Karen L' Hannah, WV

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Using Data to Drive Interventions and Create a
Culture of Safety in Rural Hospitals A
Four-StateCollaborative

• Karen L. Hannah, WV
• Christine OConnell, HI
• Rebecca Royer, IN
• Eva Powell, NC

Publication number 8SOW-WV-HOSP07.31
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Disclaimer
This material was prepared by the West Virginia
Medical Institute (WVMI), the Medicare Quality
Improvement Organization for West Virginia, under
contract with the Centers for Medicare Medicaid
Services (CMS), an agency of the U.S. Department
of Health and Human Services. The contents
presented do not necessarily reflect CMS
policy. Publication number 8SOW-WV-HOSP07.31
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Acknowledgements

• Part of this project is funded under AHRQ grant
  1UC1HS014920-1
• We would also like to acknowledge the assistance
  of Katherine Jones, PhD, PT, Assistant Professor
  of Preventive and Societal Medicine, University
  of Nebraska Medical Center

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Background

• WVMI received funding in 2004 for an AHRQ grant
  to improve patient safety in rural hospitals.
• As part of this grant, we surveyed our rural
  hospitals using the AHRQ Hospital Survey on
  Patient Safety Culture.
• We used the AHRQ template to create a scannable
  form of the survey, which we analyze using SAS
  and export to the AHRQ PowerPoint template.

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Background cont.

• In the 8th SOW, QIOs are required to use the AHRQ
  survey in Task 1c2.
• WVMI offered scanning and analysis services to
  any interested QIO.
• Three states Hawaii, Indiana and North Carolina
  took us up on our offer.

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The 4-State Collaborative Forms

• We began to notice similarities in survey
  response scores in several dimensions.
• Up to that point, we only had AHRQ benchmarking
  data for comparison.
• AHRQ benchmark data based on responses from large
  teaching hospitals not relevant to small rural
  and CAHs.
• Through a series of emails and conference calls,
  we decided to pool our resources.

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The 4-State Collaborative

• Began with the data common areas in which all
  our hospitals needed to improve.
• Weve begun a series of WebExs and instructional
  teleconferences hospitals in all 4 states
  invited to attend.
• Speakers can be QIO, recognized experts or
  hospitals themselves.
• First teleconference held 12/06/06.

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The Data

• Combined 30 rural IPG hospitals in our 4-state
  collaborative 80 are critical access.
• Many similarities, but some state/position
  differences noted.
• Data indicated areas where we might fruitfully
  work together.

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Dimension Scores by State
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Dimension Scores by Position Type
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Dimension Scores by Position Type
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Executive vs. Frontline Perceptions

• Executives overestimate
• Teamwork Climate 4X
• Safety Climate 2.5X
• Executive Confidence vs. Executive Accuracy
• Often wrong but rarely in doubt
• Currently no incoming data-streams
• Frontline data fills the gap

Source Brian Sexton, Ph.D., Assistant Professor.
Dept of Anesthesiology and Critical Care
Medicine, Johns Hopkins University
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Comments

• Comments analyzed according to taxonomy developed
  by Dr. Katherine Jones et al. at the University
  of Nebraska (slightly modified).
• Almost 600 comments received from 4 states.
• Almost 20 of comments dealt with specific
  patient safety concerns.
• Other significant categories dealt with staffing
  concerns (13) lack of leadership (12)
  evidence of positive safety culture (6) lack of
  communication openness (5) organizational pride
  (5) lack of teamwork (4) and bad apples
  (4).

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Themes Used to Code Comments

• Bad Apple
• Blame and Shame Culture
• Denial of Fallibility
• Evidence of Positive Safety Culture
• Evidence of Teamwork
• Frustrations with Organizational Change
• Ignorance Patient Safety is Responsibility of All
• Lack of Communication Openness
• Lack of Leadership - Patient Safety
• Lack of Leadership Professionalism
• Lack of Professionalism Staff
• Lack of System Continuity Across Shifts
• Lack of Teamwork
• Leadership Encourages Reporting
• Leadership Support for Patient Safety

• Management Emphasis on Productivity Not a
  Learning Organization - Lack of Action
• Not a Learning Organization - Lack of Feedback
• Not a Learning Organization - Lack of Reporting
• Organizational Pride
• Pathological Culture
• Patient Safety Concern
• Patient Safety is a Top Priority
• Professional Norm of Perfectionism
• ADDED
• Staffing Concerns
• I Hate My Job
• Doesnt Apply to Me
• Other Complaint

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Top Ten Comment Categories
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Top Ten Comment Categories by State
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Indiana

• Nine critical access hospitals (CAHs)
• Eight in the identified participant group
• One volunteer
• Average of all participants
• F1 Hospital management provides a work climate
  that promotes patient safety.
• 84 strongly agree/agree

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Indiana

• Primary areas of concern from the AHRQ survey
• Handoffs and transitions
• Non-punitive response to error
• Communication openness
• Teamwork across hospital units
• Feedback and communication about errors
• Frequency of events reported

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Indiana Challenges

• QIO challenges
• Participating hospitals high scores and
  sustaining through remeasurement
• Increasing number of event/error reporting has
  some board members concerned
• Losing staff members that do not buy into the
  Just Culture approach
• Culture change does not happen in one year
• One hospital moved to a new facility

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Indiana Interventions

• QIO interventions
• Sharing educational resources
• Institute for Healthcare Improvement (IHI)
  educational resources
• Leadership documents
• Adverse Events document
• SBAR documents from Web site and teleconference
  series
• Medication reconciliation documents
• JCAHO
• Improving handoff communications

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Indiana Interventions

• QIO interventions (continued)
• Face-to-face meetings
• Teleconferences
• Encouraged networking
• Medication error tracking
• Posters to promote patient safety
• Four-state collaborative effort
• Brochure to promote non-punitive environment

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Indiana Collaborative Teleconferences

• Improving Patient Safety in a Rural Hospital
• Hardin Medical Center, Savannah, Tennessee
• Medication errors
• Education and reeducation
• Rounding
• Safety Committee
• Newsletter
• Orientation express
• Learning centers
• SBAR
• Used between departments
• Reporting to the board of directors

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Indiana Collaborative Teleconferences

• Culture Change The Patient as the Priority
• Rush Memorial Hospital, Rushville, Indiana
• Non-punitive environment
• Risk variance reporting tool
• SBARQ
• Universal documentation form
• Manager/staff communication
• Teamwork program
• Respect and Unity Starts Here (RUSH)
• Arm bands
• Patient safety committee
• Leadership development
• Crucial Conversations

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Indiana Interventions

• Hospital actions
• Improving patient safety education and
  communication
• Newsletters, intranets, personal e-mails
  (personal thank-yous), reviewing management
  practices
• Focusing on pride in the workplace and
  blameless culture
• Designating patient safety ambassadors
• Crucial conversations

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Indiana Interventions

• Incorporating health information technology
• Electronic health records, piloting computerized
  physician order entry, barcoding, online event
  reporting and tracking
• Conducting storytelling sessions
• Employee open forums
• Focus on near misses or missed opportunities
• Presenting to the board of directors

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Indiana Interventions

• Conducting safety fairs
• Safety alerts
• Arm bands
• Patient falls
• Case conference for high risk patients

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Indiana

• Key stakeholders
• Indiana Hospital and Health Association
• Indiana Rural Health Association
• Indiana Patient Safety Center
• Indiana Office of Rural Health
• Indiana State Department of Health

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Indiana

• Indiana Patient Safety Center
• Mandatory reporting of adverse events
• Publicly reported
• Providing the AHRQ survey online
• Benchmarking
• Node for the 5 Million Lives Campaign
• Piloting a patient safety course at IUPUI
• Regional coalitions

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West Virginia Interventions

• Teleconference on 1/09/07 with Patty Ruddick on
  the WV Falls Collaborative.
• Hospitals from all 4 states invited to attend.
• Project for small rural hospitals and long term
  care facilities on using patient safety
  collaboratives to reduce repeat falls in at-risk
  patients.
• Project pilot tested in 2 facilities.

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West Virginia Interventions

• Goal to reduce rate of repeat falls.
• Adopted Veterans Administration Root Cause
  Analysis (RCA) tool to identify factors involved
  in initial falls.
• Patient-specific interventions developed based on
  RCA.
• Data tracked over time and submitted to WVMI for
  analysis.

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West Virginia Interventions

• Facilities can participate in training without
  officially joining collaborative.
• Currently 10 hospitals and 2 nursing homes
  participating.
• Will be 4 additional teleconferences in this
  series.
• Presentation after lunch in Galerie 2 if you are
  interested in learning more!

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Hawaii

• Nine critical access hospitals (CAHs)
• All CAHs have been part of a statewide
  collaborative under the direction of the State
  of Hawaii Office of Rural Health
• Stroudwater Associates has been working with
  CAHs on balanced scorecards
• Five of the CAHs and one rural hospital
  included in the IPG
• All nine CAHs one rural hospital completed AHRQ
  survey

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Challenges Hawaii

• QIO Challenges
• Seven of the nine CAHs have more nursing home and
  ER beds rather than acute beds.
• Only one CAH has reported data. Many others will
  likely not have any data to report. A lot of
  time has been spent recruiting for data
  reporting.
• WebEx attendance has been low.

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Interventions Hawaii

• QIO Interventions
• Four-state collaborative effort with IN, WV, NC
• Collaboration with the four states that are part
  of the Mountain-Pacific Quality Health QIO
• Survey data and toolkits to all hospitals
• WebEx learning sessions for hospitals
• Presentation of data and information to hospitals
  at the quarterly meeting of the Hawaii
  Performance Improvement Collaborative (HPIC)
  under the Office of Rural Health (captive
  audience for presentations)
• Site-visits to hospitals for review of data,
  assistance with action plans, training

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Interventions Hawaii

• WebEx- several arranged. Most recent 1/30/07 by
  St. Peter Community Hospital in MN arranged by
  our WY office
• Medical director and CEO presented the hospitals
  work on a culture of patient safety
• The hospital reviewed the challenges and
  modifications they were able to make to
  participate in IHIs 100K Lives Campaign
• Great examples of adaption of measures for CAH
  setting

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Interventions Hawaii

• HPIC meeting
• Next meeting in April
• Review statewide results from AHRQ survey and go
  over best practices
• Meet individually with hospital representatives
  present at the meeting
• Site Visits
• Assist with implementing change models with
  involvement of senior leadership
• Visits planned for March
• Survey data re-reviewed individually
• Assist with individualized action plans

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Interventions North Carolina

• 7 IPG hospitals, 1
• Individual calls to redirect attention safety
  culture work February 2007
• Pre-work conference call with IPG group to
  prepare for action plan implementation Late
  February 2007
• Work to receive hospitals plans of action
• Have received 2 Action Plans to date

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Interventions North Carolina

• Visit Hospitals March and April
• Meet with senior leaders
• Partner with NCHA
• Connections w/Senior Leaders
• Board Retreats
• Couple work with Boards on Board element of 5M
  Lives Campaign
• Implementation of Action Plans May through
  September
• Individual assistance
• Conference calls

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Lessons Learned

• There is strength in numbers!
• Hospitals in all 4 states have begun
  participating in our teleconferences feedback
  has been extremely positive.
• Small rural hospitals and CAHs want to learn what
  works for peers.
• QIOs whose hospitals have similar characteristics
  can assist each other, regardless of location.

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Questions?

• Karen Hannah, khannah_at_wvmi.org
• Chris OConnell, coconnell2_at_hiqio.sdps.org
• Becky Royer, rroyer2_at_inqio.sdps.org
• Eva Powell, epowell_at_ncqio.sdps.org
• Dave Lomely, dlomely_at_wvmi.org
• Patty Ruddick, pruddick_at_wvmi.org