felt empowered and were willing to participate in the new initiatives. Along with improving perceptions of patient safety, RN satisfaction scores also increased. This process may be helpful for nurse managers prioritizing unit initiatives to improve the patient safety culture and nursing satisfaction.




1. Cropley S. Nurses on guard: culture of safety. Texas Board of Nursing Bulletin. 2015;46(3):4-5. [Context Link]


2. Julianne M. Nurses create a culture of patient safety: it takes more than projects. Online J Issues Nurs. 2011;16(3):2. [Context Link]


3. Weaver SJ, Lofthus J, Sawyer M, et al. A collaborative learning network approach to improvement: the CUSP learning network. Jt Comm J Qual Patient Saf. 2015;41(4):147-159. [Context Link]


4. Cooper M, Makary MA. A comprehensive unit-based safety program (CUSP) in surgery: improving quality through transparency. Surg Clin North Am. 2012;92(1):51-63.


5. Hsu YJ, Marsteller JA. Influence of the comprehensive unit-based safety program in ICUs: evidence from the keystone ICU project. Am J Med Qual. 2016;31(4):349-357. [Context Link]


6. Lin DM, Weeks K, Bauer L, et al. Eradicating central line-associated bloodstream infections statewide: the Hawaii experience. Am J Med Qual. 2012;27(2):124-129. [Context Link]


7. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med. 2013;41(1):263-306. [Context Link]


8. Hata RK, Han L, Slade J, et al. Promoting sleep in the adult surgical intensive care unit patients to prevent delirium. Nurs Clin North Am. 2014;49(3):383-397. [Context Link]


9. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003;18(2):71-75. [Context Link]


10. Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact of the comprehensive unit-based safety program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf. 2010;36(6):252-260. [Context Link]


11. Montalvo I. The National Database of Nursing Quality Indicators(R) (NDNQI(R)). http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJI. [Context Link]