Moving on from CUSP to CUP: empowering multidisciplinary teams and integrating them in the management structure of hospital organization

Figures & data

Figure 1 The Theory of the Division:¹ The departmentalized structure is responsible for dividing the organization, creating gaps in multidisciplinary communication and teamwork issues among physicians, nurses, and other care providers, leading to problems of safety, effectiveness, and efficiency in health care.

Abbreviation: admin, administration.

Figure 2 Moving on from anatomy to physiology: The CUP model converted departmental structure into various multidisciplinary processes and made them a part of the systemic decision-making structure, which made multidisciplinary communication and teamwork a “systemic” activity.

Figure 3 An example of the process map to create the system by integrating different CUPs in a hospital organization.

Abbreviations: CUP, Comprehensive Unit-based Process.

Table 2 Example of key performance indicators (KPI) of surgical hospitalization CUP analyzed in a monthly meeting

	Previous year’s average	Target	Jan	Feb	Mar	Apr	May	Jun
Number of discharges	468	—	420	481	542	458	509	506
% discharged before 12 noon on the same day they were “clinically” discharged.	27	30	28	33	37	32	29	29
Average hospital stay (days)	7.8	6*	7.8	6.85	7.6	7.6	7.2	7.2
Mortality rate (%)	2.6	0	2.1	1.8	1.45	1.7	1.74	1.6
Number of patients readmitted within 30 days	17	0	15	23	32	20	25	15
Inter-consultations rate (%)	1.15	–	1.25	1.24	1.58	1.5	1.41	1.5
Pre-surgical waiting in programmed interventions (days)	0.88	0	0.83	0.92	0.81	0.74	0.72	0.86
Diagnostic testing (%)	1.45	–	1.05	1.4	1.7	1.8	1.4	1.8
Nosocomial bacteremia (%)	1.62	0	1.61			1.57
Falling of the bed (%)	0.84	0	0.22	0.82	1.1	1.5	0.78	0.59
Pressure ulcers (%)	3	1.5**	2			1.8

Note: *Benchmark based on average levels of 5 major surgical DRGs in the region. ** 0% nosocomial.

Abbreviations: CUP, Comprehensive Unit-based Process.

Table 1 Major improvements achieved during risk analysis

Identification of improvement opportunities based on risk analysis	Hospitalization CUPs
	Critical care	Maternity	Psychiatry	Surgical	Medical
Major ambulatory surgery could be done without hospitalizing				X
Inter-consultation response commitment for the same day	X	X	X	X	X
100% quality checks on unit-dose medication preparations by another person	X	X	X	X	X
Identifying dangerous medication with red stickers in the shelves	X	X	X	X	X
Weighing final preparations of cytostatic preparations					X
Reserving quota in magnetic resonance imaging, CT scan machines and endoscopes	X		X	X	X
Social condition checklist on all patients on day 1 of being hospitalized			X	X	X
Accompany vulnerable patients to toilet to avoid falling				X	X
Avoid rehabilitation delays for post-surgical patients				X

Abbreviations: CUP, Comprehensive Unit-based Process.

Table 3 Compared to the “departmentalized” structure, the benefits of the CUP structure observed

	Departmentalized structure	Comprehensive Unit-based Process (CUP) structure
Scope of the activity	Each knowledge worker is focused only about their task: physicians about their own, nurses about theirs, and so on.	The team is focused on the collective task and its effect on patient outcome: whether or not the patient gets cured.
Decision-making structure	Decisions are made by uni-disciplinary department heads without the understanding of consequence of such decisions on the rest of the multidisciplinary team members.	Decision making by multidisciplinary team heads with the understanding of how such decisions affect all, including the patient outcome.
Patient-centeredness	Each knowledge worker (physician, nurse etc.) contributes with what they know best, without being aware of the overall consequence of collective efforts on the patient.	The team collectively plans and executes a treatment plan to solve the patient’s problems.
Customer communication	Requests made at the front-office may be ignored at the back-office. Examples: patient food preferences, medication allergy etc.	Customer preferences and needs are correctly and collectively executed.
Accountability	Individually everyone may believe to have done their job correctly, but there may be a collective failure without accountability (For example, a wrong patient operated due to communication failure).	Collective responsibility of clinical activity undertaken by the entire multidisciplinary team.
Social relationship among employees of different departments	Social life is uni-disciplinary. During breaks and meal times, people are found to socialize among members of their own departments (ie, physicians with physicians, nurses with nurses, etc.), making multidisciplinary communication opportunities limited.	Improved social interaction as members of one multidisciplinary group, with increased communication opportunities. Team “agglutination” expected in the long-run due to shared destiny.
Internal communication	No horizontal communication with other members of the multidisciplinary team during the activity. There is only a vertical communication among people of one’s own group. Physician-nurse cooperation is limited.	There is horizontal communication with other members of the multidisciplinary team. Vertical communication within their group of knowledge workers will also continue during clinical and training sessions.
Measurement of results	Physical presence and individual skill levels can only be measured, however, it is difficult to measure the contribution of a “single factor” in a multifactorial collective outcome.	Measuring results of the multidisciplinary activity is possible. Collectively the results can be measured and controlled.

Govindarajan R. Healthcare Disorder Is Curable (In Spanish). Barcelona: Marge Medica Books; 2011.

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