Assessing and Nurturing a Culture of Safety 7th Annual Safety Healthcare Conference North Platte, NE October 6, 2006

1. Assessing and Nurturing a Culture of Safety 7th Annual Safety Healthcare ConferenceNorth Platte, NEOctober 6, 2006 Katherine Jones, PhD, PT Acknowledge Anne and AndreaAcknowledge Anne and Andrea

2. 2 Objectives Explain the concept of culture of safety Explain uses of safety culture assessments Explain patterns in aggregate survey results Identify determinants of safety culture Identify critical success factors to nurture a culture of safety Identify tools to improve culture, e.g. Teamwork & Communication (SBAR, CUSS) Unsafe Acts Algorithm (ensure accountability) Role of voluntary reporting

3. 3 Errors in Our Health Care System IOM: To Err is Human 44,000 � 98,000 deaths per year due to medical errors 3% - 4% of hospital admissions result in adverse events Cost $17 - $29 billion/yr Adults get 55% of recommended care (McGlynn et al. N Engl J Med 2003; 348;2635-45.) There are 44,000 � 98,000 deaths per year due to medical errors. Which is equivalent to the 8th cause of death...One airplane crash per day. Comparatively, there are 43,458 deaths/year due to MVA and 42,297 due to Breast Cancer.There are 44,000 � 98,000 deaths per year due to medical errors. Which is equivalent to the 8th cause of death...One airplane crash per day. Comparatively, there are 43,458 deaths/year due to MVA and 42,297 due to Breast Cancer.

4. 4 A 2002 survey conducted by the Harvard School of Public Health and the Kaiser Family Foundation found that 42% of the public and 35% of physicians have been personally involved with a medical error. A 2002 survey conducted by the Harvard School of Public Health and the Kaiser Family Foundation found that 42% of the public and 35% of physicians have been personally involved with a medical error.

5. 5 Institute of Medicine �The problem is not bad people; the problem is that the system needs to be made safer.� �To Err is Human: Building a Safer Health �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.� �Crossing the Quality Chasm: A New Health System for the 21st Century.

6. 6 Six Aims to Achieve Quality IOM (2001). Crossing the Quality Chasm. Safety: �the prevention of harm caused by errors of commission and omission� A system that produces care that is effective, patient-centered, timely, efficient, and equitable requires a foundation of a culture of safety Creating a safe health care system is the foundation for achieving the quality of care that we all want to provide. In Crossing the Quality Chasm: A New Health System for the 21st Century, the IOM defined safety as� Safe � avoid injury to patients from care that is intended to help Effective � provide services based on scientific knowledge (avoid overuse and underuse) Patient-centered � provide care that is respectful and responsive to individual patient preferences, needs, and values Timely � reduce waits and harmful delays for both those that give and receive care Efficient � avoid waste of resources including equipment, supplies, ideas, and energy Equitable � provide care that is not different due to personal characteristics (gender, ethnicity, geographic location, socioeconomic status) Creating a safe health care system is the foundation for achieving the quality of care that we all want to provide. In Crossing the Quality Chasm: A New Health System for the 21st Century, the IOM defined safety as� Safe � avoid injury to patients from care that is intended to help Effective � provide services based on scientific knowledge (avoid overuse and underuse) Patient-centered � provide care that is respectful and responsive to individual patient preferences, needs, and values Timely � reduce waits and harmful delays for both those that give and receive care Efficient � avoid waste of resources including equipment, supplies, ideas, and energy Equitable � provide care that is not different due to personal characteristics (gender, ethnicity, geographic location, socioeconomic status)

7. 7 Culture of Patient Safety IOM (2004). Keeping Patients Safe. �An integrated pattern of individual and organizational behavior, based upon shared beliefs and values, that continuously seeks to minimize patient harm that may result from the processes of care delivery.� So what is a culture of patient safety? In Patient Safety: Achieving a New Standard for Care, the IOM defined a culture of patient safety as�. (IOM 2004)So what is a culture of patient safety? In Patient Safety: Achieving a New Standard for Care, the IOM defined a culture of patient safety as�. (IOM 2004)

8. 8 Culture is ��The way we do things around here and why we do them.� Carroll & Quijada (2004). Quality and Safety in Health Care. More simply�.More simply�.

9. 9 There are limits to what human beings can see, hear, attend to, remember, and comprehend...phone numbers are limited to seven digits because that is the maximum number of discrete items we can keep in our short term memory. In addition, our behavior tends to migrate over time from the rule-based standards to what is of greatest individual benefit in the situation. This slide provides a model of how human behavior migrates to unsafe boundaries. Another term for this migration is �normalization of deviance.� This model is based on the work of Rene Amalberti. Within the expected safe space of action on the far right, we are bounded by regulations, standards, and evidence-based practice. However, our usual space of action is somewhat less than the standard. As we become rushed and pre-occupied with being late or having too much to do, we can easily migrate beyond the �illegal normal� to the unsafe space. Example: What is the posted speed limit on the interstate? Answer: 75 MPH (this is the expected safe space). WhatThere are limits to what human beings can see, hear, attend to, remember, and comprehend...phone numbers are limited to seven digits because that is the maximum number of discrete items we can keep in our short term memory. In addition, our behavior tends to migrate over time from the rule-based standards to what is of greatest individual benefit in the situation. This slide provides a model of how human behavior migrates to unsafe boundaries. Another term for this migration is �normalization of deviance.� This model is based on the work of Rene Amalberti. Within the expected safe space of action on the far right, we are bounded by regulations, standards, and evidence-based practice. However, our usual space of action is somewhat less than the standard. As we become rushed and pre-occupied with being late or having too much to do, we can easily migrate beyond the �illegal normal� to the unsafe space. Example: What is the posted speed limit on the interstate? Answer: 75 MPH (this is the expected safe space). What

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11. 11 An example of a culture that may not value safety...An example of a culture that may not value safety...

12. 12 Understand safety related attitudes Identify areas in need of improvement Raise awareness about culture in patient safety Evaluate patient safety interventions, track changes over time Conduct internal & external benchmarking Fulfill directives or regulatory requirements JCAHO national patient safety goal? Uses of Safety Culture SurveysNieva & Sorra (2003). Quality and Safety in Healthcare. Similar to individual patient care, we can�t create an effective treatment plan until we know the nature of a problem and can measure the effectiveness of an intervention. Safety culture surveys can be used to�. Similar to individual patient care, we can�t create an effective treatment plan until we know the nature of a problem and can measure the effectiveness of an intervention. Safety culture surveys can be used to�.

13. 13 Don�t doubt that conducting a survey will raise expectations of employees that action will be taken in response to the results.Don�t doubt that conducting a survey will raise expectations of employees that action will be taken in response to the results.

14. 14 Our Specific Aims As part of UNMC�s AHRQ-funded Partnerships in Implementing Patient Safety Grant� Determine attitudes about patient safety in CAHs Identify strengths and areas for improvement Raise awareness about role of culture Determine if differences exist between hospitals based upon length of participation in medication safety project Create external benchmarks specific to CAHs Similar to the uses of safety culture surveys described by Nieva & Sorra, our specific aims were� Two groups of CAHs 13 in voluntary medication error reporting project 1 � 4 years 11 began project Sept. 2005 Nieva & Sorra Understand safety related attitudes Identify areas in need of improvement Raise awareness about culture in patient safety Evaluate patient safety interventions, track changes over time Conduct internal & external benchmarking Fulfill directives or regulatory requirementsSimilar to the uses of safety culture surveys described by Nieva & Sorra, our specific aims were� Two groups of CAHs 13 in voluntary medication error reporting project 1 � 4 years 11 began project Sept. 2005 Nieva & Sorra Understand safety related attitudes Identify areas in need of improvement Raise awareness about culture in patient safety Evaluate patient safety interventions, track changes over time Conduct internal & external benchmarking Fulfill directives or regulatory requirements

15. 15 Critical Processes in Safety Culture Assessment  Nieva & Sorra (2003). Quality and Safety in Healthcare. Involve key stakeholders at all stages Select a valid instrument Use effective data collection procedures Implement action planning/initiating change

16. 16 Barriers to Effective Data Collection ��not unusual for these procedures to be overlooked by staff conducting assessments in healthcare organizations.� Lack of knowledge of survey administration methods Concerns about anonymity Group administration introduces bias (priming for desired results) Inappropriate collapsing of work area/job title Lack of technology/knowledge for data entry and analysis

17. 17 Addressing Barriers Survey all eligible staff in Critical Access Hospitals Minimize bias�do not use group administration, incentives, or �priming� Use multiple contacts�advance communication & follow-up to maximize response rates Ensure anonymity, accurate data entry, analysis Focus on action planning Consider contractor with experience in survey administration methods (university, hospital assoc.) Confidentiality�especially for handwritten comments Efficiency�We had resources for printing, scanning, data analysis Focus�on utilization of results rather than data collection and analysisConfidentiality�especially for handwritten comments Efficiency�We had resources for printing, scanning, data analysis Focus�on utilization of results rather than data collection and analysis

18. 18 Administering the Survey Time frame 4th Quarter 2005 Hospitals provided lists of employees in four groups for which instrument validated Range of sample sizes = 35 � 241 Demographics (work area, job title) modified to reflect small rural hospital For example, options of medicine, surgery, obstetrics, pediatrics, intensive care, psychiatry/mental health, rehabilitation deleted and replaced by acute/skilled care; Pharmacist, dietician, therapies all collapsed into allied health to maintain anonymityFor example, options of medicine, surgery, obstetrics, pediatrics, intensive care, psychiatry/mental health, rehabilitation deleted and replaced by acute/skilled care; Pharmacist, dietician, therapies all collapsed into allied health to maintain anonymity

19. 19 Administering the Survey Four contacts used to maximize response rate Provided template for prenotification letter from CEO Survey �kit� mailed to each hospital every 2-3 weeks x3 with envelope for each employee Personalized cover letter Survey Postage paid envelope to mail survey to UNMC Surveys coded to track response rate and avoid entering duplicate responses

20. 20 Returns Overall response rate 1584/2266 (70%) Range of responses across 24 hospitals 92/180 (51%) 45/49 (92%)

21. 21 Analyzing the Survey Returns scanned and entered into access database Descriptive analysis with customized Premier Excel tool Collapsing of work area, job title Aggregate results reported if n > 5 (vs > 11) Area for improvement if negative > 25% (vs > 50%) Statistical analysis with SAS to account for nesting Comments coded according to 23 themes Based on review of literature, survey dimensions, iterative coding Premier tool creates graphs and tables to display safety culture dimensions by work area, unit, or profession Premier tool creates graphs and tables to display safety culture dimensions by work area, unit, or profession

22. 22 Survey Instrument�14 Dimensions Seven department-level aspects related to error and event reporting The instrument contains 10 dimensions, which are each made up of 3 � 4 questions, and four dimensions which are considered outcomesThe instrument contains 10 dimensions, which are each made up of 3 � 4 questions, and four dimensions which are considered outcomes

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24. 24 Survey Instrument�14 Dimensions Three hospital-level aspects related to patient safety

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26. 26 Survey Instrument�14 Dimensions Four outcome measures

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28. 28 Aggregate Results from 24 Critical Access Hospitals

29. 29 This graph compares the aggregate composite positive responses from the 24 CAHs (red) to the AHRQ benchmark. Across all survey dimensions, the CAHs are 8% more positive than the AHRQ Benchmark. The AHRQ benchmark was created when the survey was pilot tested in 2004 among 20 hospitals (1,419 responses/ 4928 surveys administered)�where small was considered fewer than 300 beds. < 300 beds = 9 301-500 = 4 500 = 7 One key finding is that the core patient safety values of nonpunitive response to error, feedback and communication about error, and communication openness are among the LEAST positively perceived across 44 hospitals and over 3000 respondents. A second key finding is that teamwork and handoffs across departments are also areas for improvement�and that smaller hospitals seem to have more positive perceptions of these dimensions than larger hospitals. This graph compares the aggregate composite positive responses from the 24 CAHs (red) to the AHRQ benchmark. Across all survey dimensions, the CAHs are 8% more positive than the AHRQ Benchmark. The AHRQ benchmark was created when the survey was pilot tested in 2004 among 20 hospitals (1,419 responses/ 4928 surveys administered)�where small was considered fewer than 300 beds. < 300 beds = 9 301-500 = 4 500 = 7 One key finding is that the core patient safety values of nonpunitive response to error, feedback and communication about error, and communication openness are among the LEAST positively perceived across 44 hospitals and over 3000 respondents. A second key finding is that teamwork and handoffs across departments are also areas for improvement�and that smaller hospitals seem to have more positive perceptions of these dimensions than larger hospitals.

30. 30 This graph compares the composite positive responses of management to non-management personnel within the 24 CAHs. On average, management perceptions of patient safety are 7% more positive than non-management across the 12 dimensions. The greatest differences, which are statistically significant, are in nonpunitive response to error, feedback and communication about error, and communication openness�.the core dimensions of a culture of safety. This graph compares the composite positive responses of management to non-management personnel within the 24 CAHs. On average, management perceptions of patient safety are 7% more positive than non-management across the 12 dimensions. The greatest differences, which are statistically significant, are in nonpunitive response to error, feedback and communication about error, and communication openness�.the core dimensions of a culture of safety.

31. 31 This graph compares the aggregate composite positive responses of management, providers (MDs, Pas, NPs), and nurses within the 24 CAHs. Providers are less positive than nurses and management regarding nonpunitive response to error. Depending upon the question providers (MDs, PAs) tend to look like management or nurses. Consider the specific question from the communication openness dimension: �Staff feel free to question the decisions or actions of those with more authority.� 55% of management responded positively, meaning they agreed. 53% of physicians responded positively Only 38% of nurses responded positively. Consider the question from the nonpunitive response to error dimension: �When an event is reported, it feels like the person is being written up, not the problem.� 72% of management responded positively meaning they disagreed 51% of nursing 40% of providers This graph compares the aggregate composite positive responses of management, providers (MDs, Pas, NPs), and nurses within the 24 CAHs. Providers are less positive than nurses and management regarding nonpunitive response to error. Depending upon the question providers (MDs, PAs) tend to look like management or nurses. Consider the specific question from the communication openness dimension: �Staff feel free to question the decisions or actions of those with more authority.� 55% of management responded positively, meaning they agreed. 53% of physicians responded positively Only 38% of nurses responded positively. Consider the question from the nonpunitive response to error dimension: �When an event is reported, it feels like the person is being written up, not the problem.� 72% of management responded positively meaning they disagreed 51% of nursing 40% of providers

32. 32 This slide compares the composite positive responses within the 13 experienced hospitals to those of the 11 hospitals that joined the project in July 2005. On average, the experienced hospitals are about 3 � 4% more positive in all dimensions than the new hospitals except for handoffs & transitions and staffing. These differences may reflect fact that new hospitals are smaller than experienced. The greatest differences, which were statistically significant, were in nonpunitive response to error and communication openness. Specifically, 53% of respondents within the experienced hospitals perceived nonpunitive response to error positively compared to 47% within the 11 hospitals that were new to the project. 62% of respondents within the experienced hospitals perceived communication openness positively compared to 55% within the 11 hospitals that were new to the project. This slide compares the composite positive responses within the 13 experienced hospitals to those of the 11 hospitals that joined the project in July 2005. On average, the experienced hospitals are about 3 � 4% more positive in all dimensions than the new hospitals except for handoffs & transitions and staffing. These differences may reflect fact that new hospitals are smaller than experienced. The greatest differences, which were statistically significant, were in nonpunitive response to error and communication openness. Specifically, 53% of respondents within the experienced hospitals perceived nonpunitive response to error positively compared to 47% within the 11 hospitals that were new to the project. 62% of respondents within the experienced hospitals perceived communication openness positively compared to 55% within the 11 hospitals that were new to the project.

33. 33 Since our patient safety project is primarily concerned with medication safety, we were interested in looking at the differences between nurses within each group of hospitals. The greatest differences, which were statistically significant, were in the core values of nonpunitive response to error (15%) and communication openness (14%). Since our patient safety project is primarily concerned with medication safety, we were interested in looking at the differences between nurses within each group of hospitals. The greatest differences, which were statistically significant, were in the core values of nonpunitive response to error (15%) and communication openness (14%).

34. 34 Comments 240 Comments received Frankness of comments reflects confidence in anonymity Coded comments can validate, explain quantitative results (mixed methods research) Similar themes in comments across hospitals 21% reported a specific patient safety concern 9% perceived a lack of leadership in patient safety 7% perceived that patient safety is a top organization priority

35. 35 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

36. 36 Identifying Strengths and Areas for Improvement

37. 37 Use of the minimum (orange) and maximum (black) positive score for each dimension within a group of peers creates a screening tool to identify strengths (manager actions promoting patient safety, teamwork within depts) and areas for improvement (Hospital management support for patient safety, nonpunitive response to error, feedback and communication about error, and communication openness)Use of the minimum (orange) and maximum (black) positive score for each dimension within a group of peers creates a screening tool to identify strengths (manager actions promoting patient safety, teamwork within depts) and areas for improvement (Hospital management support for patient safety, nonpunitive response to error, feedback and communication about error, and communication openness)

38. 38 This slide provides examples of ranges for individual questions within each dimension and demonstrates how culture varies between organizations. This slide provides examples of ranges for individual questions within each dimension and demonstrates how culture varies between organizations.

39. 39 Determinants of Culture Westrum (2004). Quality and Safety in Healthcare. Leaders communicate what is important Personal power Positions (rules and departmental turf) Mission of organization Patterns of information flow reflect the climate set by leaders; use of teamwork & communication Personal use of information Individuals use standard channels of information Teams do whatever it takes to get the right information to the right people at the right time Why are cultures in organizations different? Through actions, rewards, & punishments, Leaders communicate what is important Personal power (my needs and glory) Positions (rules and departmental turf) Mission of organization Patterns of information flow--the Quantity Relevance Timeliness Appropriateness of information available --reflect the climate set by the leader Why are cultures in organizations different? Through actions, rewards, & punishments, Leaders communicate what is important Personal power (my needs and glory) Positions (rules and departmental turf) Mission of organization Patterns of information flow--the Quantity Relevance Timeliness Appropriateness of information available --reflect the climate set by the leader

40. 40 This model of the determinants of culture in an organization illustrates that an organization�s ability to learn from experience is determined by the attitudes of leaders about the use of information, the flow of information, sources of information, and the ability to work as a team. Effective use of information results in organizational learning, improvement of knowledge to evaluate and conduct processes, and ultimately in achieving the organization�s mission. Sources of Information include: Near Miss Reports, Actual Error Reports, Incident Reports, Audits, Work-outs, Routine data collection, Satisfaction Surveys, Culture Survey Characteristics of an Advanced Safety Culture Informed at all levels�all seek and provide info Trust by all�due to a just culture even bad information is shared, accepted, and acted upon Adaptable to change�learn from successes and failures It worries�success does not create complacency Adapted from Westrum (2004). A typology of organizational cultures. Quality and Safety in Health Care, 13, 22 � 27. Firth-Cozens (2001). Cultures for improving patient safety through learning: the role of teamwork. Quality and Safety in Health Care, 10, 26-31. This model of the determinants of culture in an organization illustrates that an organization�s ability to learn from experience is determined by the attitudes of leaders about the use of information, the flow of information, sources of information, and the ability to work as a team. Effective use of information results in organizational learning, improvement of knowledge to evaluate and conduct processes, and ultimately in achieving the organization�s mission. Sources of Information include: Near Miss Reports, Actual Error Reports, Incident Reports, Audits, Work-outs, Routine data collection, Satisfaction Surveys, Culture Survey Characteristics of an Advanced Safety Culture Informed at all levels�all seek and provide info Trust by all�due to a just culture even bad information is shared, accepted, and acted upon Adaptable to change�learn from successes and failures It worries�success does not create complacency Adapted from Westrum (2004). A typology of organizational cultures. Quality and Safety in Health Care, 13, 22 � 27. Firth-Cozens (2001). Cultures for improving patient safety through learning: the role of teamwork. Quality and Safety in Health Care, 10, 26-31.

41. 41 Three Types of Culture Westrum (2004). Quality and Safety in Healthcare. Pathological�use of information to enhance personal power Bureaucratic� use of information to adhere to rules, positions, and protect turf Generative�use of information to concentrate on the mission; not persons or positions

42. 42 Typology of Organizational CulturesWestrum (2004). Quality and Safety in Health Care, 13, ii22-ii27.

43. 43 Typology of Organizational CulturesWestrum (2004). Quality and Safety in Health Care, 13, ii22-ii27.

44. 44 Characteristics of an Advanced Safety Culture Hudson (2003). Quality and Safety in Healthcare . Informed at all levels�all seek and provide info Trust by all�due to a just culture even bad information is shared, accepted, and acted upon Adaptable to change�learn from successes and failures It worries�success does not create complacency

45. 45 Critical Processes�Implementing Action Plans Nieva & Sorra (2003). Quality and Safety in Healthcare. Provide feedback to all Conducting survey raised expectations Benchmark to the range to identify areas of strength and need for improvement Do you have a management gap? Communicate shared understanding of data and action plans Prioritize need for change Implement and sustain 1 � 2 tools at a time to maintain focus

46. 46 Action Plan to Improve Non-punitive Response to Error Finding�non-punitive response to error is consistently least positively perceived Tool� �Just Culture� from David Marx (www.justculture.org) Punishment based on risk NOT outcome or violation of rule Tool�Reason�s Unsafe Acts Algorithm Tool�Non-punitive voluntary reporting

47. 47 Just Culture Outcome-based discipline�the more severe the outcome, the more blameworthy the actor�regardless of intent Rule-based discipline�did an individual violate a rule? Did they intentionally violate the rule? Risk-based discipline�if an individual intends to take a risk, disciplinary action is appropriate The problem with outcome-based discipline is that punishment may deter those who choose to engage in risky behavior but has no impact on an individual who did not intend to make a mistake. The problem with rule-based discipline is that the usual focus is whether the rule was intentionally violated and we lose sight of whether the actor knew the risk being taken when the rule was violated. Typically, most violations of policy/procedure develop over time without the workforce�s knowledge of the relationship to risk. Discipline must be base upon whether an individual intentionally and knowingly took a risk. TThe problem with outcome-based discipline is that punishment may deter those who choose to engage in risky behavior but has no impact on an individual who did not intend to make a mistake. The problem with rule-based discipline is that the usual focus is whether the rule was intentionally violated and we lose sight of whether the actor knew the risk being taken when the rule was violated. Typically, most violations of policy/procedure develop over time without the workforce�s knowledge of the relationship to risk. Discipline must be base upon whether an individual intentionally and knowingly took a risk. T

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49. 49 Patient Safety Model (USP, 2004) A Non-punitive culture will improve data collection in a voluntary reporting system. Data collection can include voluntary reporting, observation, and chart review. Data Analysis and Planning change can take the form of PDCA, RCA, HFMEA Implementing change requires dissemination of findings, support from leadership, stakeholder analysis and action planning by those involved in the process. Culture is negatively affected when no change results from reporting. A Non-punitive culture will improve data collection in a voluntary reporting system. Data collection can include voluntary reporting, observation, and chart review. Data Analysis and Planning change can take the form of PDCA, RCA, HFMEA Implementing change requires dissemination of findings, support from leadership, stakeholder analysis and action planning by those involved in the process. Culture is negatively affected when no change results from reporting.

50. 50 Purpose: learn from experience (Leape, 2002) All parties aware of hazards Share lessons with others Identify latent system causes of medication error Implement change in processes through quality improvement projects Monitor impact of quality improvement projects Measure of �mindfulness��awareness of staff about safety Role of Voluntary Reporting in Culture DATA COLLECTION Without voluntary medication error reporting you don�t know how to begin to improve your medication use system. With complete reporting, you can identify system causes of specific error types and where those errors originate in the system. DATA COLLECTION Without voluntary medication error reporting you don�t know how to begin to improve your medication use system. With complete reporting, you can identify system causes of specific error types and where those errors originate in the system.

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52. 52 Characteristics of Successful Reporting Systems (Leape, 2002) Nonpunitive�reporters free from fear Confidential�identities of reporters not important Independent�firewall exists between those receiving error reports & those with disciplinary power Systems-oriented Expert analysis�recognize underlying system causes Timely�prompt analysis and dissemination Responsive�disseminate and implement We have worked with John Roberts of The Nebraska Rural Health Association to obtain a grant for $9,500 to learn more about how limited human resources in small rural hospitals might be a barrier to the confidentiality and anonymity required for successful reporting systems. What impact does it have on reporting in a facility when the same individual responsible for employee disciplinary actions is also responsible for investigating the system sources of error. We have worked with John Roberts of The Nebraska Rural Health Association to obtain a grant for $9,500 to learn more about how limited human resources in small rural hospitals might be a barrier to the confidentiality and anonymity required for successful reporting systems. What impact does it have on reporting in a facility when the same individual responsible for employee disciplinary actions is also responsible for investigating the system sources of error.

53. 53 Systems-oriented Reporting Describe the error�most important! Categorize the error (e.g. medication errors) Severity Phase of origination (node) Type Identify causes and contributing factors Identify level of staff making/reporting Identify interventions/monitoring needed if the error reached the patient Identify actions to avoid future errors How do we achieve systems oriented reporting? How do we achieve systems oriented reporting?

54. 54 Action Plan to Improve Hospital Management Support  Finding�management and front line staff have different views of the culture of safety Tool�Patient Safety Leadership WalkRoundsTM* Senior leaders talk with front line staff informally but regularly to understand their perceptions Use the scripted opening statements to get started Follow-up! Use GLITCH book, database

55. 55 Action Plan to Improve Hospital Management Support Finding� the attitudes of senior leaders determine the flow of critical information Tool� American Hospital Association Strategies for Leadership: Hospital Executives and their Role in Patient Safety* A self-assessment tool for leaders to increase visibility and activity in patient safety

56. 56 Action Plan to Improve Communication Finding�lack of communication openness�a majority of nurses did not feel free to question decisions or actions of those with more authority Tools SBAR*�A structured framework for communication that ensures all parties have the same mental model of the situation, concerns about the situation, and potential solutions CUSS�acronym for two challenges to clearly indicate concern

57. 57 Barriers to CommunicationHaig (2006). Joint Commission Journal on Quality and Patient Safety. Lack of structure and standardization Uncertain who is responsible for care management Differences in authority, gender, and race Physicians and nurses have different communication styles physicians seem to favor �bulleted� summaries nurses often use detailed, descriptive narratives

58. 58 SBAR S - Situation - what is happening at the present time? B - Background - what are the circumstances leading up to the situation? A - Assessment - what do I think the problem is? R - Recommendation - what should we do to correct the problem?

59. 59 CUSS Two Challenges and then �Stop the line!� �I�m Concerned.� �I�m uncomfortable.� �Stop. Patient safety is at risk!�

60. 60 What to do if CUSS doesn�t work http://video.google.com/videoplay?docid=1882664901133929840

61. 61 Action Plan to Improve Teamwork Finding�Nearly one-fourth of RNs agree that hospital units do not coordinate well Tool� TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety)* Teams make fewer mistakes than individuals TeamSTEPPS teaches core components of teamwork �Leadership, Situation Monitoring, Mutual Support, and Communication Teams make fewer mistakes than individuals when each member knows his/her responsibilities, as well as those of other team members TeamSTEPPS teaches core facets of teamwork �Leadership, Situation Monitoring, Mutual Support, and Communication Teams make fewer mistakes than individuals when each member knows his/her responsibilities, as well as those of other team members TeamSTEPPS teaches core facets of teamwork �Leadership, Situation Monitoring, Mutual Support, and Communication

62. 62 Action Plan to Improve Communication and Teamwork Finding�lack of communication and teamwork within and across departments� shift change is problematic, information falls through the cracks Tool� Patient Safety BriefingsTM* Increase awareness of safety within departments Provide a structured means of communication within and across departments

63. 63 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

64. 64 Ground Rules for Briefings All gather in a designated area Be brief�5 minutes and stick to it! Remember the purpose: increase awareness of safety issues Remember non-punitive: information for patient care only�never used in performance appraisal All opinions have equal value Ask open-ended questions

65. 65 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?

66. 66 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 patient�s comment prevented? Are there safety issues (staff or patient) that should prompt action? Are there process changes that should be made?

67. 67 Action Plan to Improve Hospital Handoffs & Transitions Finding�shift change is problematic, information falls through the cracks Tool� IPASSTHEBATON (Strategies and Tools to Improve Healthcare Handoffs and Transitions)* Captures key elements to be communicated in a structured method with the opportunity to ask questions, clarify and confirm

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69. 69 Elements of a Culture of Safety Singer et al. (2003). Quality and Safety in Healthcare. Commitment to safety articulated at highest levels Resources, incentives, rewards provided Safety is the primary priority at the expense of �production� Communication across all organizational levels is frequent and candid Unsafe acts are rare despite high production Errors and problems are reported when they occur Organizational learning is valued

70. 70 Lessons Learned Core patient safety values of nonpunitive response, communication openness, and feedback are lagging Perceptions of safety culture can vary by department & position within hospitals of all sizes and across systems Management has more positive perception of safety culture than front-line Hospitals should provide anonymous means to communicate patient safety concerns Collaborate to implement tools and learn from peers...tool time conference call discussions

71. 71 Lessons Learned: Patient Safety/QI Critical Success Factors Shared goal is widely communicated Senior management engaged and supportive Follow principles of CQI�visualize processes, use rapid cycle change Clinical leadership/champion Collaborative multidisciplinary teams Timely feedback to staff regarding use of data Non-punitive organizational culture

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74. 74 References American Hospital Association. (2001). Strategies for leadership: hospital executives and their role in patient safety. Retrieved March 9, 2006 from http://www.coloradopatientsafety.org/Hosp_Exec_Patient_Safety_MA.pdf Agency for Health Care Research and Quality. Hospital Survey on Patient Safety Culture. Retrieved March 9, 2006 from http://www.ahrq.gov/qual/hospculture/ Bradley, E. (2005). Improving complex systems: Top performing hospitals in door-to-balloon times for patient with AMI. Presented at 2005 meeting of AcademyHealth. Carroll, J.S. and Edmondson, A.C. Leading organizational learning in health care. Quality and Safety in Health Care, 2002; 11: p. 51-56. Carroll, J.S. and Quijada, M.A.. Redirecting traditional professional values to support safety: changing organizational culture in health care. Quality and Safety in Health Care, 2004; 13: p.16-21.  Department of Defense. (2005). Healthcare communications toolkit to improve transitions in care. Retrieved March 30, 2006 from https://patientsafety.satx.disa.mil/

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