Build a Foundation for Quality: Interpreting HSOPSC Results and Action Planning

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Build a Foundation for Quality Interpreting
HSOPSC Results and Action Planning

• 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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Skills Objectives (What you do)

• Use examples of HSOPSC results to
• Identify safety culture strengths weaknesses
• Aggregate across an organization
• Within work areas
• Within job titles
• Identify gaps between beliefs behaviors within
  dimensions
• Describe key practices to address weakness
• Create an action plan to engineer key practices

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Knowledge Objectives (What you know)

• Build on previous knowledge
• Recognize that HSOPSC dimensions measure four
  components of an informed, safe culture
• Compare beliefs and behaviors within HSOPSC
  dimensions
• Identify relationships between HSOPSC dimensions
• Recognize that culture varies within an
  organization
• Define active learning transformative learning
• List four stages of active learning
• Describe three attitudes toward transformative
  learning
• Describe key organizational practices that
  support four components of an informed, safe
  culture

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Attitudes Objectives (What you think is
important)

• Believe that active learning in teams leads to
  transformative learning in organizations
• Value the cumulative effect of the interaction of
  key practices that support organizational learning

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Active and Transformative Learning

• Active Learning
• An approach to working with and developing
  people which uses work on a real project or
  problem as the way to learn.
• Transformative Learning
• The use of critical reflection to transform
  taken-for-granted frames of reference
  (assumptions) reframe the problem

Mezirow et al. (1990). Learning as
Transformation. San Francisco Josey-Bass.
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Characteristics of Transformative Learners

• Seek more accurate and complete information
• Free from coercion
• Open to alternative points of view
• Objectively consider evidence
• Critically reflect on own assumptions
• Have an opportunity to participate in discussion
  and problem solving
• Willing to accept a new frame of reference that
  is validated through evidence and discussion

Mezirow et al. (1990). Learning as
Transformation. San Francisco Josey-Bass, pp.
13-14.
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Frame of Reference? Think Pair Share

• 1 not at all 2 to some extent 3
  a great deal
• There is an organization wide sense of
  susceptibility to the unexpected.
• Everyone feels accountable for reliability.
• Leaders pay as much attention to managing
  unexpected events as they do to achieving formal
  organization goals.
• We spend time identifying how our activities
  could potentially harm patients, employees, the
  organization.
• We pay attention to when and why our patients and
  our employees might feel frustrated or
  disenfranchised.
• There is widespread agreement about how things
  could go wrong.

Weick Sutcliffe (2001). Managing the
Unexpected. p. 90
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What is your frame of reference?

• Employees should be more careful and
  professional.
• My organization could better support employees
  with the infrastructure they need to be a high
  reliability organization.

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Stages of Active Learning

• Expand an existing frame of reference
• Communication could be improved lets try SBAR
• Learn a new frame of reference
• Human beings easily misunderstand each other so
  communication should be structured lets use
  SBAR
• Transform your point of view
• Hospitals should embrace concepts of high
  reliability because human error is inevitable
  HROs use structured communication lets use SBAR
• Transform your habits of mind
• Because human beings are imperfect, I can use
  structured communication in my professional and
  personal communication to decrease likelihood of
  misunderstandings

Mezirow et al. (1990). Learning as
Transformation. San Francisco Josey-Bass.
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Attitudes toward Transformative Learning

• Embrace and absorb
• Skeptical then connect
• Resistant and defensive

Mezirow et al. (1990). Learning as
Transformation. San Francisco Josey-Bass.
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Solution
Change belief system
Difficulty of Implementation
Modify existing behavior
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Measurement To Identify Impairments
Interventions To Improve Practices
ENGINEERING A CULTURE OF SAFETY Inventory of
Tools www.unmc.edu/rural/patient-safety/tools/Inve
ntory.htm
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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)

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A Reporting culture is engineered by implementing
practices . . .

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

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

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Characteristics of Successful Reporting Systems

• Nonpunitive reporters do not fear punishment
• Confidential reporter not revealed to those who
  discipline
• Independent reporting system independent of
  discipline
• Expert analysis reports analyzed by those with
  systems knowledge
• Timely reports are analyzed promptly
  recommendations disseminated rapidly
• Systems-oriented recommendations focus on
  systems
• Responsive those receiving reports are capable
  of disseminating/implementing recommendations

Leape, LL. (2002). Reporting of adverse events.
NEJM, 347, p. 1636.
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www.MEDMARX.com
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Systematic Data Collection in Medication Error
Reporting

• Description of the error
• Error severity based on the outcome to patient
• Phase of the medication use process in which the
  error originates
• Type of the error
• Cause of the error
• Contributing factors to the error
• Information about the drug(s) involved

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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
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Near-miss Log Sheet
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Reporting Error Severity
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Reporting Where Errors Originate
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Reporting Types of Errors
Jones et al. (2006). http//www.unmc.edu/rural/doc
uments/pr06-08.pdf
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Reporting Causes
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Reporting Contributing Factors
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What we heard about using MEDMARX as the
foundation for reporting in Critical Access
Hospitals

• Before the project, we just counted errors. We
  never went past the type of error.
• Without the language of errors associated with
  MEDMARX, all we could talk about was who did it
  and not what happened and why. MEDMARX created a
  standardized process that allowed us to collect
  more information. The use of MEDMARX and its
  graphs and charts contributes to the perception
  of errors as having a system source.

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Safety Briefings Background

• Based on briefings developed in aviation to
  overcome barriers to communication
• All staff are equal when voicing safety concerns
• Safety is discussed routinely, 24/7, in the
  context of daily work

http//www.ihi.org/IHI/Topics/PatientSafety/Safety
General/Tools/SafetyBriefings28IHITool29.htm
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Ground Rules for Briefings

• All gather in a designated area
• Be brief5 minutes and stick to it!
• Remember the purpose increase awareness of
  safety issues
• Remember non-punitive information for patient
  care onlynever used in performance appraisal
• All opinions have equal value
• Ask open-ended questions

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Start of Shift Briefing

• What safety issues should staff be aware of
  today?
• Are there patients with similar names ?
• Non-formulary drugs ordered?
• Elderly patients at risk for falls?
• New equipment?
• Changes in the work environment?
• Changes in work flow?
• Any staff assigned work that is not routine?
• Any staff doing work usually performed by others?
  
• Any staff working unusual shifts?

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End of Shift Debriefing

• Who encountered a safety issue related to
  medications?
• Who had a near miss with a medication today?
• How many staff had patients who asked questions
  or made comments about medications today?
• How many were near misses that a patients
  comment prevented?
• Are there safety issues (staff or patient) that
  should prompt action?
• Are there process changes that should be made?

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Improvements in nurse perceptions of reporting
culture 2005 vs. 2007 as a result of systematic
reporting of medication errors using MEDMARX
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Nurse 05
Aggregate 05
Nurse 07
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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.
  

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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

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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.
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Execute Just Culture . . . UNSAFE ACTS ALGORITHM
NO
NO
NO
YES
NO
YES
YES
YES
YES
NO
Known medical condition?
NO
YES
YES
YES
NO
YES
NO
Culpable
Gray Area
Blameless
Adapted from James Reason. (1997). Managing the
Risks of Organizational Accidents.
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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

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Improvements in nurse perceptions of just culture
2005 vs. 2007 as a result of systematic reporting
of medication errors using MEDMARX and education
about human error
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Nurse 07
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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.

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

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

http//teamstepps.ahrq.gov
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Importance of Team Structure

• Team Structure
• Complementary skills
• Interdependent tasks
• Clear role expectations
• Common purpose
• Performance goals
• Mutual accountability
• Curriculum
• Train the Trainer
• Fundamentals
• Essentials

http//teamstepps.ahrq.gov
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Skill Overview Leadership

• Organize the team
• set clear goals delegate tasks
• manage resources
• Ensure team members share information
• Formal team meetings informal exchange sessions
• Make decisions through collective input
• Empower team members to speak up
• Resolve conflict
• Actively model and facilitate good teamwork
• May be designated or situational

http//teamstepps.ahrq.gov
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Skill Overview Situation Monitoring
SituationMonitoring(Individual Skill)
SituationAwareness(Individual Outcome)
Status of the patient Team Members Environment Pro
gress toward Goal
Shared Mental Model(Team Outcome)
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Skill Overview Mutual Support

• Back up behavior to prevent work overload
• Task assistance is sought and offered
• Provide effective feedback Timely, Respectful,
  Specific, Directed towards improvement,
  Considerate
• Advocate for the patient through conflict
  resolution
• CUS to solve information conflicts
• Im concerned ( I need clarity)
• Im uncomfortable
• Consequences in terms of patient safety
• DESC Script to solve personal conflicts
• Describe the behavior
• Express how the situation makes you feel
• Suggest alternatives
• Consequences stated in terms of patient safety

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TeamSTEPPS Mutual SupportTwo-Challenges
Rule
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Skill Overview Communication

• Exchange of information between a sender and a
  receiver
• Effective communication
• Brief
• Clear
• Timely
• Complete Know the plan, share the plan, review
  risk
• JCAHO National Patient Safety Goals require
  improvement in communication

Salisbury Hohenhous (2008)
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Communication Skills

• SBAR
• Situation what is going on with the pt.
• Background clinical background
• Assessment what do I think is the problem
• Recommendation how can we correct it

• Call-out
• Inform all team members simultaneously
• Check-back
• Close the loop as receiver accepts a message,
  sender double-checks to ensure message was
  received

http//teamstepps.ahrq.gov
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Communication Skills

• Handofftransfer of information (along with
  authority and responsibility) during transitions
  in care must include opportunity to ask
  questions, clarify, and confirm

• Introduction
• Patient
• Assessment
• Situation
• Safety Concerns

• Background
• Actions
• Timing
• Ownership
• Next

http//teamstepps.ahrq.gov
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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 and Follow-Up with
  Co-Workers
• Distractions
• Fatigue
• Workload
• Misinterpretation of Cues
• Lack of Role Clarity

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Disruptive Behavior

• Old frame of reference
• Tolerate the behavior as a way of doing business
• Shrug off the problem minor occurrence with no
  ill effects to patients or staff
• New frame of reference
• Disruptive behaviors have profound effect on
  patient safety and quality of care
• Not unique to physicians or healthcare
• Consequences permeate the organization
• Affect staff morale, patient and family
• Community perceptions and hospital reputation.
• Hospitals can no longer take a passive approach
  to disruptive behaviors

Rosenstein O'Daniel (2008). Neurology, 70,
1564-1570.
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Disruptive Behavior Calls for Leadership

• Joint Commission Standard LD.03.01.01 (1/09)
• Leaders create and maintain a culture of
  safety and quality throughout the organization.
• Elements of Performance for LD.03.01.01
• Leaders regularly evaluate the culture of safety
  and quality using valid and reliable tools.
• Leaders prioritize and implement changes
  identified by the evaluation.
• . . .3 - 11

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Improvements in nurse perceptions of flexible
culture 2005 vs. 2007 as a result of systematic
reporting of medication errors using MEDMARX,
education about human error, introduction of SBAR
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Nurse 07
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Nurse 07
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Nurse 07
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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

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Current Intervention TeamSTEPPS

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

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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.

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Five Basic Steps ofRoot Cause Analysis

• 1. Gather the facts using a timeline
• 2. Understand what happened
• 3. Identify root causes using causal statements
• 4. Determine system improvements to minimize risk
  of repeating the error
• 5. Create action plans to implement and monitor
  effectiveness of changes

http//www.unmc.edu/rural/patient-safety/Toolbox/I
nteraction/Interaction.htm http//www.unmc.edu/r
ural/patient-safety/tools/Conducting20Individual
20RCA.pdf
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Aggregate RCA

• Staff may be more receptive to change
• Process change based on multiple events
• Focus on potentially serious events--close calls
  and errors that reached the patient
• Staff may be less defensive because focus not on
  a harmful event...blame less prevalent
• May be used in any setting
• Inpatient, outpatient, long term care, acute
  care, home care
• Use in all types of reported events
• Falls, pressure ulcers, employee events, lab

http//www.unmc.edu/rural/patient-safety/Toolbox/I
nteraction/Interaction.htm
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Leadership WalkRoundsTM

• Senior leaders demonstrate commitment to safety
  and learn about safety issues by making regular
  rounds to discuss safety with 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
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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?

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Improvements in nurse perceptions of learning
culture 2005 vs. 2007 as a result of systematic
reporting of medication errors using MEDMARX,
education about human error, introduction of
SBAR, quarterly aggregate RCAs of falls and
nonharmful medication errors, and individual RCA
of harmful medication errors
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Nurse 07
70
Nurse 05
Nurse 07
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Nurse 05
Nurse 07
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Nurse 05
Nurse 07
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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.

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Active Learning

• Form groups of 5
• Review the Benchmark Graph
• What are the strengths and weaknesses revealed by
  the aggregate data?
• What practices are needed to support an informed,
  safe culture?
• Do you need additional information?
• Premier Excel Data Tool
• What are the top three practices you would
  recommend?

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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.
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8 Steps of Change
ENDURE
EXPAND
EVALUATE
EXECUTE
EDUCATE
ENGAGE
John Kotter
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Lessons Learned

• HSOPSC 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 HSOPSC 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

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Lessons Learned

• Behaviors that support an informed safe culture
• Assess safety culture using effective data
  collection methods
• Create an infrastructure that supports systematic
  error reportingreporting is the foundation of an
  informed, safe culture
• 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 WalkroundsTM)
• Systematically learn from events using individual
  RCA and aggregate RCA to learn from multiple
  non-harmful errors

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• 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
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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