Delaware success stories

DE Success StoriesQuality improvement endeavors can often feel overwhelming, but chances are, you can learn from the experiences that another physician, hospital or nursing home has had in a similar situation. Coupled with support from Quality Insights Quality Innovation Network, learning what has worked for others — and what didn't — is a valuable strategic planning component. 

We encourage you to read the success stories, contact us for more information, and also let us know if you have a Quality Insights' success story to share.

Christiana Care Sees Success With CUSP

Kathleen Wroten, MSN, RN, CIC, Manager of Infection Prevention at Christiana Care Health System in Delaware, knows that the Comprehensive Unit-based Safety Program (CUSP) is effective. She has seen the program work to improve care and patient outcomes first hand.
Christiana Care Health System includes two teaching hospitals, and both had units that participated in the CUSP collaborative beginning in 2010 aimed at reducing Central Line-Associated Blood Stream Infections (CLABSIs). This collaborative was led by the state hospital association as part of a national initiative. Infection Prevention and the staff in Christiana Care’s Intensive care units (ICU) recognized that decreasing CLABSIs was difficult using their current practices. The teams were eager to find better ways to eliminate CLABSI infections and the CUSP collaborative work supported this goal.

The former Nurse Manager of the Wilmington ICU, Donna Casey, felt strongly that the CUSP model improved care and even eliminated CLABSI in her unit. Casey states, “I think that my most valuable lesson from CUSP was, while completing the investigation of defects, we were able to determine that line maintenance was our concern. Without the tool to investigate defects we might not have come to that conclusion.  From there, we were able to develop a strategy for staff return demonstration of technique in a fun, non-threatening, non-punitive manner, getting everyone engaged in preventing CLABSI.”
Christiana Care invites others to learn from their experience so that they, too, can implement the CUSP model in their hospitals and celebrate the successes of their teams in reducing infections and improving patient safety and quality of care.


  “CUSP allows staff to learn in a more meaningful way, why infections might occur. What happened? How could it have been prevented?”
  -Kathleen Wroten

CUSP, as an improvement framework, starts at the unit level.
The input from Christiana Care’s bedside staff was important in understanding how CUSP tools could be applied to their work. The learning from defects component of CUSP allowed staff to understand not only what happened, but what they might need to change in order to fix the problem. Staff sees themselves as providing quality patient care and they do. Using the CUSP principles and tools prompted them, however, to look even deeper into their practices, making changes where they determined to be most appropriate and effective. In addition, through a safety survey, the staff gained a better understanding the unit’s safety culture.
CUSP must draw expertise from all levels of staff.
Senior leadership support is essential for an effective CUSP collaborative, both initially and ongoing. In addition, physician involvement on CUSP teams is a must—unit changes impact care and physicians need to contribute to these discussions and practice changes.

Christiana Care’s CUSP teams included staff from nursing, respiratory therapy, housekeeping, infection prevention, pharmacy, and other departments. All levels of staff were considered when building the teams.
CUSP teams bring disciplines together and allow for opportunities to examine other disciplines’ practices. Teams think about ways to streamline processes and decrease potentials for defects. For example, in one ICU, nurses identified that labs were drawn several times a day through central lines on a single patient. By brainstorming with nursing, physicians, and other disciplines, they consolidated the number of times the central line was accessed, decreasing the opportunity for infection. A daily rounding tool was used to evaluate the necessity of the central line, as well as, other factors in care of the patient.

One of Christiana Care’s star units was the Wilmington campus medical-surgical intensive care unit. They were early adopters of CUSP and have sustained zero CLABSIs for greater than 3 years.

Globally, as a result of the CUSP process, Christiana Care implemented several changes to their CLABSI protocol. They refined their “Scrub the Hub” process, which ultimately added a product to make scrubbing the hub convenient and easy to do perform effectively. The use of an electronic checklist became a requirement along with requiring a nurse at the bedside to ensure that all insertion practices were completed. Nurses were empowered to “stop” the insertion if any of the required practices were not followed. Additionally, staff created a conveniently-located central line cart that contained all products necessary for line insertion including proper surgical attire, central line kits with full barrier drapes, Chlorhexidine Gluconate (CHG) for proper skin preparation, and CHG disc for bacterial protection of skin around the line.
CUSP is a never-ending journey.
CUSP was so effective at Christiana that it spread to other units of the facility. While the initial collaborative focused on four Christiana Care’s intensive care units, CUSP spread to the Christiana Emergency Department, dialysis and the operating rooms as well.
Even after spreading to other units, Christiana Care’s CUSP quality improvement efforts remain ongoing. Improvements made as part of the CUSP collaborative became permanent changes to care delivery and those changes have been sustainable.
As the next chapter in their CUSP journey, Christiana Care has joined a new collaborative focusing on ventilator-associated pneumonia, anticipating that the teams will have another positive experience, learning from staff and national partners.