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Agency for Healthcare Research Quality

Using a Comprehensive Unit-based Safety Program to Prevent Healthcare-Associated Infections

The Agency for Healthcare Research and Quality (AHRQ) supports numerous projects that are helping hospitals in all 50 States, the District of Columbia, and Puerto Rico to employ a Comprehensive Unit-based Safety Program (CUSP) to reduce healthcare-associated infections (HAIs). The CUSP approach can be applied to patient safety problems, including various types of preventable infections, such as central line-associated blood stream infections (CLABSIs), catheter-associated urinary tract infections, and ventilator-associated pneumonia, in intensive care units (ICUs) and other hospital units.

This page provides an overview of CUSP and links to useful resources on the Web.

Overview | CUSP in Action | CUSP Resources

Image: Photo of a four-member health care team having a discussion in a hospital hallway.


CUSP is a structured strategic framework for safety improvement that integrates communication, teamwork, and leadership to create and support a culture of patient safety that can prevent harms. The program features: evidence-based safety practices, staff training tools, standards for consistently measuring infection rates, engagement of leadership, and tools to improve teamwork among doctors, nurses, and other members of the health care team.

The following five steps from CUSP equip frontline providers with the tools, metrics, and framework to tackle the challenges of quality improvement:

  • Step 1. Staff are educated on the science of safety.
  • Step 2. Staff complete an assessment of patient safety culture.
  • Step 3. A senior hospital executive partners with the unit to improve communications and educate leadership.
  • Step 4. Staff learn from unit defects.
  • Step 5. Staff use tools, including checklists, to improve teamwork, communication, and other systems of work.

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CUSP in Action

CUSP was first applied on a large scale in the Keystone Project, which deployed this approach in more than 100 ICUs in Michigan beginning in 2003.The project targeted clinicians' use of five evidence-based procedures, recommended by the Centers for Disease Control and Prevention, to reduce rates of CLABSI: Hand hygiene, using full-barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site when possible, and removing unnecessary catheters. Using a checklist to ensure the procedures were followed, the Keystone Project:

  • Reduced the rate of CLABSI by two-thirds within 3 months.
  • Saved more than 1,500 lives and nearly $200 million in the program's first 18 months.
  • Decreased the rate of CLABSI to the point where these infections became rare events in the participating ICUs, which continued to sustain this reduction 3 years after first adopting CUSP.

The findings of dramatically decreased infection rates were published in the December 28, 2006, issue of the New England Journal of Medicine (Select for abstract on PubMed®).

CUSP Expansion

In October 2009, AHRQ announced an expansion of CUSP to hospitals in all 50 States, the District of Columbia, and Puerto Rico to continue the national implementation of this approach for reducing HAIs. The CUSP program also is expanding to include other settings in addition to ICUs, and more types of preventable infections. Select for press release.

Keystone Project Shows Reduced Death Rates in ICUs

The Keystone Project also reported that Medicare patients treated in Michigan ICUs were less likely to die while hospitalized than Medicare ICU patients in other Midwestern hospitals that did not implement CUSP. Specifically, a person's chance of dying decreased by about 24 percent in Michigan after the program was implemented compared to only 16 percent in surrounding Midwestern states where the program was not implemented. Select for press release and abstract on PubMed®.

Keystone Project Shows Reduced Pneumonia Rates in ICUs

Rates of pneumonia were also dramatically reduced in patients on ventilators in Michigan ICUs through the use of CUSP. Participating ICUs cut by more than 70 percent the rate of pneumonia in patients who were on ventilators. This reduction was sustained for the duration of the study's follow-up, a period of up to two and a half years. Select for press release.

Keystone Project Sustains Zero Blood Stream Infections for up to 2 Years

ICUs in both large and small hospitals in Michigan stopped CLABSIs for up to 2 years after implementing CUSP. Researchers found that 60 percent of the 80 ICUs evaluated went 1 year or more without an infection, and 26 percent achieved 2 years or more. Smaller hospitals sustained zero infections longer than larger hospitals. Select for press release and abstract on PubMed®.

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CUSP Resources

Central Line Insertion Care Team Checklist

  • CUSP Toolkit
    The CUSP toolkit includes training tools to make care safer by improving the foundation of how your physicians, nurses, and other clinical team members work together.

First page of 'Ending Healthcare-Associated Infections' fact sheet

  • Ending Healthcare-Associated Infections
    Fact sheet that provides an overview of CUSP and highlights AHRQ-supported projects that use the program.

Title page of the 'Eliminating CLABSI' report


Berenholtz, SM, Pham JC, Thompson, DA, Needham DM, Lubomski LH, Hyzy RC, Welsh R, Cosgrove SE, Sexton JB, Colantuoni E, Watson SR, Goeschel CA, Pronovost PJ. Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit. ICHE 2011 Feb 17.

Goeschel CA, Pronovost PJ. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. "Harnessing the Potential of Health Care Collaboratives: Lessons from the Keystone ICU Project." Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Aug.

Lin DM, Weeks K, Bauer L, Combes JR, George CT, Goeschel CA, Lubomski LH, Mathews SC, Sawyer MD, Thompson DA, Watson SR, Winters BD, Marsteller JA, Berenholtz SM, Pronovost PJ, Pham JC. Eradicating central line-associated bloodstream infections statewide: The Hawaii experience. Am J Med Qual 2011 Sep 14. [Epub ahead of print]

Lipitz-Snyderman A, Needham DM, Colantuoni E, Goeschel CA, Marsteller JA, Thompson DA, Berenholtz SM, Lubomski LH, Watson S, Pronovost PJ. The ability of intensive care units to maintain zero central line-associated bloodstream infections. Arch Intern Med 2011 May 9;171(9):856-8.

Lipitz-Snyderman A, Steinwachs D, Needham DM, et al. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ 2011 Jan 28;342:d219. doi: 10.1136/bmj.d219.

Pronovost PJ, Cardo DM, Goeschel CA, et al. A research framework for reducing preventable patient harm. Clin Infect Dis 2011 Feb;52(4):507-13.

Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study. BMJ 2010 Feb 4;340:c309.

Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006 Dec 28;355(26):2725-32.

Romig M, Goeschel C, Pronovost P, Berenholtz SM. Integrating CUSP and TRIP to improve patient safety. Hosp Pract (Minneap) 2010 Nov;38(4):114-21.


Using Collaboratives to Reduce Central Line-Associated Bloodstream Infections (CLABSI): A National Implementation Program
Presenter: John R. Combes, M.D., and Peter Pronovost, M.D.
Date: September 2009
Venue: AHRQ Annual Conference

Overview of STOP-BSI Program
Presenter: Peter Pronovost, M.D.
Date: September 2009
Venue: AHRQ Annual Conference

10 Years After "To Err is Human": An RCA of Patient Safety Research
Presenter: Peter Pronovost, M.D.
Date: September 2008
Venue: AHRQ Annual Conference

Press Releases

ICUs in Michigan Sustain Zero Blood Stream Infections for Up to 2 Years
May 9, 2011

Rates of Pneumonia Dramatically Reduced in Patients on Ventilators in Michigan Intensive Care Units
February 17, 2011

Landmark Initiative to Reduce Healthcare-Associated Infections Cuts Deaths Among Medicare Patients in Michigan Intensive Care Units
January 31, 2011

AHRQ Awards $34 Million to Expand Fight Against Healthcare-Associated Infections
November 4, 2010

Annual Quality and Disparities Reports Include Data on Rates of Health Care-Associated Infections, Obesity and Health Insurance
April 13, 2010

HHS Awards $17 Million in a New National Initiative to Fight Health Care-Associated Infections
October 23, 2009

10-State Project To Study Methods To Reduce Central Line-Associated Bloodstream Infections in Hospital ICUs
February 19, 2009

AHRQ Awards $3 Million To Help Reduce Central Line-Associated Bloodstream Infections in Hospital ICUs
October 1, 2008

Advice Columns

Healthcare-Associated Infections: They Can Happen to You
By AHRQ Director Carolyn M. Clancy, M.D.
May 4, 2010

Simple Steps Can Reduce Health Care-Associated Infections
By AHRQ Director Carolyn M. Clancy, M.D.
July 1, 2008


Prevention of Central Line-Associated Bloodstream Infections

New Study Looks at Ways to Reduce Catheter-Related Bloodstream Infections in Hospital ICUs

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Current as of September 2012

Internet Citation:

Using a Comprehensive Unit-based Safety Program to Prevent Healthcare-Associated Infections. September 2012. Agency for Healthcare Research and Quality, Rockville, MD.


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