Background: The Comprehensive Unit-based Safety Program (CUSP) promoted by AHRQ is typically a staff nurse led quality improvement team focused on improving elements of unit-level patient safety. Physician engagement in projects is encouraged, but at our institution there was not consistent collaboration between hospitalists and CUSP teams.

Purpose: To understand how incorporating a unit based medical director into regular CUSP planning and implementation can impact quality and patient safety on a hospitalist managed observation unit.

Description: A unit CUSP team was formed led by the unit assistant nurse manager with participation from unit nurses, case manager, medical director, CUSP facilitator and ad hoc members as required to achieve CUSP goals. The team defined an overall goal of achieving the “right patient in the right bed” reflecting historical challenges of the unit being used as a patient overflow space which challenged its ability to appropriately standardize and implement protocol based observation care. The team met monthly to review progress and plan next activities.
The CUSP team was able integrate everyone’s unique skills to drive several key improvement efforts. Initially the team relied on data analysis from the medical director to identify the potential volume of patients for the unit. This was then supplemented by nursing support tools in collaboration with bed management to develop a protocol that prioritized observation patients while ensuring there were no vacant beds during times of high hospital capacity. These efforts improved observation patient fidelity from 51% to 71%. Ongoing refinements have current unit fidelity at 80%. With a more consistent patient cohort the CUSP team next shifted focus to optimizing unit processes. Next we refined and implemented interdisciplinary rounding involving nurses, providers, and case management to target throughput and length of stay (LOS). The average observation patient LOS decreased from 42.7 hours in the 16-weeks pre-intervention to 38.6 hours in the 16 weeks post-intervention. This allowed the unit to increase the number of weekly observation patient discharges by nearly 6 patients. Further refinements have reduced average LOS to 36.8 hours with an additional 1.4 discharges per week in our second 16-week period post-intervention. Across the top 10 diagnoses seen on the observation unit in the 3 months post-implementation, improved flow saved 46.4 bed days and the system had an opportunity to save an additional 71 bed days if observation patients admitted to the general floor received the same efficient care.

Conclusions: Utilization of the CUSP working group with standing participation from the unit based medical director resulted in significant improvements in unit level functioning. Unmeasured, but anecdotally apparent, the collaboration has improved camaraderie and teamwork across the unit which likely contributes to successful project implementation. Given observed successes we will continue to utilize the CUSP team as we begin to refine disease protocols to continue to improve the quality and safety of patient care on the medical observation unit.