Katherine Jones, PT, PhD

1
Build Infrastructure for Safety and Quality
Interpreting Results from the AHRQ Hospital
Survey on Patient Safety Culture

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

Webinar June 19, 2009 200 pm 400 pm
Supported by AHRQ Office of Communications and
Knowledge Transfer, Nebraska Rural Hospital
Flexibility Program, St. Elizabeth CAH Link,
Good Samaritan Network
2
Objectives

• Use a working definition of culture of patient
  safety to interpret HSOPS results
• Identify four components of safety culture
• Benchmark your HSOPS results to a peer group of
  37 Critical Access Hospitals and to any previous
  results
• Compare results for attitudes and behaviors
  within HSOPS dimensions
• Identify variation in safety culture by work area
  and job title
• Describe key practices that support safety
  culture
• Explain effect of TeamSTEPPS training on HSOPS
  results
• Create an action plan to engineer key practices
  that support safety culture TeamSTEPPS is one
  practice

3
Acronyms

• AHRQ Agency for Healthcare Research and Quality
• HRO High Reliability Organization
• HSOPS Hospital Survey on Patient Safety Culture

4
The Problem and Challenge

• 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, p. 49
• 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. 7

5
Chain of Impact at the Point of Care
Healthcare System Structures Processes
Organizational Structures Processes
Beliefs Culture Behaviors
Individual Provider Structures Processes
Interpersonal Care
Technical Care
Quality at Point of Care

• The quality, safety and value of care can be no
  better than the structures and processes used by
  providers in direct contact with the patient.
  Culture is a lens through which organizations
  support providers at the point of care.
• Nelson et al. (2002) Joint Commission Journal on
  Quality Improvement, 28, 472-493.
• Swuste P. (2008). Human Factors and Ergonomics in
  Manufacturing, 18, 438-453.

5
6
What did we measure with HSOPS?

• Safety CultureThe enduring, shared beliefs and
  behaviors that reflect an organizations
  willingness to learn from errors
• Four 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
• People who work in teams make fewer errors

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. Institute
of Medicine. To err is human Building a safer
health system. Washington, DC The National
Academies Press 2000.
7
Four Components of Safety Culture
A culture of safety is informed. It never forgets
to be afraid
Flexible

• Reason, J. (1997). Managing the Risks of
  Organizational Accidents. Hampshire, England
  Ashgate Publishing Limited.
• Battles et al. (2006). Sensemaking of patient
  safety risks and hazards. HSR, 41(4 Pt 2),
  1555-1575.

8
How to Become an HRO Engage in Continuous
Improvement
9
How do we measure safety culture in healthcare?

• Patient Safety Culture Surveys funded by AHRQ
  and developed by Westat to support a culture of
  patient safety and quality improvement in the
  Nation's health care system http//www.ahrq.gov/qu
  al/patientsafetyculture/
• Hospital Survey on Patient Safety Culture (HSOPS)
  11/04
• Nursing Home Survey on Patient Safety Culture
  (NHSOPS) 12/08
• Medical Office Survey on Patient Safety Culture
  (MOSOPS) 12/08

10
HSOPS

• Original AHRQ Survey available
  http//www.ahrq.gov/qual/patientsafetyculture/
• AHRQ Comparative Database for HSOPS
• 2009 Comparative Database for Benchmarking
• 622 hospitals and 196,462 hospital staff
  respondents
• UNMC will submit your results to the database by
  June 30
• Access to a report with your hospital compared to
  national data
• First time completing the survey in 2008 or 2009
  send the following information to Anne
  (askinner_at_unmc.edu)
• AHA ID (7 digits)
• Medicare Provider ID (7 digits)
• You will receive request from Westat for Data Use
  Agreement

11
UNMC Rural-Adapted Version of HSOPS

• Available at www.unmc.edu/rural/patient-safety
  
• Developed by UNMC as part of AHRQ Partnerships in
  Implementing Patient Safety Grant 05 -07
• Collapses work areas and position to reflect CAH
  environment
• Allows sorting by Work Area/Position if gt 5
  respondents
• Creates valid benchmark data for CAHs
• Allows valid tracking of safety culture over time
  within a CAH to evaluate patient safety
  interventions

12
Original AHRQ HSOPS
33
Rural-Adapted AHRQ HSOPS
9
13
Original AHRQ HSOPS
22
Rural-Adapted AHRQ HSOPS
7
14
HSOPS

• 42 items categorized in 12 dimensions
• 2 dimensions measure outcomes at dept/unit level
• Overall perceptions of safety
• Frequency of events reported
• 7 dimensions measure culture at dept/unit level
• 3 dimensions measure culture at hospital level
• 2 additional items measure outcomes at dept/unit
  level
• Number of Events Reported
• Patient Safety Grade

15
O Outcome measure at level of unit/department U
Measured at level of unit/department H
Measured at level of hospital
15
16
16
17
Responses

• 37 CAHs participated in survey
• 34 Nebraska
• 2 Iowa
• 1 Louisiana
• 3465 returns/ 4601 sent 75.3 response rate
• Average response rate reported to National
  Database 52
• Range of Response Rates across 37 CAHs 51 -
  96
• Acceptable Rate is 50
• Do nonresponders differ from responders?
• Lower response rate limits comparisons by work
  area/job title
• Good Rate is 60
• Ensures that results are reflective of
  organization respondents not likely to differ
  significantly from nonresponders

18
Your Results
19
Excel Tool Template Demo

• Contains raw data
• Instructions for interpretation of results
• Demographics of respondents
• Aggregate results and item level results by
• work area, position, and direct patient care
• Your primary DATA ANALYSIS TOOL

20
Excel Tool Security Settings

• For Excel versions prior to Excel 2007
• Click Tools on the Excel Menu Bar
• Click Macro
• Click Security and then select Medium,
• Close the file and re-open it.
• For Excel 2007
• Click the Windows button in the top left corner
  of the screen
• Click Excel Options on the bottom of the menu
• Click Trust Center on the left of the menu
• Click Trust Center Settings.... on the middle
  right of the menu
• Click Macro Settings on the left of the menu
• Select Enable all macros
• Click OK at the bottom of the menu
• The macros should now be active. If you
  experience problems, please close and reopen
  Excel.

21
Aggregate Results for Comparison

• Number of Events Reported
• None 53
• 1 to 2 26
• 3 to 5 13
• 6 to 10 5
• 11 to 20 2
• 21 or more 1

• Patient Safety Grade
• A - Excellent 27
• B - Good 53
• C - Acceptable 17
• D - Poor 2
• E - Failing 0.06

22
(No Transcript)
23
(No Transcript)
24
Benchmarks

• Compare aggregate results to peer group (external
  benchmark)
• Identify strengths and opportunities for
  improvement
• Compare aggregate results over time
• Compare results by work area and job title to
  the aggregate
• Your primary COMMUNICATION TOOL
• X-Axis contains 12 dimensions
• 2 dept level outcome measures
• 7 dept level safety dimensions
• 3 hospital level safety dimensions

25
(No Transcript)
26
Comparison of Strengths/Weaknesses
27
(No Transcript)
28
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?

29
(No Transcript)
30
(No Transcript)
31
(No Transcript)
32
Item Level Over Time TS

• Compare item level results for hospital over time
  
• Compare item level results to peer group
• Assess teamwork-related knowledge and behavior

33
Hospital taking great steps to improve pt.
safety. Ex increasing tech comp. charting,
EMAR.etc.
Patient safety, med error reporting, event
reporting and accountability have improved 10
fold in the past 5 years. TEAM STEPPS training,
very good!
34
I'm an itinerant surgeon and go to (sample town)
4-6x/year. Of the numerous small hospitals I go
to, they are probably one of the most concerned
with patient safety. They also seem to work well
together.
35
I think administration is working very hard to
promote safety. We all should be proud to work
here and be cooperative with making it work.
36
Since TEAMSTEPPS training, the culture of safety
has increased, there are still safety concerns
esp. in the specialty areas or when a special pt
comes in
37
We have a lot of personalitiesa lot of older
employees who feel they have done their part and
time for someone else to carry the load. We also
have slackers who hide and don't pitch in when
there is an increase in work.
38
Comments Coded by Theme

• Open ended comments coded by 27 culture-related
  themes
• Provides respondents direct feedback feedback
  is a gift
• 17 of respondents provided an open-ended comment
• Respondents from hospitals with more positive
  perceptions of safety tended to provide fewer
  comments

39
Comments Coded by Theme

• Top Comments 13 Baseline CAHs
• Patient Safety Systems F/back 7
• Safety Concern 5
• Lack of Effective Teamwork 5
• Safety Concern - Staffing 3
• Patient Safety is a Top Priority 2
• Lack of Professionalism - Leadership 2

• Top Comments 24 TeamSTEPPS Hospitals
• Lack of Effective Teamwork 8
• TeamSTEPPS Feedback 6
• Patient Safety Systems F/back 6
• Safety Concern 5
• Lack of Professionalism - Staff 3
• Progress in Patient Safety 3

40
Coding Open-Ended Comments
41
Coding Open-Ended Comments
42
HSOPS Action Plan

• Work sheet to anchor your action plan in your
  mission and strategic goals and identify
  practices needed to support safe culture
• How will improved teamwork and communication
  skills help you achieve your mission and
  strategic goals?

43
Interpreting Results to Develop an Action Plan

• Anchor plan in history, mission, strategic goals
• Understand response rate (gt 60 best)
• Wrap your mind around reverse worded questions
• Identify organization-wide areas in need of
  improvement
• Identify microcultures by work area/job title
• Identify gaps between beliefs/behaviors within
  work areas / job titles

44
Interpreting Results to Develop an Action Plan

• Identify practices in place that support 4
  components within departments
• Score card item 6 on plan
• Relate open-ended comments to quantitative
  results
• Create an explicit plan to strengthen four
  components of a safe culture within depts by
  implementing specific practices
• Web site where tools are posted
• www.unmc.edu/rural/patient-safety

45
Four Components of Safety Culture
A culture of safety is informed. It never forgets
to be afraid

• Reason, J. (1997). Managing the Risks of
  Organizational Accidents. Hampshire, England
  Ashgate Publishing Limited.
• Battles et al. (2006). Sensemaking of patient
  safety risks and hazards. HSR, 41(4 Pt 2),
  1555-1575.

46
A Reporting culture is engineered by implementing
practices . . .

• Any safety information system depends crucially
  on the willing participation of the workforce,
  the people in direct contact with the hazards. To
  achieve this, it is necessary to engineer a
  reporting culturean organization in which people
  are prepared to report their errors and
  near-misses. (Reason, p. 195)

47
A Reporting culture is engineered by implementing
practices . . .

• Successful reporting systems (Leape, 2002)
• Nonpunitive
• Confidential
• Independent
• Expert analysis
• Timely
• Systems-oriented
• Responsive

• Practices/Tools
• Reporting Form
• Near miss log
• Chart audit
• Secret Shopper
• Safety Briefings
• Leadership WalkRoundsTM
• Bulletin board/ suggestion box/telephone hotline

48
www.MEDMARX.com
49
NCC MERP Taxonomy of Error Severity

• A capacity to cause error
• B error occurred, did not reach patient
• C error reached patient, no harm
• D error reached patient, monitoring and
  intervention required
• E temporary harm requiring intervention
• F temporary harm requiring initial or prolonged
  hospitalization
• G permanent harm
• H intervention required to sustain life
• I error contributed to or resulted in death

http//www.nccmerp.org/pdf/taxo2001-07-31.pdf
50
Near-miss Log Sheet
51
Sample Action Plan Aims

• We need to improve our reporting culture because
  just 25 of nurses frequently report near misses.
• We will do this by using the NCC MERP taxonomy of
  error severity to categorize errors we will
  educate staff regarding the purpose of the
  taxonomy.
• We will implement a near miss reporting log in
  all clinical work areas and collect near misses
  at shift change and WalkRounds by Sept. 1, 2009.

52
Four Components of Safety Culture
A culture of safety is informed. It never forgets
to be afraid

• Reason, J. (1997). Managing the Risks of
  Organizational Accidents. Hampshire, England
  Ashgate Publishing Limited.
• Battles et al. (2006). Sensemaking of patient
  safety risks and hazards. HSR, 41(4 Pt 2),
  1555-1575.

53
A Just culture is engineered by implementing
practices . . .

• The willingness of workers to report depends on
  their belief that management will support and
  reward reporting and that discipline occurs based
  on risk-takingthere is a clear line between
  acceptable and unacceptable behavior
  organizational practices support a just culture.
  

54
A Just culture is engineered by implementing
practices . . .

• Practices/Tools
• Understanding human error (Reason 2003, 2006)
• Active errors (sharp end)
• Latent errors
• Just Culture and behavior (Marx, 2001)
• Conduct human error, negligence, reckless,
  intentional rule violation
• Disciplinary decision-making outcome-based,
  rule-based, risk-based
• Unsafe Acts Algorithm
• Disruptive Behavior Policy/Standards

55
A just culture requires an understanding of the
nature of human error.
Just Culture Engage Educate
Missed exit XR not reg
Run stop sign Adult dose vs. flush
Cell phone drunk Refuse time out
U Turn No 5 Rights
Marx, D. (1997). Patient safety and the just
culture A primer for health care executives.
Reason, J. (1997). Managing the risks of
organizational accidents.
56
Execute Just Culture . . . UNSAFE ACTS ALGORITHM
Sabotage, malevolent damage
Culpable
Gray Area
Blameless
Adapted from James Reason. (1997). Managing the
Risks of Organizational Accidents.
57
Importance of Just Culture

• The single greatest impediment to
• error prevention in the medical
• industry is that we punish people
• for making mistakes.
• Dr. Lucian Leape
• Professor, Harvard School of Public Health
• Testimony before Congress on
• Health Care Quality Improvement

58
Sample Action Plan Aims

• We need to improve our nonpunitive response to
  error and perception of a just culture because
  60 of nurses feel like the person is being
  reported rather than the event.
• We will do this by being transparent with all
  staff about how the decision is made whether or
  not to hold an individual accountable for an
  event.
• We will teach all managers to use the Unsafe Acts
  Algorithm as a guide to deciding individual vs.
  system culpability by Sept.1, 2009.

59
Four Components of Safety Culture
A culture of safety is informed. It never forgets
to be afraid

• Reason, J. (1997). Managing the Risks of
  Organizational Accidents. Hampshire, England
  Ashgate Publishing Limited.
• Battles et al. (2006). Sensemaking of patient
  safety risks and hazards. HSR, 41(4 Pt 2),
  1555-1575.

60
A Flexible culture is engineered by implementing
practices . . .

• The willingness of workers to report depends on
  their belief that authority patterns relax when
  safety information is exchanged because managers
  respect the knowledge of front-line
  workersorganizational practices support a
  flexible culture, which adapts to changing
  demands.

61
The Problem

• Absence of team-related skills such as
  leadership, structured communication,
  adaptability to changing workloads, planning,
  team performance improvement
• The Solution
• People make fewer errors when they work in
  teams.
• To Err is Human Building a Safer Health System

62
A Flexible culture is engineered by implementing
practices . . .
Team Strategies Tools to Enhance Performance
Patient Safety
http//teamstepps.ahrq.gov/
63
Outcomes of TeamSTEPPS

• Knowledge
• Shared Mental Model of Team Skills
• Attitudes
• Mutual Trust
• Team Orientation
• Performance
• Adaptability
• Accuracy
• Productivity
• Efficiency
• Safety

64
TOOLS and STRATEGIES Brief Huddle
Debrief STEP Cross Monitoring Feedback Advocacy
and Assertion Two-Challenge Rule CUS DESC
Script Collaboration SBAR Call-Out Check-Back Hand
off

• OUTCOMES
• Evidence-based Shared Mental Model
• Adaptability
• Team Orientation
• Mutual Trust
• Team Performance
• Patient Centered
• Patient Safety!!

• BARRIERS
• Inconsistency in Team Membership
• Lack of Time
• Lack of Information Sharing
• Hierarchy
• Defensiveness
• Varying Communication Styles
• Conflict
• Lack of Coordination/Follow-Up with Co-Workers
• Distractions
• Fatigue
• Workload
• Misinterpretation of Cues
• Lack of Role Clarity

65
Paradigm Shift to Team System Approach
Single focus (clinical skills) Individual
performance Under-informed decision-making Loose
concept of teamwork Unbalanced workload Having
information Self-advocacy Self-improvement Individ
ual efficiency
Dual focus (clinical and team skills) Team
performance Informed decision-making Clear
understanding of teamwork Managed
workload Sharing information Mutual support Team
improvement Team efficiency
66
Sample Action Plan Aims

• We need to improve our communication within depts
  because just 18 of acute/skilled care personnel
  feel free to question the decisions/actions of
  those with more authority.
• We will strengthen our communication skills and
  make it psychologically safe to advocate for the
  patient.
• We will do this by using SBAR for communication
  between all who exchange patient information, and
  by teaching all staff to use CUS.
• We will start with acute care Nurses and support
  staff will effectively use SBAR and CUS by Dec.
  1, 2009.

67
Sample Action Plan Aims

• We need to improve our ability to manage changing
  work loads because 83 of acute/skilled care
  staff believe they support one another but just
  15 help each other out when it gets busy.
• We will do this by teaching leadership skills
  including briefs, huddles, and debriefs and
  mutual support skills including seeking and
  offering task assistance.
• We will start with acute care Nurses and support
  staff will effectively use huddles, briefs, and
  debriefs and seek and offer task assistance by
  Dec. 1, 2009.

68
Four Components of Safety Culture
A culture of safety is informed. It never forgets
to be afraid

• Reason, J. (1997). Managing the Risks of
  Organizational Accidents. Hampshire, England
  Ashgate Publishing Limited.
• Battles et al. (2006). Sensemaking of patient
  safety risks and hazards. HSR, 41(4 Pt 2),
  1555-1575.

69
Reporting, Just, and Flexible practices support
organizational Learning

• Practices/Tools
• Individual RCA
• Aggregate RCA
• FMEA
• Safety Briefings
• Leadership WalkRounds
• Close the loop with reporting

• Ultimately, the willingness of workers to report
  depends on their belief that the organization
  will analyze reported information and then
  implement appropriate changeorganizational
  practices support a learning culture.

70
Leadership WalkRoundsTM

• Senior leaders demonstrate commitment to safety,
  learn about safety issues by making regular
  rounds to discuss safety with front-line staff
• Communication is two-way, leaders and staff talk
  honestly and listen carefully (reporting)
• Unannounced or announced but must be regular
  (weekly)
• Focus on systems not individuals (just)
• Close the loop on communication (flexible)
• use a notebook and database to track reported
  events and their resolution (learning)
• Digital camera can capture unsafe
  equipment/environment

http//www.unmc.edu/rural/patient-safety/Toolbox/I
nteraction/Interaction.htm
71
Were interested in focusing on the system and
not individuals

• Can you think of any events in the past day or
  few days that have resulted in prolonged
  hospitalization for a patient?
• Have there been any near misses that almost
  caused patient harm but didnt?
• Have there been any incidents lately that you
  can think of where a patient was harmed?
• What aspects of the environment are likely to
  lead to the next patient harm?
• Is there anything we could do to prevent the
  next adverse event?
• Can you think of a way in which the system or
  your environment fails you on a consistent
  basis?
• How are we actively promoting a just culture and
  a non-punitive, confidential reporting policy?

72
Sample Action Plan Aims

• We need to improve our practices to support
  organizational learning because less than 1/3 of
  staff believe that our procedures and systems are
  good at preventing errors.
• We will improve our communication and feedback
  about error by using Safety Briefings, Leadership
  WalkRounds, feeding back aggregate results of
  error reports, and summarizing RCA action plans.
  
• We will educate staff in individual and aggregate
  RCA.
• We will start with acute care Nurses and
  clinical support departments will effectively use
  individual and aggregate RCA by March 1, 2010.

73
The Importance of Teams in Organizational Learning

• Teams are the fundamental learning units in
  modern organizations. Unless teams can learn,
  organizations cannot learn.
• Peter Senge (1990). The Fifth Discipline The Art
  and Practice of the Learning Organization. New
  York Doubleday Currency, p. 10.

74
What is a learning culture?

• It observes and collects data
• It reflects and draws correct conclusions from
  information systems
• It creates and plans change based on information
• It has the will to act and implement change
• Learning disabilities are tragic in children,
  but they are fatal in organizations. -- Peter
  Senge

Reason, J. (1997). Managing the Risks of
Organizational Accidents. Hampshire, England
Ashgate Publishing Limited.
75
Conclusion HSOPS Guides Implementation of an
Infrastructure for Patient Safety

• Interaction between effective practices results
  in sensemaking within macro- and microsystems
• Sensemaking requires data, which is interpreted
  within the context of the lived experiences of
  those in direct contact with patients
• Sensemaking can not occur without data, trust
  and teamwork
• Battles et al. (2006). Sensemaking of patient
  safety risks and hazards. HSR, 41(4 Pt 2),
  1555-1575.

75
76
Lessons Learned

• Behaviors that support an informed safe culture
• Assess safety culture using effective data
  collection methods
• Create an infrastructure that supports systematic
  reporting
• Adhere to principles of just culture
• Implement team training to support a flexible
  culture
• Learn from error in the context of daily work
  (Safety Briefings and Leadership Walkrounds)
• Systematically learn from events using individual
  RCA and aggregate RCA to learn from multiple
  non-harmful errors

77
Lessons Learned

• HSOPS is a strategic management tool
• Identifies practices needed to support an
  informed, safe culture
• Rural-adapted survey reveals culture variation
  within small rural hospitals
• Detects and evaluates change in culture over time
  
• Reassessment with HSOPS reveals
• How leaders use information
• If organizations engineered practices to support
  four components of culture in response to
  baseline survey
• Presence/absence of change strategy

78
Diffusion of InnovationsChange Strategy for
TeamSTEPPS

• Getting a new idea adopted, even when it has
  obvious advantages, is difficult. Many
  innovations require a lengthy period of many
  hears from the time when they become available to
  the time when they are widely adopted. Rogers
  in Diffusion of Innovations, p. 1

79
Diffusion of InnovationsChange Strategy for
TeamSTEPPS

• Decision process
• Knowledge Training
• Persuasion View innovation favorably
• Implementation Use innovation, re-invent
• Confirmation Use of innovation is reinforced

• Characteristics of successful innovation
• Relative advantage Better than the old way
• Compatability Fits with my values and
  experience
• Complexity Not too difficulty
• Trialability Can take it for a test drive
  dosing strategy
• Observability I see others doing it

80
(No Transcript)
81
(No Transcript)
82
Big Picture

• What did we measure with the survey?
• Safety Culture
• Why did we measure safety culture?
• 24 CAHs - Evaluate impact of TeamSTEPPS
• 13 CAHs - Determine baseline safety culture to
  inform action plan for TeamSTEPPS
• What did we learn?
• TeamSTEPPS is a complex patient safety
  intervention
• TeamSTEPPS is an investment in your human capital
• People have to be ready to improve their teamwork
  and communication skills

83
Summary Role of HSOPS

• 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 over time within an organization
• Conduct internal external benchmarking
• Meet regulatory requirements

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
84
Why conduct HSOPS with UNMC?

• Use rural-adapted version of HSOPS that reflects
  CAH environment enables sorting by work
  area/position
• Standardize administration of survey
• Provide anonymity to employees
• Obtain guidance in analysis and interpretation
• Benchmark results to peers
• 24 CAHS evaluate patient safety interventions
  over time
• Medication Error Reporting 2005 2007
• TeamSTEPPS 2008 2009
• Establish a baseline (13 CAHs) to plan TeamSTEPPS
  intervention

85

• Once the AHRQ survey identified areas for
  improvement, through the grant, we spent the next
  year working on those areas. The education and
  training on teamwork, communication, and RCA gave
  us tools we hadnt heard of. We have seen our
  organization change from one that makes the same
  errors over and over to one that analyzes errors
  and attempts to learn from them.

Lessons Learned from Dundy County, Nebraska
86
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

87
Contact Information

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