A Longitudinal Study of an Intervention to Enhance Organizational Emphasis on Safety

1. A Longitudinal Study of an Intervention to Enhance Organizational Emphasis on Safety Academy Health June 9, 2008 Sara J. Singer Coauthors: Anita Tucker, Shoutzu Lin, Alyson Falwell, Jennifer Hayes Financial support was provided by AHRQ RO1 HSO13920 and Wharton’s Fishman Davidson Center

2. Motivation for studyingOrganizational Emphasis on Safety • Organizational emphasis on safety (OES) can • Improve safety performance (Weiner et al, 1997; Vogus & Sutcliffe, 2007; Zohar & Luria 2003) • Shape worker behavior and attitudes (Carroll et al 2002, Edmondson 2003) • OES comes from managers who are visibly committed to safety (Gaba 2000, Weick 2001) • Less in known about mechanisms for increasing OES in organizations where it is low (Dixon and Shofer 2006) • Notable exceptions Frankel et al 2005, Pronovost et al 2004

3. Possible mechanism for increasing Organizational Emphasis on Safety • Low levels of OES may result from decoupling of Senior Managers (SM) from the frontlines • SM may be unaware of safety risks and opportunities for improvement • SMs shape resource allocation, process design, and organizational culture  Which influence frontline staff’s ability to provide safe patient care • Challenge for SMs is leveraging frontline knowledge about system weaknesses

4. Our intervention: Leveraging Front Line Expertise (LFLE) • Over 18-month period, expose SMs to frontline work systems in context • Frontlinework system visit: Observe staff in context • Safety communication forum: Listen to staff concerns about patient safety • Debrief meeting:Prioritize “operational failures,” propose resolutions and assign responsibility for action • Feedback to staff: Communicate about actions taken • Through LFLE, SMs are more likely to • Recognize need for improvement • Allocate resources appropriately • Make decisions supportive of safety Repeat every 3 months on a different work area

5. One hospital’s implementation ED Med/Surg Outpatient Physical Therapy Endoscopy

6. Hypotheses: Expected impact of LFLE on OES

7. Methods • 24 hospitals randomly selected (from a random, stratified sample of 92) for an 18-month intervention (2005 – 2006) • 20 hospitals completed intervention • Intervention hospitals did not differ significantly from US hospitals with respect to urban location and teaching status • Work areas where intervention was most commonly implemented: ED, ICU, OR/PACU, and Medical/Surgical Wards

8. Data • Pre (2004-5) and Post (2006-7) survey of personnel in 49 control hospitals and 20 intervention hospitals • Sample: 100% senior managers (dept head and above); 10% nursing staff • Response rates: 76% SM and 67% nurses in 2004, 62% SM and 50% nurses in 2006

9. Measure • Organizational emphasis on safety (OES) (a=.80) • Senior management considers patient safety when program changes are discussed. • Senior management has a clear picture of the risk associated with patient care. • I have enough time to complete patient care tasks safely. • My unit provides training on teamwork in order to improve patient care performance and safety. • Overall, the level of patient safety at this facility is improving. • All items used 5-point Likert response scale • Computed mean of all items, weighted equally

10. Senior managers Used two-level HLM to compare post-intervention perception of OESamong SM in intervention hospitals (n=20) to non-intervention hospitals (n=49) Nurses Used three-level HLM to compare post-intervention perception of OES among nurses in intervention work areas (ED, ICU, OR/PACU, Med/Surg) (n=66) to same areas in non-intervention hospitals (n=172) Analysis • Examined impact of intervention assignment and of greater implementation (# failures identified, % failures acted upon, and % failures with feedback) • Controlled for DV baseline and for individual, work area, and hospital characteristics

11. Impact of LFLE on Organizational Emphasis on Safety:Mean post-differences controlling for pre-differences A positive coefficient is associated with an improved perception (OES “got better”) ** p<0.01, * p<0.05, ^ p<0.1 Standard errors in parentheses SM model compared intervention v non-intervention hospitals; Nurse model compares work areas. Models included as control variables: age, tenure, discipline, teaching status, urban location, number of hospital beds, and in the nurse model only, work area.

12. Conclusions • Our research represents one of the first quasi-experimental controlled studies to test an intervention to increase exposure of senior managers to frontlines Demonstrated ability to conduct intervention with senior managers in a healthcare setting • Exposing senior managers to frontline safety hazards in context improved SM and nurses’ assessment of organizational emphasis on safety Which we expect in turn may improve patient safety

13. Thank You

14. Summary of results • H1: SM perception of OES T Were not influenced by hospital participation in LFLE 8 Declined marginally with identification of more operational failures R Improved with more action to address failures • 0.206 increase in OES represents a 5% change in the mean (.206/4.00) or 31% of a SD (0.206/0.66) • H2: Nurse perception of OES TWere not influenced by work area participation, identification, or action R Improved with more feedback • 0.393 increase in OES represents a 11% change in the mean (.393/3.50) or 49% of a SD (0.393/0.81) • With more with action and feedback, the intervention produced an effect among senior managers in intervention hospitals and among nurses in intervention work areas