Build a Foundation for Quality: Measure and Improve Patient Safety Culture

1
Build a Foundation for Quality Measure and
Improve Patient Safety Culture

• Katherine Jones, PT, PhD
• Anne Skinner, RHIA

NRHA Quality and Clinical Conference July 15,
2008
Supported by AHRQ Grant 1 U18 HS015822 and NRHA
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Objectives

• What you should know (knowledge)
• What you should do (skills)
• What you should believe/value (attitudes)
• Acronyms
• AHRQ Agency for Healthcare Research and Quality
• HRO High Reliability Organization
• HSOPSC Hospital Survey on Patient Safety Culture

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Knowledge Objectives (What you Know)

• Define culture of patient safety
• List four components of a culture of patient
  safety
• Recognize that HSOPSC dimensions measure four
  components of a culture of patient safety
• Compare beliefs and behaviors within HSOPSC
  dimensions
• Identify relationships between HSOPSC dimensions
• Explain benefits of using rural-adapted version
  of HSOPSC
• Recognize that culture varies within an
  organization

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Skills Objectives (What you do)

• Conduct HSOPSC to meet Joint Commission
  Leadership Standards (Standard LD.03.01.01)
• http//www.jointcommission.org/NR/rdonlyres/
  D53206E8-D42B-416B-B887-491B6D5AA163/0/HAP_LD.pdf
  
• Leaders regularly evaluate the culture of safety
  and quality using valid and reliable tools
• Leaders prioritize and implement changes
  identified by the evaluation
• Use the correct version of HSOPSC
• Conduct HSOPSC using sound methodology
• Implement an appropriate action plan (PM session)

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Attitudes Objectives (What you think is
important)

• Recognize value of HSOPSC as
• a diagnostic tool that identifies organizational
  learning impairments
• an assessment of fitness to engage in quality
  improvement and patient safety programs
• Justify use of resources to conduct HSOPSC
• Become a learning organization
• Meet Joint Commission Standards of Leadership
  beginning Jan. 2009

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The Problem

• The problem is not bad people the problem is
  that the system needs to be made safer . . .
• IOM (2000). To Err is Human Building a Safer
  Health System

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and the Challenge

• The biggest challenge to moving toward a safer
  health system is changing the culture from one of
  blaming individuals for errors to one in which
  errors are treated not as personal failures, but
  as opportunities to improve the system and
  prevent harm.
• IOM (2001). Crossing the Quality Chasm A New
  Health System for the 21st Century, p. 79

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Definition of Safety Culture

• Enduring, shared beliefs and behaviors that
  reflect an organizations willingness to learn
  from errors
• Three beliefs present in a safe, informed
  culture
• Our processes are designed to prevent failure
• We are committed to detect and learn from error
• We have a just culture that disciplines based on
  risk

Wiegmann. A synthesis of safety culture and
safety climate research 2002. http//www.humanfac
tors.uiuc.edu/ReportsPapersPDFs/TechReport/02-03.
pdf
Institute of Medicine. Patient safety
Achieving a new standard of care. Washington,
DC The National Academies Press 2004.
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Active Learning Think Pair Share

• Our processes are designed to prevent failure
• Our procedures and systems are good at
  preventing errors from happening.
• 73 agree (range 41 - 86)
• We are committed to detect and learn from error
• Mistakes have led to positive changes here.
• 68 agree (range 53 - 84)
• We have a just culture that disciplines based on
  risk
• Staff worry that mistakes they make are kept in
  their personnel file.
• 46 disagree (range 24 - 60)

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Components of Safety Culture
Reason, J. Managing the Risks of Organizational
Accidents. Hampshire, England Ashgate
Publishing Limited 1997.
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Informed, Safe Culture Essential for a High
Reliability Organization (HRO)

• Complex operations
• Potential for catastrophic failure
• Interdependent tasks
• Specific roles
• Common goalsafe, effective

Weick Sutcliffe. (2001). Managing the
unexpected Assuring high performance in an age
of complexity. San Francisco Josey-Bass.
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Need for high reliability? Think Pair
Share

• Agree or Disagree
• Work processes are accomplished in sequential
  linear steps that rarely vary.
• Feedback and information on what is happening is
  direct and simply verified.
• Work processes are well understood and easily
  comprehensible.
• Work processes do not require coordinated actions
  involving multiple people and equipment.
• There is a lot of slack in our work processes
  things dont have to be done right the first
  time.
• There is a lot of opportunity to improvise when
  things go wrong.

Weick Sutcliffe (2001). Managing the
Unexpected. p. 100
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HROs

• Southwest Airlines has not had any fatal events
  involving a passenger since it began service in
  1971.
• http//www.airsafe.com/events/airlines/luv.htm
• The two significant accidents in the 50-year
  history of civil nuclear power generation are
  
• Three Mile Island (USA 1979) where the reactor
  was severely damaged but radiation was contained
  and there were no adverse health or environmental
  consequences
• Chernobyl (Ukraine 1986) where the destruction of
  the reactor by steam explosion and fire killed 31
  people and had significant health and
  environmental consequences. The death toll has
  since increased to about 56.
• http//www.world-nuclear.org/info/inf06
  .html

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Healthcare is Not an HRO

• Medical Errors Costing U.S. Billions
• TUESDAY, April 8, 2008 (HealthDay News) -- From
  2004 through 2006, patient safety errors resulted
  in 238,337 potentially preventable deaths of U.S.
  Medicare patients and cost the Medicare program
  8.8 billion, according to the fifth annual
  Patient Safety in American Hospitals Study.
• http//www.washingtonpost.com/wp-dyn/content/artic
  le/2008/04/08/AR2008040800957.html

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Healthcare is Not an HRO

• Joint Commission Sentinel Event Alert
• WEDNESDAY, July 9, 2008
• Intimidating and disruptive behaviors can . . .
• foster medical errors, contribute to poor patient
  satisfaction and preventable adverse outcomes,
• increase the cost of care, and cause qualified
  clinicians, administrators and managers to seek
  new positions in more professional environments.
• Safety and quality of patient care is dependent
  on teamwork, communication, and a collaborative
  work environment.
• To assure quality and to promote a culture of
  safety, health care organizations must address
  the problem of behaviors that threaten the
  performance of the health care team.
• http//www.jointcommission.org/SentinelEvents/Sent
  inelEventAlert/sea_40.htm

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How to Become an HRO Engage in Continuous
Improvement
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Measure Beliefs and Behaviors with HSOPSC

• Developed by AHRQ to provide healthcare
  organizations with a valid tool to assess safety
  culture http//www.ahrq.gov/qual/hospculture/
• 42 items categorized in 12 dimensions
• 7 dimensions measure culture at dept/unit level
• 3 dimensions measure culture at hospital level
• 2 dimensions are outcome measures
• 2 additional items are outcome measures

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Versions of HSOPSC

• Original AHRQ HSOPSC
• 14 different work areas
• 14 different job titles
• Sort by work area or job title if gt 11
• Rural-adapted AHRQ HSOPSC
• 12 different work areas - 7 choose other
• Collapsed Medicine, Obstetrics, Pediatrics,
  Intensive Care, Psychiatry/mental health,
  Rehabilitation, Anesthesiology to Acute/Skilled
  Care
• Added Long-term care, Home Health Care, Therapies
• 6 different job titles - 8 choose other
• Sort by work area or job title if gt 5

1/3 in national database choose other
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Original AHRQ HSOPSC
Rural-Adapted AHRQ HSOPSC
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Original AHRQ HSOPSC
Rural-Adapted AHRQ HSOPSC
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URLs for Surveys

• Rural-adapted version
• http//www.unmc.edu/rural/patient-safety
• Click on Hospital Survey on Patient Safety Culture
   Resources 
•  
• Original AHRQ version
• http//www.ahrq.gov/qual/hospculture/
• Click on Hospital Survey Toolkit

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UNMC Use of Rural-Adapted HSOPSC

• AHRQ PIPS Grant Focus on Medication Error
  Reporting
• Fall 2005 Baseline assessment of 23 CAHs (2,266
  employees)
• Spring 2007 Reassessment of 21 CAHs (2,350)
• Shared with QIOs rural adaptations of survey
  Excel data tool
• Two publications accepted for AHRQ Advances in
  Patient Safety
• Consulting provided to 45 hospitals in four
  states outside NE
• Developed fee for service model to conduct survey
  in CAHs
• Fall 2006 2 CAHs (440 employees)
• Spring 2007 4 CAHs (454 employees)
• Fall 2007 3 CAHs (440 employees)

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Barriers to Effective HSOPSC Data Collection in
CAHS

• Lack of knowledge of sound survey administration
• Group administration introduces bias (priming for
  desired results)
• Inappropriate collapsing of work area/position
• Concerns about anonymity in small organizations
• Lack of technology/knowledge for data entry and
  analysis

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UNMC Use of Rural-Adapted HSOPSC

• NRHA HSOPSC Pilot Program/NRHA Quality Initiative
  
• NRHA contracted with UNMC to administer HSOPSC
• Standardized rural survey
• Sound survey methodology (yields response rate gt
  50)
• RESULT Valid database for rural benchmarking
• Reflects IOM Quality Through Collaboration
• Summer 2008 11 Hospitals participating (1808
  employees)
• NRHA subsidizing cost of conducting the survey

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UNMC Use of Rural-Adapted HSOPSC

• UNMC Totals Administering HSOPSC
• 45 rural hospitals
• 7,605 employees
• Response Rate to date 4117/5797 71

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What do your UNMC/NRHAresults look like?

• Premier Customized Excel Data Tool available for
  entering and analyzing the survey data
  http//www.premierinc.com/quality-safety/tools-se
  rvices/safety/store/custom-tool
• Set Macro security level at medium from your
  toolbar
• (Tools Macro Security, then click medium)
• Benchmark Graph
• Communicate results
• Overview of facility-wide action plan
• Benchmark to Peers
• Management vs. Non-management Spreadsheet
• Code Open-ended Comments
• Executive Summary

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O Outcome measure U Measured at level of
unit/department H Measured at level of hospital
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Just Culture Reporting Nurse Beliefs
Behaviors
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Reporting Feedback Nurse Beliefs Behaviors
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Flexible Culture Nurse Communication Teamwork
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Flexible Culture Teamwork Staffing
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Flexible Culture Hospital Handoffs Transitions
Acute/ Skilled
Surgery
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Learning Culture Learning Overall Perceptions
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Aggregating Data Results In Loss Of Information

• What does the average height of two people tell
  you about either one?
• What do your hospitals aggregate results tell
  you about a specific department or job area?

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Comparison of percent-positive scores on 12
safety culture dimensions by work area, 2007
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Comparison of percent-positive scores on 12
safety culture dimensions by position, 2007
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Administering the Survey

• Obtain list of all employees in four categories
• Direct patient contact
• Work directly affects patient care (ward clerk,
  pharm lab techs)
• Management
• Provider (MD, PA, APRN)
• Cost Estimate based on fixed and variable costs
• 100 employees approx 1,500
• Dillman tailor-designed method of 4 contacts
• Pre-notification letter
• Wave 1 cover letter, survey, postage paid
  envelope to UNMC
• Postcard reminder
• Wave 2 thank you or repeat wave 1

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Data Analysis and Reporting

• Surveys scanned into database
• Each hospitals data imported into Excel Data
  Tool
• Benchmark Graphs
• Management vs. Non-management Spreadsheet
• Coding of Open-ended comments
• Executive Summary
• Distribute all documents electronically
• Telephone Conference Call

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Coding Open-Ended Comments

• Qualitative analysis using themes from the
  literature
• 15 provide a comment
• Most prevalent themes
• Feedback about patient safety systems
• Specific patient safety concern
• Evidence of positive patient safety culture
• Lack of teamwork
• Organizational pride

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Coding Open-Ended Comments
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Coding Open-Ended Comments
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Understanding Your Results

• Response Rate
• gt 60 best, how do responders and nonresponders
  differ?
• Wrap your mind around reverse worded questions
• Positive for patient safety, positive may be to
  disagree
• Can you identify microcultures by job title/work
  area?
• Are open-ended comments consist with data?
• What is your pattern of information flow?
• Generative, bureaucratic, pathologic?
• What practices are supporting the 4 components?

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Role of HSOPSC

• Measure beliefs and behaviors needed to support
  an informed, safe culture
• Raise awareness about role of culture
• Identify impairments in organizational learning
• Evaluate effectiveness of patient safety
  interventions
• Conduct internal external benchmarking
• Meet regulatory requirements (Joint Commission)

Nieva, Sorra. (2003). Safety culture assessment
a tool for improving patient safety in healthcare
organizations. Qual Saf Health Care, 12(Suppl
II), ii17-ii23. Jones, Skinner, Xu, Sun,
Mueller. (2008). The AHRQ Hospital Survey on
Patient Safety Culture a tool to plan and
evaluate patient safety programs. Advances in
Patient Safety New Directions and Alternative
Approaches. (In press).
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The Responsibility of Leadership

• Our systems are too complex to expect merely
  extraordinary people to perform perfectly 100 of
  the time. We as leaders have a responsibility to
  put in place systems to support safe practice.
• James Conway,
• former VP and COO Dana Farber Cancer Institute

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Contact Information

• Katherine Jones, PhD, PT
• kjonesj_at_unmc.edu
• Anne Skinner
• askinner_at_unmc.edu
• Web site where tools are posted
• www.unmc.edu/rural/patient-safety

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The AHRQ Hospital Survey on Patient Safety
Culture A Service Offered by the University of
Nebraska Medical Center and the National Rural
Health Association

• Administration
• Interpretation
• Action Planning

• For more information, please contactAnne
  Skinneraskinner_at_unmc.edu 402-559-8221