Katherine Jones, PT, PhD And Team Supported by AHRQ Grant 1 U18 HS015822 AHRQ Knowledge Transfer

1. Challenges to Improving Safety at the Point of CareBuilding Infrastructure: Lessons Learned from Critical Access Hospitals AHRQ Annual MeetingSept. 9, 2008 Katherine Jones, PT, PhD And Team Supported by AHRQ Grant 1 U18 HS015822 AHRQ Knowledge Transfer National Rural Health Association Nebraska Department of HHS

2. Objectives Knowledge: Patient safety infrastructure requires common knowledge of a theoretical framework to achieve sensemaking Skill: Assess culture and implement change; comply with Joint Commission Leadership Standards (LD.03.01.01) Attitude: Believe that key safety culture practices create the infrastructure that organizations must use to support frontline workers who improve quality and keep patients safe

3. Critical Access Hospitals (CAHs) • Limited to • 25 inpatient beds • 96 hour average length of stay • Receive cost-based reimbursement to maintain access to care in rural areas • 1,289 CAHs concentrated in Midwest; ¼ of general community hospitals in US

4. What does a CAH look like?

5. Chain of Impact at the Point of Care Healthcare System Structures & Processes Organizational Structures & Processes Culture Individual Provider Structures & Processes The quality, safety and value of care can be no better than the structures and processes used by providers in direct contact with the patient. Culture determines how organizations support providers at the point of care. Nelson et al. (2002) Joint Commission Journal on Quality Improvement, 28, 472-493. Swuste P. (2008). Human Factors and Ergonomics in Manufacturing, 18, 438-453. Technical Care Interpersonal Care Quality at Point of Care

6. How can organizations effectively support providers at the point of care? • AHRQ-supported research with Critical Access Hospitals (CAHs) provides evidence consistent with Dr. Clancy’s message: “How to translate research into improvement:” • Infrastructure • Capacity • Incentives • Implementing a Program of Patient Safety in Small Rural Hospitals • Evaluating the Effect of TeamSTEPPSTM Training on the Culture of Safety in Critical Access Hospitals

7. Implementing a Program of Patient Safety in Small Rural Hospitals • One of 17 AHRQ PIPs grants funded 7/05 – 6/07 (AHRQ Grant 1 U18 HS015822) • Purpose: To implement the patient safety practices of voluntary medication error reporting and organizational learning in 24 Critical Access Hospitals. • Aim 1: Develop the organizational infrastructure for reporting and analyzing medication errors that is needed to identify system sources of error.

8. Evaluating the Effect of TeamSTEPPSTM Training on the Culture of Safety in Critical Access Hospitals • Funding through AHRQ and Nebraska DHHS • Purpose: To implement the patient safety practice of teamwork and communication training in 25 Critical Access Hospitals. • Aim 1: Evaluate the impact of the TeamSTEPPS training program on safety culture using the rural-adapted version of the AHRQ Hospital Survey on Patient Safety Culture.

9. The Components of an Effective Patient Safety System* The components are: (1) monitoring progress/maintaining vigilance, (2) knowledge of epidemiology of patient safety risks and hazards, (3) development of effective practices and tools, (4) building infrastructure for effective practices, and (5) achieving broader adoption of effective practices *Farley DO, Damberg CL, Ridgely MS, et al. Assessment of the AHRQ patient safety initiative final report—Evaluation report IV. Rand Organization; 2008 Technical Report No. 563. http://www.rand.org/pubs/technical_reports/TR563/.

10. Phase One: Reporting in an Effective Patient Safety System 1. Knowledge of Epidemiology of Medication Errors 2. Tool: Process Maps Forms, Database 4. Building Infrastructure: 14 CAHs report to MEDMARX, Safety culture education 5. Achieving Broader Adoption: 35 CAHs report to MEDMARX, Ongoing NCPS RCA education 3. Monitor Progress: Benchmarking reports, Change management Four CAHs in Nebraska sought help from UNMC to make sense of their medication errors. • Understand the epidemiology of medication errors • Develop effective tools: process maps, reporting forms, database • Monitor progress: benchmarking reports and assistance to manage process change • AHRQ funding supported an infrastructure—subscriptions to MEDMARX,, education about disclosure of errors, just culture, root cause analysis • AHRQ funding enabled broader adoption of these practices across 35 CAHs in three states

11. Sensemaking Tools From PIPS Grant: Process map, Reporting Form

12. Sensemaking Tools From PIPS Grant: Transform data into information 12

13. Phase Two: Assessing Progress in an Effective Patient Safety System 2. Tools: AHRQ HSOPS using Dillman tailored design method, Benchmark Graphs, Unsafe Acts Algorithm 1. Knowledge: working definition, role of culture in patient safety 4. Building Infrastructure: Rural adaptation of HSOPS to assess rural microcultures 5. Achieving Broader Adoption: PIPS TOOLKIT, Develop service to conduct HSOPS in CAHs for NRHA 3. Monitor Progress: Assess change in culture due to practices Second action research cycle of our PIPS Grant • Knowledge that reporting is the foundation of a culture of safety; working definition • Need an effective tool to assess culture • Monitor progress and assess change in culture due to reporting infrastructure • Build rural quality improvement infrastructure by adapting HSOPS to the rural environment • Achieved broader adoption of rural-adapted version of HSOPS by disseminating it to QIOs and contracting with the National Rural Health Association

14. Working Definition of Safety Culture • Enduring, shared beliefs and behaviors that reflect an organization’s willingness to learn from errors* • Three beliefs present in a safe, informed culture** • Our processes are designed to prevent failure • We are committed to detect and learn from error • We have a just culture that disciplines based on risk *Wiegmann. A synthesis of safety culture and safety climate research; 2002. http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/02-03.pdf **Institute of Medicine. Patient safety: Achieving a new standard of care. Washington, DC: The National Academies Press; 2004.

15. What are the components of safety culture? • Reporting – staff report their errors • Just – reporting is rewarded, clear line between acceptable & unacceptable behavior • Flexible – authority patterns relax when safety information is exchanged • Learning – action is taken based on safety information systems Reason, J. Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited; 1997.

16. How can organizations effectively support providers at the point of care? Use the AHRQ Hospital Survey on Patient Safety Culture (HSOSPS) to identify and monitor impairments in organizational learning at the level of units/departments and staff positions Implement effective practices within each of the four components of a safe culture that address impairments within microsystems Ensure interactions between the practices to engineer an infrastructure—a culture—that supports organizational learning 16

17. How does HSOPS identify impairments in organizational learning? HOSPS measures staff perceptions of the beliefs and behaviors that support a safe culture HSOPS is a valid, reliable instrument comprised of 51 items categorized in 12 dimensions 12 dimensions reflect the four components of an informed, safe culture A tool to evaluate, plan, reevaluate patient safety programs; Small rural hospitals require support to use it effectively Nieva, Sorra. (2003). Safety culture assessment: a tool for improving patient safety in healthcare organizations. Qual Saf Health Care, 12(Suppl II), ii17-ii23. Jones,Skinner, Xu, Sun, Mueller. The AHRQ Hospital Survey on Patient Safety Culture: a tool to plan and evaluate patient safety programs. In Henriksen et al., Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 2. Culture and Redesign. AHRQ Publication No. 08-0034-1. Rockville, MD: Agency for Healthcare Research and Quality; August 2008. 17

18. Benchmark HSOPS Graph of Aggregate Hospital Results 18

19. HSOPS Graph Comparing Nurse to Aggregate Hospital Results 19

20. Benchmark HSOPS Graph of Aggregate Results 2005 and 2007 20

21. Interactions Between Components

22. Pass substitution test? (Could someone else have done the same thing)? Pass substitution test? (Could someone else have done the same thing)? NO NO NO YES Were the actions as intended? Were the actions as intended? Evidence of illness or substance use? Evidence of illness or substance use? Knowingly violated safe procedures? Knowingly violated safe procedures? History of unsafe acts? History of unsafe acts? NO NO NO YES YES YES NO YES Were procedures available, workable, intelligible, correct and routinely used? Were procedures available, workable, intelligible, correct and routinely used? Were the consequences as intended? Were the consequences as intended? Known medical condition? Deficiencies in training, selection, or inexperienced? Deficiencies in training, selection, or inexperienced? Blameless error Blameless error NO YES YES Blameless error, corrective training, counseling indicated Blameless error, corrective training, counseling indicated Substance abuse without mitigation Substance abuse without mitigation YES NO NO System induced violation System induced violation YES NO Possible reckless violation Possible reckless violation System induced error System induced error Sabotage, malevolent damage Sabotage, malevolent damage Substance use with mitigation Substance use with mitigation Possible negligent behavior Possible negligent behavior Culpable Culpable Gray Area Gray Area Blameless Blameless Adapted from James Reason. (1997). Managing the Risks of Organizational Accidents. Execute Just Culture . . . UNSAFE ACTS ALGORITHMwww.unmc.edu/rural/patient-safetyclick on Just Culture

23. Phase Three: Integrating Team Training in an Effective Patient Safety System 1. Knowledge that a culture of safety is engineered from interacting practices 2. Tool: TeamSTEPPSTM 4. Building Infrastructure: Creating a rural TeamSTEPPS community 3. Achieving Broader Adoption: Train the trainer in 25 CAHs 5. Monitor Progress: Reassess change in culture March 2009 Third action research cycle • Knowledge that a culture of safety in high reliability organizations is engineered from interacting practices of the four components of culture within microsystems (units/positions) • HSOPS results indicated the need for training in teamwork and communication. • We conducted the train the trainer course in 25 CAHs in April 2008; will add 7 more in 2009 • We are building a community of TeamSTEPPS coaches/trainers across the state • We will reassess safety culture in 25 CAHs in March 2009

24. HSOPS Identifies Readiness for Teamwork Training TeamSTEPPS training must be supported by systematic error reporting, just culture practices, and use of learning tools such as individual and aggregate RCA, Leadership WalkRounds, and Safety Briefings

25. SENSEMAKING TRUST Conclusion:Infrastructure for Effective Practices • Interaction between effective practices results in sensemaking within macro- and microsystems of care • Sensemaking requires data, which is interpreted within the context of the lived experiences of those in direct contact with patients • Sensemaking can not occur without data from reporting, trust and teamwork

26. Infrastructure: Lessons Learned from Dundy County, Nebraska “Once the AHRQ survey identified areas for improvement, through the grant, we spent the next year working on those areas. The education and training on teamwork, communication, and RCA gave us tools we hadn’t heard of. We have seen our organization change from one that makes the same errors over and over to one that analyzes errors and attempts to learn from them.”

27. Rural Adaptation of HSOPS • Original HSOPS designed for large urban hospitals • 14 different work areas • 14 different staff positions • Sort by work area or position if > 11 • Rural-adapted HSOPS for hospitals with < 50 beds • 12 different work areas - 12% choose “other” • Collapsed multiple departments to Acute/Skilled Care • Added Long-term care, Home Health Care, Therapies • 6 different job titles - 8% choose “other” • Sort by work area or job title if > 5 1/3 in national database choose “other”

28. Original AHRQ HSOPS Work Area Demographics Rural-Adapted HSOPS Work Area Demographics Rural Adaptation of HSOPS 2008 Comparative Database Report: 33% of 160,196 respondents choose “other” UNMC CAH Comparative Database: 12% of 4,117 respondents choose “other”

29. Original AHRQ HSOPS Staff Position Demographics Rural-Adapted HSOPSStaff Position Demographics Rural Adaptation of HSOPS 2008 Comparative Database Report: 22% of 160,196 respondents choose “other” UNMC CAH Comparative Database: 8% of 4,117 respondents choose “other”

30. Where can I get the HSOPS? • Original HSOPS From the AHRQ website http://www.ahrq.gov/qual/hospculture/ Click on Hospital Survey Toolkit • Rural-adapted version for CAHs with 25 or fewer beds from UNMC web site (see our poster in the mAHRQet Place Café ) http://www.unmc.edu/rural/patient-safety Click on Hospital Survey on Patient Safety Culture Resources Contact information Katherine Jones, PT, PhD Anne Skinner, RHIA kjonesj@unmc.eduaskinner@unmc.edu

31. Contact Information Katherine Jones, PhD, PT kjonesj@unmc.edu Anne Skinner askinner@unmc.edu Web site where tools are posted www.unmc.edu/rural/patient-safety Supported by AHRQ Grant 1 U18 HS015822 National Rural Health Association Nebraska Department of HHS