Instructional Slide: How To Use This Template Presentatio n

1. Instructional Slide: How To Use This Template Presentation This template PPT presentation is intended to illustrate some of the ways the NYSPFP culture of safety survey report can be used to present your hospitals data to leadership within your hospital. The PPT can be adapted for use in the following ways: • Hospital-specific data should be inserted into this PPT template where noted with an Xor annotated in the notes for the slide. • Hospitals should insert data from their 2013 Culture of Safety Survey Hospital Specific Results to slides 9–15. This data can be accessed on the NYSPFP Web site: https://www.nyspfp.org/Members/myData.aspx under the heading, “Building Culture and Leadership.” Note that the charts and commentary provided in the slides that follow are for illustrative purposes only and refer to a report created for a fictional hospital. NYSPFP encourages hospitals to adapt this PPT to the their hospital-specific needs related to the AHRQ safety culture dimensions. Please contact your NYSPFP Project Manager if you have any questions. Thank you.

2. Hospital Re-Survey on Patient Safety Culture St. Elsewhere Hospital January 2014

3. Background • The AHRQ Culture of Safety (CoS) survey examines dimensions of organizations’ culture of patient safety to assist in identifying strengths and areas for patient safety culture improvement, as well as to evaluate the impact of patient safety initiatives and interventions on hospital safety culture. • This is the second administration of the survey through NYSPFP; the first was administered to XXX respondents between March-May, 2012. • The most current survey was administered to XXX respondents in September-October, 2013. • Comparing results from both surveys allows us to measure the differences in scores, and identify priority focus areas.

4. CoS Survey Measures • The CoS survey is designed to measure four patient safety “outcomes”: • Overall perceptions of safety • Frequency of events reported • Number of events reported • Overall patient safety grade • The CoS also measures ten dimensions of culture pertaining to patient safety: Teamwork within and across units Organizational learning-continuous improvement Staffing Non-punitive response to error Supervisor expectations and actions promoting safety Communication openness Feedback and communication about error Frequency of events reported Hospital management support for patient safety Hospital handoffs and transitions

5. High-Level Overview • HOSPITALperformed the second administration of the AHRQ CoS survey, as a participant in the NYS Partnership for Patients (NYSPFP) on 09/09/2013 through 10/04/2013. • X% increase/decreasein response rate to CoSSurvey • X% increase/decreasein staff rating the overall safety as excellent at HOSPITAL

6. CoS Respondent Demographics • In this report, data are available for Xstaff positions • Staff who worked for X yearsat HOSPITALwere most likely to respond (X%of responses)

7. Overview of NYSPFP CoS Re-Survey Results

8. Dashboard View CoS Survey Results: Overall Safety Grade Assigned by Staff

9. Overview of Composite Statistics

10. Dashboard View CoS: Safety Measurement for Work Areas

11. Greatest Increase in Scores by Dimension

12. Greatest Decrease in Scores by Dimension

13. Areas of Strength All dimensions at or above NYSPFP 90th percentile and national mean

14. Areas for Improvement All dimensions at or below the NYSPFP 25th percentile and national mean

15. Summary of Priority Action Items • Domains of Focus: • Frequency of events reported • Overall perception of safety • Handoffs • Staffing

16. Suggested Next Steps • Phase 1: 1-3 months • Disseminate results to department and unit managers • Share results with staff through “town hall” meetings and solicit staff suggestions on improvements • Hold focused groups to explore root causes, analyze differences between units/departments or staff position to determine opportunities to strengthen systems • Phase 2: 3-6 months • Develop hospital and departmental strategic action plans based on above. • Examples of targeted interventions: • Standardize hand-off processes, including rolling-out training on TeamSTEPPS principles such as SBAR or I PASS THE BATON • Improve event reporting system(s): is system easy to access, user-friendly, does staff receive feedback routinely? • Implement strategies to further promote patient safety and performance improvement • Phase 3: 6-18 months • Re-survey