Featured Speaker: Sara J. Singer, MBA Doctoral Fellow

1. Featured Speaker: Sara J. Singer, MBA Doctoral Fellow Harvard University PhD Program in Health Policy Boston, Massachusetts

2. Leveraging Front-line Expertise (LFLE): A research-based intervention to improve patient safety culture October 25, 2006 Improving Safety Culture and Outcomes in Health Care Research Team & 24 Participating Hospitals Research support was provided by the Agency for Healthcare Research and Quality and Wharton’s Fishman Davidson Center

3. Overview • Theory behind the intervention • Brief description of the intervention • Preliminary results from the intervention • Intervention evaluation

4. TheorySafety at Work • Despite hazardous work environments, some organizations have High Reliability (consistently error-free) (Roberts 1990) • Key Findings: • Senior managers’ support is essential (Alcoa…Southwest…Aircraft carriers) • HROs focus on process reliability rather than efficiency (Roberts 1990) • Employees need sufficient training, motivation, and staffing (Srivastava 1986) • These factors are considered important elements of “SAFETY CLIMATE”

5. Prior researchMeasuring Safety Climate • An important measure is the difference between perceptions of senior managers’ and frontline employees’ (FLE) • Senior managers’ perceptions are consistently more positive than those of FLE (Singer et al., 2003,2006) • FLE perceptions better predict safety performance (Singer et al., 2006) • Senior managers might fail to allocate necessary resources to improve systems (Auty & Long 1999, MacDuffie 1997) • Improving systems often requires managerial intervention (Tushman 1997, Tucker 2004)

6. The LFLE Intervention • Systematic process to engage senior managers with the front-lines of care • Worksite observations: Seeing the work environment first-hand, talking with front-line staff in context—all with a patient safety lens • Safety forums: Unit-based, on-site, multi-disciplinary open-communication forums designed to gather patient safety “helps and hinderers” from front-line staff • Debrief meetings: Interdisciplinary/ multi-level teams organize, prioritize, and take responsibility for safety issues identified from worksite observations and safety forums

7. LFLE process and its purpose Worksite observations Understand context Safety town forums Gather wider feedback Debrief meetings Organize information, select items for resolution, assign responsibility Promote follow-up Communicate with unit Communicate outcome of visits and meetings to unit staff Set expectations, promote understanding

8. Focus on one area for 3-months, through multiple perspectives

9. Hospital Participation • 32 out of the 92 survey hospitals were randomly selected to participate • 8 declined to participate • 1 dropped out and was replaced • Distributed by size and region, similar to overall hospital sample

10. Preliminary assessment • Intervention hospitals varied widely • Commitment of hospitals based on their senior managers’ early participation and preparedness for the intervention • Capabilities of hospitals based on their current use of senior managers’ rounds, forms style meetings, and related processes • Assessment suggested most had similar potential for a successful implementation

11. Preliminary Findings • 1,124 hinderers from the 24 hospitals • 183 worksite observations • 49 safety forums • Two-thirds of all observations/forums were in four units: • ER/ED (26%) • OR/PACU/Surgery (17%) • Med-Surg ward (15%) • ICU (10%)

12. Hinderers by unit

13. Preliminary Analysis of ED Hinderers Framework adapted from Frankel, A., et al. 2005.

14. Sample resolution for hinderers

15. Benefit of seeing in context • "I don't think the automatic door would have been fixed without the intervention. It was a small issue—although an important one—so it probably would have been overlooked without the intervention. By having senior administrators looking at the problem, there was recognition of the need to fix it.“ -VP of Nursing, Hospital 39.

16. Data from evaluation interview18/24 evaluations reported

17. Reported follow-up communication • 89% of the hospitals reported that staff received or sometimes received follow-up communication to issues raised

18. Obstacles to successful implementation • “Competing priorities” was cited as the primary obstacle to resolving hinderers (72%) and providing follow-up communication (44%) • Other impediments to resolving issues raised by staff included: • Financial constraints (56%) • Long lead time, requiring budget request (44%) • Limited manpower/staff (33%) • Not enough time (33%)

19. Lessons learned • Maintain flexibility in substituting people to do the visits (i.e. if one senior manager has to cancel, the visit continues with another person filling in) • A clinical perspective helped non-clinician senior managers make the most of worksite visits • Benefit of middle managers’ participation & pre-work • Brief unit staff in advance • Use to focus senior manager attention on key issues • Promotes agreement on priorities • Problem resolution and communication required time and attention, but these were difficult to maintain

20. Next StepsEvaluating the Intervention • We hypothesize that the data will show • Improvement in safety culture survey results over time relative to non-intervention hospitals • Greater reduction in difference between responses of front line employees & senior managers • Positive changes towards improving safety • Hospital interest in adoption and continuation of intervention • “I think we cared about safety before, but we needed something to focus us down on what to do to achieve it. That’s what the Stanford intervention did. We’ll continue it. From now on, it will be part of what we do.” CEO • “[The senior managers] were really hesitant to start the town meetings, particularly, but once they got into it they were like this is the greatest thing since sliced bread. They really are into this.” Liaison