Patient Safety Culture in the Nursing Home: Perspectives of Providers and Administrators, and Methods for Assessment

1. Patient Safety Culture in the Nursing Home: Perspectives of Providers and Administrators, and Methods for Assessment Steven M. Handler, MD, MS Nicholas G. Castle, MHA, PhD Subashan Perera, PhD University of Pittsburgh

2. Faculty Disclosures: Drs. Handler, Castle, and Perera have no relevant financial relationships they need to disclose.

3. Overall Goals of this Session Recognize the importance of patient safety culture in the nursing home setting Describe the most recent data on patient safety culture in the nursing home setting Measure and evaluate patient safety culture in your own facility using the tools and techniques that will be provided

4. Part I - Objectives Describe the evolution of patient safety from the perspective of the Institute of Medicine (IOM) Define and describe the key elements of patient safety culture (PSC) Describe what PSC instruments are available and how they have been used Summarize the results of a study conducted to assess PSC in the nursing home (NH) setting from the perspectives of physicians, advanced practitioners, pharmacists, and nurses Available measures of NH quality From AMDA presentation: Objectives (no more than four): Describe the evolution of patient safety culture from the perspective of the Institute of Medicine. Define and describe the key elements of patient safety culture. Describe what patient safety culture instruments are available and how they have been used. Summarize a study conducted to assess patient safety culture in the nursing home setting.Available measures of NH quality From AMDA presentation: Objectives (no more than four): Describe the evolution of patient safety culture from the perspective of the Institute of Medicine. Define and describe the key elements of patient safety culture. Describe what patient safety culture instruments are available and how they have been used. Summarize a study conducted to assess patient safety culture in the nursing home setting.

5. Improving the Quality ofCare in Nursing Homes Quality of care and quality of life in many NHs are not satisfactory More effective government regulation can improve quality in NHs Regulation is necessary but not sufficient for high-quality care A system to obtain standardized data on residents is essential (i.e., MDS) This report was the impetus for the Omnibus Budget Reconciliation Act of 1987. The following changes were enacted: -Mandatory use of the MDS -Reduction in chemical and physical restraint useThis report was the impetus for the Omnibus Budget Reconciliation Act of 1987. The following changes were enacted: -Mandatory use of the MDS -Reduction in chemical and physical restraint use

6. To Err is Human: Building a Safer Healthcare System This report focused national attention on the quality of care and prevalence of medical errors in the healthcare system The report suggested that medical errors are the 5th to 8th leading cause of death in the US These errors are costly as well, with as much as 30 billion dollars in lost income and excessive health care expenditures Although this report states that as many as 98,000 people die as a result of medical error Although this report highlighted ALL errors, we will focus our attention on errors caused by medication Although most patient-safety efforts have been directed toward acute care, we need to remind ourselves of the number of people in LTC Speaks nothing about intangiblesAlthough this report states that as many as 98,000 people die as a result of medical error Although this report highlighted ALL errors, we will focus our attention on errors caused by medication Although most patient-safety efforts have been directed toward acute care, we need to remind ourselves of the number of people in LTC Speaks nothing about intangibles

7. Follow-up report that didn�t receive as much press as Improving the Quality of Care in Nursing HomesFollow-up report that didn�t receive as much press as Improving the Quality of Care in Nursing Homes

8. Crossing the Quality Chasm: A New Health System for the 21st Century This report suggested that the biggest challenge to moving toward a safer healthcare system is changing the patient safety culture from one in which individuals are blamed for errors to one in which errors are treated as opportunities to improve the system and prevent harm. -Hopefully, you can now see, that there is a evolution in thinking over time... From one of focusing on individuals and suggesting that regulation (external) be the primary motivator for improved quality and safety�to focusing on systems and organizations and the primary motivator for change is associated with institutional culture (internal motivation). -Make a slide on this transformation-Hopefully, you can now see, that there is a evolution in thinking over time... From one of focusing on individuals and suggesting that regulation (external) be the primary motivator for improved quality and safety�to focusing on systems and organizations and the primary motivator for change is associated with institutional culture (internal motivation). -Make a slide on this transformation

9. Patient Safety: Achieving a New Standard for Care All health care settings should establish comprehensive patient safety programs operated by trained personnel within a culture of safety These programs should encompass: case finding�identifying system failures analysis�understanding the factors that contribute to system failures system redesign�making improvements in care processes to prevent errors in the future Increasing specificity of PSC and required components As part of a culture of safety, organizations need to commit to detecting as many patient injuries and near misses as possible through the following means: Active surveillance based on case finding through real-time, interventional, prospective data-based clinical trigger systems, as well as retrospective chart review driven by code-based trigger systems. Routine self-assessments to identify error-prone or high-risk processes, systems, or settings that could jeopardize patient safety (see Box 5-1). Standardized, widely understood, and easily accessible mechanisms for voluntary reporting, with an independent team completing all the paperwork. These mechanisms could include a simple computerized reporting system allowing front-line care professionals to mark possible injuries for independent review; telephone and e-mail tip lines enabling front-line professionals, patients, and family members to report potential adverse events or near misses; and a system for asking front-line health professionals, as they leave work, whether they experienced any unsafe conditions or observed any injuries or near misses during their just-completed workday. BOX 5-1Examples of High-Risk Areas That Deserve Special Attention Many and varied interactions with diagnostic and/or treatment technology; many different types of equipment being utilized Multiple individuals involved in the care of individual patients and many hand-offs of care High acuity of patient illness or injury Ambient atmosphere prone to distractions or interruptions Need for rapid care management decisions; care givers being time pressured High-volume and/or unpredictable patient flow Use of diagnostic or therapeutic interventions having a narrow margin of safety, including high-risk drugs Communication barriers with patients and/or co-workers Instructional setting for care delivery, with inexperienced caregiversIncreasing specificity of PSC and required components As part of a culture of safety, organizations need to commit to detecting as many patient injuries and near misses as possible through the following means: Active surveillance based on case finding through real-time, interventional, prospective data-based clinical trigger systems, as well as retrospective chart review driven by code-based trigger systems. Routine self-assessments to identify error-prone or high-risk processes, systems, or settings that could jeopardize patient safety (see Box 5-1). Standardized, widely understood, and easily accessible mechanisms for voluntary reporting, with an independent team completing all the paperwork. These mechanisms could include a simple computerized reporting system allowing front-line care professionals to mark possible injuries for independent review; telephone and e-mail tip lines enabling front-line professionals, patients, and family members to report potential adverse events or near misses; and a system for asking front-line health professionals, as they leave work, whether they experienced any unsafe conditions or observed any injuries or near misses during their just-completed workday. BOX 5-1Examples of High-Risk Areas That Deserve Special Attention Many and varied interactions with diagnostic and/or treatment technology; many different types of equipment being utilized Multiple individuals involved in the care of individual patients and many hand-offs of care High acuity of patient illness or injury Ambient atmosphere prone to distractions or interruptions Need for rapid care management decisions; care givers being time pressured High-volume and/or unpredictable patient flow Use of diagnostic or therapeutic interventions having a narrow margin of safety, including high-risk drugs Communication barriers with patients and/or co-workers Instructional setting for care delivery, with inexperienced caregivers

10. Preventing Medication Errors Outlined a national agenda for reducing medication-related problems in all clinical settings including NHs To achieve this goal: Complete patient information and decision-support tools available Communicate patient-specific medication-related information in an interoperable format Assess the safety of medication use through active monitoring The full benefit of technologies for preventing medication errors will not be achieved unless a culture of safety is created first Latest in the Quality Chasm series To achieve high levels of safety culture, the IOM suggests that health care organizations devote sufficient attention to safety and also make resources available including: Complete patient information and decision-support tools available Communicate patient-specific medication-related information in an interoperable format Assess the safety of medication use through active monitoring Culture change must precede technology change: clinical setting, IT, and social/organizational structure Latest in the Quality Chasm series To achieve high levels of safety culture, the IOM suggests that health care organizations devote sufficient attention to safety and also make resources available including: Complete patient information and decision-support tools available Communicate patient-specific medication-related information in an interoperable format Assess the safety of medication use through active monitoring Culture change must precede technology change: clinical setting, IT, and social/organizational structure

11. Patient Safety Culture (PSC) Defined PSC examines how perceptions, behaviors, and competencies of individuals and groups determine an organization�s commitment, style, and proficiency in health and safety management. Because of the influence of the IOM reports, PSC is an emerging area of health services research thatBecause of the influence of the IOM reports, PSC is an emerging area of health services research that

12. Key Elements of PSC A shared belief that healthcare is a high-risk undertaking An organizational commitment to detecting and analyzing patient injuries and near misses An environment that balances the need for reporting of events and the need to take disciplinary action -High-risk organizations such as nuclear power and chemical manufacturing industries -VA is probably the most progressive of all healthcare environments, having strategies already in place for active and passive surveillance, as well as techniques to review errors (i.e., RCA) or event predict them in advance (FMEA)-High-risk organizations such as nuclear power and chemical manufacturing industries -VA is probably the most progressive of all healthcare environments, having strategies already in place for active and passive surveillance, as well as techniques to review errors (i.e., RCA) or event predict them in advance (FMEA)

13. PSC Instruments There are least nine such instruments available; all have been used in the hospital setting however There are least nine such instruments available; all have been used in the hospital setting however

14. PSC Assessments Have Been Used to: Identify areas for improvement Evaluate the success of patient safety interventions Develop internal and external benchmarking Fulfill regulatory requirements JCAHO national pt safety goalsJCAHO national pt safety goals

16. Study Objectives Assess patient safety culture in the nursing home setting Determine whether various healthcare professionals differ in their perceptions of patient safety culture Compare patient safety scores of nursing homes with those of hospitals

17. Methods: Survey Instrument The Hospital Survey on Patient Safety Culture (HSOPSC) was designed Westat under contract by the Agency for Healthcare Research and Quality (AHRQ) and has 12 dimensions and 2 outcome measures Each dimension has 3�5 questions and uses a 5-point Likert scale of agreement ("strongly disagree" to "strongly agree") or frequency ("never" to "always") The outcome measures use single-item responses about the number of "events" reported (defined as errors of any type, regardless of whether they result in patient harm) and the overall patient safety grade (�excellent� to �failing�)

19. HSOPSC Patient Safety Dimensions Communication openness -�Staff feel free to question the decision or actions of those with more authority� Feedback and communication about error -�We are informed about errors that happen in this unit� Frequency of events reported -�When a mistake is made that could harm the patient, but does not, how often is this reported?� Provide examplesProvide examples

20. HSOPSC Patient Safety Dimensions Handoffs and transitions -�Shift changes are problematic for patients in this hospital� (r) Management support for patient safety -�The actions of hospital management show that patient safety is a top priority� Nonpunitive response to error -�When an event is reported, it feels like the person is being written up, not the problem� (r)

21. HSOPSC Patient Safety Dimensions Organizational learning and continuous improvement -�After we make changes to improve patient safety, we evaluate their effectiveness� Overall perceptions of safety -�Patient safety is never sacrificed to get more work done� Staffing -�We have enough staff to handle the workload� Provide examples Provide examples

22. HSOPSC Patient Safety Dimensions Supervisor/manager expectations and actions promoting patient safety -�My supervisor/manager seriously considers staff suggestions for improving patient safety� Teamwork across units -�There is good cooperation among hospital units that need to work together� Teamwork within units -�People support one another in this unit�

23. HSOPSC Survey Instrument To create publicly accessible benchmark data, the survey was pilot-tested with 1,419 hospital employees from 21 hospitals across the US in 2003 Analyses showed that all 12 dimensions had acceptable levels of internal consistency (Cronbach�s alpha =0.63 to 0.84) Our survey had Cronbach�s that ranged from 0.5-0.84Our survey had Cronbach�s that ranged from 0.5-0.84

24. Methods: HSOPSC Survey Modification For this study, we modified the HSOPSC for use in the NH (PSC-NH): Definitions were added to orient participants to the goals of the survey The phrase �hospital work area/unit� was replaced with �nursing home� The demographic section was adapted to the types of professionals working in NHs PSC-NH was pilot tested before distribution No other changes were made. The PSC-NH uses the same question format, question order, and response options (see Appendix). No other changes were made. The PSC-NH uses the same question format, question order, and response options (see Appendix).

25. Study Settings Participating NHs included four independently-owned non-profit facilities in the SW PA area Three NHs were suburban and one was urban Average bed size was 150

26. Study Participants The four NHs employed 151 full- and part-time healthcare providers representing four professions: Advanced practitioners (nurse practitioners and physician assistants) Nurses Pharmacists Physicians Physicians with >/=10% of residents were asked to participatePhysicians with >/=10% of residents were asked to participate

27. Survey Distribution Between May and July 2005, NH administrative personnel distributed survey packets to all 151 healthcare workers Each packet contained a cover letter signed by the nursing home administrator and medical director explaining the study, a copy of the survey; a prepaid reply envelope for confidential return via US mail; and a $10 gift certificate request envelope A second packet was mailed out if the first was not received within 4 weeks

28. Data Analysis To calculate response rates, the number of respondents per NH or profession was divided by the total number of potential respondents per NH or profession Individual responses for each survey question was first dichotomized by defining a positive response as either �Agree/Strongly agree� or �Most of the time/Always� for positively worded questions, and �Disagree/Strongly disagree� or �Rarely/Never� for reverse worded questions

29. Data Analysis We created composite scores for each PSC dimension per respondent by calculating a mean percentage of positive responses PSC domain scores could range from 0-100, where lowers score represented worse PSC Z-scores were used to compare NH results with published hospital benchmarks; a linear mixed model was developed to compare PSC scores across professions the number of positive responses on items in a dimension divided by the total number of items in the dimension, excluding missing responsesthe number of positive responses on items in a dimension divided by the total number of items in the dimension, excluding missing responses

30. Results: Response Rates and Demographics Of 151 surveys distributed, 104 (69%) were returned Facility response rates ranged from 56 - 93% Pharmacists had the highest response rate and physicians the lowest (100% vs. 52%)

31. Most respondents were women and were full-time employees. Respondents had worked in nursing homes for a mean of 9.8 years and in their current position and current facility for a mean of 7.1 years and 5.4 years, respectively.Most respondents were women and were full-time employees. Respondents had worked in nursing homes for a mean of 9.8 years and in their current position and current facility for a mean of 7.1 years and 5.4 years, respectively.

32. Results: PSC Across Professions Only attitudes about staffing issues (e.g., having enough employees to handle the workload) differed significantly across professions (p<0.03); nurses and RPhs had higher mean PSC scores than physicians and APs The composite PSC scores for 7 of the 12 dimensions were lower for APs than the other professions; pharmacists rated 6 of the 12 dimensions higher than the other professions Overall, nurses and pharmacists had higher mean PSC scores than advanced practitioners and physicians

33. The largest differences were in nonpunitive response to error (10.6 for nursing homes versus 43.0 for hospitals; p<0.01) and teamwork within units (45.6 versus 74.0; p<0.01).The largest differences were in nonpunitive response to error (10.6 for nursing homes versus 43.0 for hospitals; p<0.01) and teamwork within units (45.6 versus 74.0; p<0.01).

34. The largest differences were in nonpunitive response to error (10.6 for nursing homes versus 43.0 for hospitals; p<0.01) and teamwork within units (45.6 versus 74.0; p<0.01).The largest differences were in nonpunitive response to error (10.6 for nursing homes versus 43.0 for hospitals; p<0.01) and teamwork within units (45.6 versus 74.0; p<0.01).

35. Results: Across Settings Summarized For five of the 12 dimensions, NH composite scores were significantly lower than hospital composite scores The largest differences were in nonpunitive response to error (10.6 for nursing homes versus 43.0 for hospitals; p<0.01) and teamwork within units (45.6 versus 74.0; p<0.01) In only one dimension, management support for patient safety, were scores higher for NHs than hospitals, but the difference was not statistically significant (66.2 versus 60.0; p=0.34)

36. What�s interesting, is that overall, NH professionals submit more reports than hospital professionals; highlighting the punitive nature of NHs However, we did an earlier study that was quoted in the latest IOM report that suggests significant underreporting in the NH setting; as such, these results are surprisingWhat�s interesting, is that overall, NH professionals submit more reports than hospital professionals; highlighting the punitive nature of NHs However, we did an earlier study that was quoted in the latest IOM report that suggests significant underreporting in the NH setting; as such, these results are surprising

37. Note that there is not much difference b/w the two settingsNote that there is not much difference b/w the two settings

38. Key Findings This study provides the most complete information available to date on patient safety culture in nursing homes from multiple clinical perspectives Various types of professionals working in nursing homes were in general agreement about 11 of 12 PSC dimensions measured in the survey On 5 of 12 dimensions, the composite scores for NHs were significantly lower than those for hospitals

39. Discussion Staffing was the only patient safety culture dimension in which NH professions differed When compared to physicians and advanced practitioners, nurses were more likely to perceive that there was enough staff to handle the workload This finding is in contrast with several studies documenting insufficient nursing staff and difficulties in recruiting and retaining qualified nursing staff

40. Discussion NHs differed from hospitals especially in perceived response to error, which was reported as more punitive in NHs This finding was not unexpected, because error-reporting policies and processes are thought to perpetuate a punitive environment in NHs Regulation, the predominant form of oversight in NHs, is thought to invoke a more punitive culture, as opposed to accreditation, the predominant form of oversight in other healthcare settings -Only a fraction of NHs are accredited by the JCAHO, despite evidence suggesting that accredited NHs have fewer complaints and deficiencies filed against them-Only a fraction of NHs are accredited by the JCAHO, despite evidence suggesting that accredited NHs have fewer complaints and deficiencies filed against them

41. Discussion Previous studies have described NHs as rigidly hierarchical and particularly difficult environments for quality-improvement initiatives This environmental characteristic may underlie the significantly lower scores in NHs compared to hospitals Only in management support for patient safety was the composite score greater for NHs than hospitals True in our own institution where Dr. Rosen recently presented here at a GRECC conference (March 24, 2006) QI difficult b/c a lot of data, but its not clear what to do with all of it�True in our own institution where Dr. Rosen recently presented here at a GRECC conference (March 24, 2006) QI difficult b/c a lot of data, but its not clear what to do with all of it�

42. Limitations Smaller numbers of non-nursing processionals may have limited the statistical power to detect significant differences across professions Only a small number of facilities in the same metropolitan area were surveyed, potentially limiting the generalizability of results Did not include Certified Nursing Assistants (CNAs), an important provider of care in the NH setting Nevertheless, nurses represent the most prevalent professional staff in most health care settings and the distribution of professions among study respondents was similar to other patient safety culture studies Staffing was lowest PSC domain and similar to what Westat reported The instrument�s psychometric properties could have been altered by modifying an instrument intended for use in the hospital setting (Cronbach�s alphas on the PSC-NH range from 0.5 � 0.84) Nevertheless, nurses represent the most prevalent professional staff in most health care settings and the distribution of professions among study respondents was similar to other patient safety culture studies Staffing was lowest PSC domain and similar to what Westat reported The instrument�s psychometric properties could have been altered by modifying an instrument intended for use in the hospital setting (Cronbach�s alphas on the PSC-NH range from 0.5 � 0.84)

43. Implications and Future Direction PSC should be assessed in more NHs with varied institutional characteristics and in a broader range of personnel Studies should examine relationships with bed size, type of ownership, staffing levels, staff turnover rate, and number and type of deficiencies Studies should assess the relationship between PSC and specific patient outcomes such as adverse drug events, falls, and transfers to higher levels of care -In order to better understand the relationship between patient safety culture and institutional characteristics, studies should examine relationships with bed size, type of ownership, staffing levels, staff turnover rate, and number and type of deficiencies -give plug to AHRQ and Westat for developing next set of instruments -Give plug for Nick Castle�s work in this area -Alice Bonner wanting to look at relationship b/w Falls and PSC scores -manuscript submitted to QSHC was accepted on -Handler SM, Castle NG, Studenski SA, Perera S, Fridsma DB, Nace DA, Hanlon JT. Patient Safety Culture Assessment in the Nursing Home. Quality and Safety in Health Care. 2006 (Accepted for publication, September 21, 2006). Nace DA, Hoffman EL, Resnick NM, Handler, SM Achieving and sustaining high rates of influenza immunization among long-term care staff. Journal of the American Medical Directors Association (Accepted for publication, September 22, 2006).-In order to better understand the relationship between patient safety culture and institutional characteristics, studies should examine relationships with bed size, type of ownership, staffing levels, staff turnover rate, and number and type of deficiencies -give plug to AHRQ and Westat for developing next set of instruments -Give plug for Nick Castle�s work in this area -Alice Bonner wanting to look at relationship b/w Falls and PSC scores -manuscript submitted to QSHC was accepted on -Handler SM, Castle NG, Studenski SA, Perera S, Fridsma DB, Nace DA, Hanlon JT. Patient Safety Culture Assessment in the Nursing Home. Quality and Safety in Health Care. 2006 (Accepted for publication, September 21, 2006). Nace DA, Hoffman EL, Resnick NM, Handler, SM Achieving and sustaining high rates of influenza immunization among long-term care staff. Journal of the American Medical Directors Association (Accepted for publication, September 22, 2006).

44. Part II - Objectives Summarize the results of a study conducted to assess PSC from the perspective of NH administrators (NHAs) Summarize the results of a study conducted to assess PSC from the perspective of Nurse Aides Available measures of NH quality From AMDA presentation: Objectives (no more than four): Describe the evolution of patient safety culture from the perspective of the Institute of Medicine. Define and describe the key elements of patient safety culture. Describe what patient safety culture instruments are available and how they have been used. Summarize a study conducted to assess patient safety culture in the nursing home setting.Available measures of NH quality From AMDA presentation: Objectives (no more than four): Describe the evolution of patient safety culture from the perspective of the Institute of Medicine. Define and describe the key elements of patient safety culture. Describe what patient safety culture instruments are available and how they have been used. Summarize a study conducted to assess patient safety culture in the nursing home setting.

46. Purpose: Resident safety culture from a top management perspective is compared with existing data from hospitals How the safety culture of nursing homes varies according to facility characteristics and market characteristics is examined.

47. Conceptual Model:

48. Hypotheses: Resident safety initiatives will be less well developed in nursing homes: H1 � the scores from the HSOPSC will be lower in nursing homes than hospitals Facility and market characteristics are often associated with quality (ownership etc.) H2 � facility and market characteristics will be associated with low nursing home HSOPSC resident safety culture scores (i.e., following the quality literature)

49. Design: Survey of nursing home administrators. Questionnaire (National Nursing Home Turnover Study [NNHTS]) mailed to the administrator of 4,000 nursing homes during 2005. 2,840 returned (response rate =71%)  Sample stratified based on county unemployment rates (terciles) Excluded homes with less than 30 beds Random selection within strata

50. Questionnaire: Included the Hospital Survey on Patient Safety Culture (HSOPSC) Modified some items to state nursing home, unit, and resident. Pilot tested with 10 NHAs

51. Design: On-Line Survey Certification and Recording System (OSCAR) Facility factors (e.g., bed size, etc) Area Resource File (ARF) Market characteristics (e.g., unemployment rates)

52. Results:

53. Results:

54. Results:

55. Results: Market characteristic: number of nursing homes in the county is significantly associated with low resident safety scores in 7 of the 12 patient safety subscales.

56. Limitations: Causal direction Practical significance of specific scores Hospital setting for instrument development Findings from NHAs Surprisingly low, expected positive response bias Similar findings for NAs

57. Implications: Safety culture scores are lower in nursing homes Safety culture scores may proxy for quality of care Practical implications, high RN staffing associated with high safety culture  Patient safety, another problem with the image of nursing homes

59. Purpose: Resident safety culture from a Nurse Aide�s perspective is compared with existing data from hospitals

60. Design: Data from 72 nursing homes and 1,579 Nurse Aides Response rate = 55% Completed HSOPSC OSCAR and ARF

61. Results: All 12 HSOPSC subscale scores were below the benchmark hospital scores Shows a less well developed safety culture Facility and market characteristics similar to those from examining quality Staffing levels For-profit ownership Average occupancy Average private-pay occupancy

62. Results:

63. Implications: Threat of nursing homes becoming known as �unsafe� places Resident safety culture may be a proxy for quality of care Practical relevance of RN staffing levels

65. Part III - Goals and Objectives Describe survey instrument distribution and obtaining a good response rate Describe data management & data quality assurance Describe computation of PSC domains Describe analytic issues

66. Survey Instrument Distribution To get the PSC-NH survey, see handout following these slides or go to www.aging.upmc.com/health-care-professionals/patient-safety.htm Mechanism for anonymous response - Number of employees - Mail with SASE - Drop off box Incentives for completing & returning - Gift cards - Separate SASE for mailing gift card

67. Survey Instrument Distribution Frequent reminders - Additional blank surveys - Donuts/bagels Pre-defined endpoint - Fixed date - Fixed response rate = # returned surveys * 100 # employees

68. Data Management & Quality The HSOPSC Microsoft Excel data entry tool was originally develop by Premier, Inc. and can be downloaded at www.premierinc.com We modified the original tool for use with the PSC-NH survey instrument. This Microsoft Excel data entry tool can be downloaded at www.aging.upmc.com/health-care-professionals/patient-safety.htm

69. Data Management & Quality Built-in checks against invalid data entry Easy reference Frozen row/column titles Color-coded rows Automatic computation of PSC domain scores and overall summary statistics

70. Data Management & Quality Backup data daily Independent double data entry & comparison - by two different individuals - by same individual, but start second round only after first round is complete Freeze cleaned data Proportions of missing responses to individual items

71. PSC Domain Score Computation Scoring guidelines published in www.ahrq.gov/QUAL/hospculture/prebenchmk.pdf Dichotomize Likert scale response to individual items as �positive� or �not positive� - �agree� & �strongly agree� are positive - �most of the time� & �always� are positive - Reverse for negatively worded questions Domain score is the proportion of positive responses to items in the domain multiplied by 100. The resulting PSC domain scores therefore range from 0-100, where lower scores are interpreted as worse PSC.

72. PSC Domain Score Example

73. PSC Domain Score Example Number of positive responses = 3 Number of items in domain = 4 Proportion of positive responses = � = 0.75 Overall perceptions of safety domain score for this respondent is 0.75 * 100 = 75

74. PSC Domain Score Analysis PSC domain scores are (pseudo) continuous measures & can use standard analytic methods Summary statistics (mean, SD, Median, etc.) One-sample t-tests to compare your facility�s PSC domain scores against published benchmarks. P-value <0.05 means your facility is significantly different from benchmark P-value =0.05 means no evidence that your facility is different from benchmark No real difference Not enough responders to the survey

75. PSC Individual Item Analysis A person�s response to a single item can be thought of as dichotomous (positive or not), and standard methods can be used Summary statistics (frequencies, proportions, percentages etc.) One-sample tests of proportions to compare your facility�s PSC domain scores against published benchmarks

76. Multiple Facilities Responders from the same facility have a tendency to be more alike than those from different ones Cannot use standard analytic methods. Need advanced methods and statistical software For PSC domain analyses, mixed linear models or advanced survey methods For individual item analyses, generalized estimating equations (GEE) models

77. Bibliography: Castle N. Nurse Aides' ratings of the resident safety culture in nursing homes. Int J Qual Health Care. 2006 Oct;18(5):370-6. Castle N, Handler S, Engberg J, Sonon K. Nursing home administrators' opinions of the resident safety culture in nursing homes. Health Care Management Review. (in press). Castle NG, Sonon KE. A culture of patient safety in nursing homes. Qual Saf Health Care. 2006 Dec;15(6):405-8. Handler S, Castle N, Studenski S, Perera S, Fridsma D, Nace D, et al. Patient safety culture assessment in the nursing home. Quality and Safety in Health Care. 2006;15(4):400-4. Hughes CM, Lapane KL. Nurses' and nursing assistants' perceptions of patient safety culture in nursing homes. Int J Qual Health Care. 2006 Aug;18(4):281-6.