Integrated Health Care SystemsCase Studies in Safety and Quality

After reading and reflecting on the information in the article below, create a case study that illustrates Key
Principles IV OR V. The case study can be related to Safety or a Quality Improvement Initiative and should be
no longer than 2 pages. See example below that may help in creation of the case study. You may use an
existing safety or quality initiative that has been implemented in your organization or you may create an
imaginary case.

Respond to at least one peers posting. These responses to other learners should be substantive posts that
contribute to the conversation by asking questions, respectfully debating positions, and presenting supporting
information relevant to the topic. Also, respond to any follow-up questions the instructor directs to you in the
discussion area.
Follow Grading Rubric for “Discussions.”
Please note that discussion postings must follow directions/grading rubrics and include:
The assignment copied and pasted into the document
Summary statement

EXAMPLE OF CASE STUDY IN SAFETY (taken from (Links to an external site.)
Johns Hopkins Hospital
In 2001, intensive care unit (ICU) physicians and staff at the Johns Hopkins Hospital in Baltimore developed its
Comprehensive Unit-Based Safety Program (CUSP) as a framework for quality improvement that can be
tested, adapted, and introduced sequentially in the hospital units. This program is part of a broader institutional
commitment to improve patient safety that was partly based on a partnership with the family of a pediatric
patient, Josie King, who was a victim of medical error at the hospital. The King family donated funds and
worked with Hopkins physicians to create a patient safety program in the hospital’s Children’s Center, which
has served as a model for improvement.
CUSP has eight steps: to (1) assess the unit’s culture of safety, (2) educate staff about safety sciences such as
systems thinking, (3) identify safety concerns, (4) meet regularly with a senior hospital executive who supports
the removal of system barriers, (5) prioritize and implement improvements, (6) document and analyze results,
(7) share success stories, and (8) reassess the unit’s safety culture.
Improvement teams (consisting of a physician, nurse, and administrator, plus other staff who wished to join)
spent time each week (four to eight hours) identifying and promoting safety improvement efforts. For example,
a short-term patient goals form was drawn up based on a survey finding that nursing staff and residents
frequently did not know the goals of patients’ therapy. The form is used as a checklist during physician-led
rounds to identify tasks that need to be completed by the care team and to identify and mitigate safety risks. A
related project aimed to reduce bloodstream infections associated with the use of central venous catheters,
which are often inserted in ICU patients to provide medication, nutrition, and fluids. A multidisciplinary team
decided on the following interventions:
Require providers to receive education about evidence-based infection control practices and successfully
complete a posttest as a precondition to inserting catheters.
Supply a catheter insertion cart with standardized supplies needed to meet infection control guidelines for the
sterile insertion of catheters. 

Add an item to the daily goals sheet that prompts the ICU team to ask physicians daily during patient rounds
whether catheters can be removed.
After the daily goals sheet was introduced, self-reported understanding of goals of care increased from 10
percent to 95 percent of residents and nurses during an eight-week period. One year following the
implementation of the CUSP initiative, the average ICU length-of-stay fell by one day in one ICU and by two
days in a second ICU. Medication errors were eliminated in orders to transfer patients out of the ICU. The
proportion of the ICU staff who gave positive ratings of the safety culture rose by nearly half in one ICU and
nearly doubled in the other, as measured on the Safety Climate Scale (Sexton and Thomas 2003 (Links to an
external site.)). Senior executives’ involvement with the ICU led to structural changes, including the creation of
specialized patient transport teams and the presence of pharmacists in ICUs. Documented catheter-related
bloodstream infections were eliminated, preventing an estimated forty-three infections and eight deaths and
saving an estimated $2 million annually.
CUSP is now being used as a framework for patient safety improvement throughout Johns Hopkins Hospital.
Initiating change efforts within a single work unit and then replicating successful approaches in other units
appears to be a promising approach to building an organizational culture of safety in the Hopkins system.
“When you create a system that reliably delivers the processes or interventions that work, spectacular
performance improvement follows,” Dr. Peter Pronovost, medical director of the Johns Hopkins Center for
Innovations in Quality Patient Care, said in a recent interview for the Joint Commission Journal on Quality and
Safety (Berman 2004 (Links to an external site.), 663)

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