A qualitative study to describe the Comprehensive Unit-based Safety Program (CUSP) and the role of organisational human factors in its application at Northern Health, Victoria, Australia

Despite more than two decades of research, sociotechnical developments and institutionalised efforts in many Western countries, the problem of adverse events still poses a threat to patient safety and the provision of quality care. Over two decades ago, the landmark report To Err is Human revealed the extent of losses caused by medical errors in the United States and recent literature continues to discuss adverse events; yet globally, significant gaps remain in knowledge and experience with the application of safety science in healthcare settings. Although the field is vast and rigorous, there is conflicting evidence of successful and sustained applications in real clinical practice. Northern Health is a health service in Melbourne’s northern region, one of the fastest growing communities in Australia. It has the busiest Emergency Department in Victoria. In 2017, Northern Health embarked on an approach to ‘high reliability organising’ (HRO), broadly applying the methodology developed by Johns Hopkins Medicine (JHM) in a clinical setting in the United States. Central to the JHM approach is the Comprehensive Unit-based Safety Program (CUSP), a program for improving patient safety culture. A localised application of CUSP has been mobilised across Northern Health hospital wards since 2018. As a safety culture program, Northern Health’s CUSP has been shown early on to be a useful tool in promoting patient safety, but the application of these principles in Australian healthcare settings has yet to be described or tested. This thesis aimed to observe the effects of CUSP — as one aspect of high-reliability organising — and describe the role of organisational human factors in its application in a public healthcare setting in Victoria, Australia. The research described how healthcare workers (HCWs) and management engage with the CUSP and seeks to understand through a safety science approach, how human factors principles are applied in the implementation of the CUSP at Northern Health. The research applied a qualitative methodology using semi-structured interviews with 15 participants (13 clinicians and two non-clinicians) of seven operational CUSPs. Participants were purposively sampled based on the maturity of their CUSP, their level of knowledge and experience, and availability. Interviews were framed by the safety science literature and conducted in person in the natural, ward-based setting at Northern Hospital and (two) via video over six months between August 2022 and March 2023. A thematic analysis was undertaken; an initial deductive framework was generated, and themes and subthemes were then inductively and deductively coded to frame results. The study demonstrated the importance of leadership, accountability, teamwork, and psychological safety for participants and highlighted the significance of organisational human factors in establishing a safety culture. Open communication was emphasised, addressing hierarchical structure, and fostering an egalitarian and democratising environment. Data were recognised as important, with CUSP providing a valuable platform for analysis and discussion. The study suggests that CUSP meetings can enhance patient safety by promoting teamwork, collaboration, and effective communication in creating a safety culture, while stressing the importance of action learning to gain a keener understanding of these organisational human factors.