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Assessing and Nurturing a Culture of Safety 7th Annual Safety Healthcare Conference North Platte, NE

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Title: Assessing and Nurturing a Culture of Safety 7th Annual Safety Healthcare Conference North Platte, NE


1
Assessing and Nurturing a Culture of Safety 7th
Annual Safety Healthcare ConferenceNorth Platte,
NEOctober 6, 2006
  • Katherine Jones, PhD, PT

Supported by AHRQ Grant 1 U18 HS015822-01
2
Objectives
  • Explain the concept of culture of safety
  • Explain uses of safety culture assessments
  • Explain patterns in aggregate survey results
  • Identify determinants of safety culture
  • Identify critical success factors to nurture a
    culture of safety
  • Identify tools to improve culture, e.g.
  • Teamwork Communication (SBAR, CUSS)
  • Unsafe Acts Algorithm (ensure accountability)
  • Role of voluntary reporting

3
Errors in Our Health Care System
  • IOM To Err is Human
  • 44,000 98,000 deaths per year due to medical
    errors
  • 3 - 4 of hospital admissions result in adverse
    events
  • Cost 17 - 29 billion/yr
  • Adults get 55 of recommended care
  • (McGlynn et al. N Engl J Med 2003 3482635-45.)

4
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5
Institute of Medicine
  • The problem is not bad people the problem is
    that the system needs to be made safer. To Err
    is Human Building a Safer Health
  • The biggest challenge to moving toward a safer
    health system is changing the culture from one of
    blaming individuals for errors to one in which
    errors are treated not as personal failures, but
    as opportunities to improve the system and
    prevent harm. Crossing the Quality Chasm A New
    Health System for the 21st Century.

6
Six Aims to Achieve Quality IOM (2001). Crossing
the Quality Chasm.
  • Safety the prevention of harm caused by errors
    of commission and omission
  • A system that produces care that is effective,
    patient-centered, timely, efficient, and
    equitable requires a foundation of a culture of
    safety

EQUITABLE
EFFICIENT
TIMELY
PATIENT-CENTERED
EFFECTIVE
SAFE
7
Culture of Patient Safety IOM (2004). Keeping
Patients Safe.
  • An integrated pattern of individual and
    organizational behavior, based upon shared
    beliefs and values, that continuously seeks to
    minimize patient harm that may result from the
    processes of care delivery.

8
  • Culture is The way we do things around here and
    why we do them.
  • Carroll Quijada (2004). Quality and Safety in
    Health Care.

http//www.safetycenter.navy.mil/photo/archive/
9
Systemic Migration to Boundaries
Illegal normal Real life standards
Safety Regulations Certification/ Accreditation
standards Evidence-based practice
BTCUs Border-Line tolerated Conditions of
Use Usual space of action
Individual Benefits
VERY UNSAFE SPACE
Expected safe space of action as defined by
professional standards
ACCIDENT
Adapted from R. Amalberti
Performance
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http//www.safetycenter.navy.mil/photo/archive/
12
Uses of Safety Culture SurveysNieva Sorra
(2003). Quality and Safety in Healthcare.
  • Understand safety related attitudes
  • Identify areas in need of improvement
  • Raise awareness about culture in patient safety
  • Evaluate patient safety interventions, track
    changes over time
  • Conduct internal external benchmarking
  • Fulfill directives or regulatory requirements
  • JCAHO national patient safety goal?

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14
Our Specific Aims
  • As part of UNMCs AHRQ-funded Partnerships
    in Implementing Patient Safety Grant
  • Determine attitudes about patient safety in CAHs
  • Identify strengths and areas for improvement
  • Raise awareness about role of culture
  • Determine if differences exist between hospitals
    based upon length of participation in medication
    safety project
  • Create external benchmarks specific to CAHs

15
Critical Processes in Safety Culture Assessment
Nieva Sorra (2003). Quality and Safety in
Healthcare.
  • Involve key stakeholders at all stages
  • Select a valid instrument
  • Use effective data collection procedures
  • Implement action planning/initiating change

16
Barriers to Effective Data Collection
  • not unusual for these procedures to be
    overlooked by staff conducting assessments in
    healthcare organizations.
  • Lack of knowledge of survey administration
    methods
  • Concerns about anonymity
  • Group administration introduces bias (priming for
    desired results)
  • Inappropriate collapsing of work area/job title
  • Lack of technology/knowledge for data entry and
    analysis

17
Addressing Barriers
  • Survey all eligible staff in Critical Access
    Hospitals
  • Minimize biasdo not use group administration,
    incentives, or priming
  • Use multiple contactsadvance communication
    follow-up to maximize response rates
  • Ensure anonymity, accurate data entry, analysis
  • Focus on action planning
  • Consider contractor with experience in survey
    administration methods (university, hospital
    assoc.)

18
Administering the Survey
  • Time frame 4th Quarter 2005
  • Hospitals provided lists of employees in four
    groups for which instrument validated
  • Range of sample sizes 35 241
  • Demographics (work area, job title) modified to
    reflect small rural hospital

medicine, surgery, obstetrics, pediatrics,
intensive care, psychiatry/mental health,
rehabilitation
Acute/Skilled Care
19
Administering the Survey
  • Four contacts used to maximize response rate
  • Provided template for prenotification letter from
    CEO
  • Survey kit mailed to each hospital every 2-3
    weeks x3 with envelope for each employee
  • Personalized cover letter
  • Survey
  • Postage paid envelope to mail survey to UNMC
  • Surveys coded to track response rate and avoid
    entering duplicate responses

20
Returns
  • Overall response rate 1584/2266 (70)
  • Range of responses across 24 hospitals
  • 92/180 (51)
  • 45/49 (92)

21
Analyzing the Survey
  • Returns scanned and entered into access database
  • Descriptive analysis with customized Premier
    Excel tool
  • Collapsing of work area, job title
  • Aggregate results reported if n gt 5 (vs gt 11)
  • Area for improvement if negative gt 25 (vs gt 50)
  • Statistical analysis with SAS to account for
    nesting
  • Comments coded according to 23 themes
  • Based on review of literature, survey dimensions,
    iterative coding

22
Survey Instrument14 Dimensions
  • Seven department-level aspects related to error
    and event reporting

23
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24
Survey Instrument14 Dimensions
  • Three hospital-level aspects related to patient
    safety

25
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26
Survey Instrument14 Dimensions
  • Four outcome measures

27
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28
Aggregate Results from 24 Critical Access
Hospitals
29
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34
Comments
  • 240 Comments received
  • Frankness of comments reflects confidence in
    anonymity
  • Coded comments can validate, explain quantitative
    results (mixed methods research)
  • Similar themes in comments across hospitals
  • 21 reported a specific patient safety concern
  • 9 perceived a lack of leadership in patient
    safety
  • 7 perceived that patient safety is a top
    organization priority

35
Themes Used to Code Comments
  • Bad Apple
  • Blame and Shame Culture
  • Denial of Fallibility
  • Evidence of Positive Safety Culture
  • Evidence of Teamwork
  • Frustrations with Organizational Change
  • Ignorance Patient Safety is Responsibility of All
  • Lack of Communication Openness
  • Lack of Leadership - Patient Safety
  • Lack of Leadership Professionalism
  • Lack of Professionalism Staff
  • Lack of System Continuity Across Shifts
  • Lack of Teamwork
  • Leadership Encourages Reporting
  • Leadership Support for Patient Safety
  • Management Emphasis on Productivity
  • Not a Learning Organization - Lack of Action
  • Not a Learning Organization - Lack of Feedback
  • Not a Learning Organization - Lack of Reporting
  • Organizational Pride
  • Pathological Culture
  • Patient Safety Concern
  • Patient Safety is a Top Priority
  • Professional Norm of Perfectionism

36
Identifying Strengths and Areas for Improvement
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39
Determinants of Culture Westrum (2004). Quality
and Safety in Healthcare.
  • Leaders communicate what is important
  • Personal power
  • Positions (rules and departmental turf)
  • Mission of organization
  • Patterns of information flow reflect the climate
    set by leaders use of teamwork communication
  • Personal use of information
  • Individuals use standard channels of information
  • Teams do whatever it takes to get the right
    information to the right people at the right time

40
MODEL OF DETERMINANTS OF CULTURE
Mission Provide high quality, safe care for
community
Processes of Care
Knowledge to Evaluate Conduct Processes
Evidence-Based Guidelines
Organizational Learning
Sources of Information
Teamwork Tools
Adapted from Westrum (2004) Firth-Cozens
(2001)
Attitudes of leaders about information
41
Three Types of Culture Westrum (2004). Quality
and Safety in Healthcare.
  • Pathologicaluse of information to enhance
    personal power
  • Bureaucratic use of information to adhere to
    rules, positions, and protect turf
  • Generativeuse of information to concentrate on
    the mission not persons or positions

42
Typology of Organizational CulturesWestrum
(2004). Quality and Safety in Health Care, 13,
ii22-ii27.
43
Typology of Organizational CulturesWestrum
(2004). Quality and Safety in Health Care, 13,
ii22-ii27.
44
Characteristics of an Advanced Safety Culture
Hudson (2003). Quality and Safety in Healthcare
.
  • Informed at all levelsall seek and provide info
  • Trust by alldue to a just culture even bad
    information is shared, accepted, and acted upon
  • Adaptable to changelearn from successes and
    failures
  • It worriessuccess does not create complacency

45
Critical ProcessesImplementing Action Plans
Nieva Sorra (2003). Quality and Safety in
Healthcare.
  • Provide feedback to all
  • Conducting survey raised expectations
  • Benchmark to the range to identify areas of
    strength and need for improvement
  • Do you have a management gap?
  • Communicate shared understanding of data and
    action plans
  • Prioritize need for change
  • Implement and sustain 1 2 tools at a time to
    maintain focus

46
Action Plan to Improve Non-punitive Response to
Error
  • Findingnon-punitive response to error is
    consistently least positively perceived
  • Tool Just Culture from David Marx
    (www.justculture.org)
  • Punishment based on risk NOT outcome or violation
    of rule
  • ToolReasons Unsafe Acts Algorithm
  • ToolNon-punitive voluntary reporting

47
Just Culture
  • Outcome-based disciplinethe more severe the
    outcome, the more blameworthy the
    actorregardless of intent
  • Rule-based disciplinedid an individual violate a
    rule? Did they intentionally violate the rule?
  • Risk-based disciplineif an individual intends to
    take a risk, disciplinary action is appropriate

48
UNSAFE ACTS ALGORITHM
NO
NO
YES
NO
Were the actions as intended?
Evidence of illness or substance use?
Knowingly violated safe procedures?
Pass substitution test?
History of unsafe acts?
NO
YES
YES
YES
NO
NO
Were the consequences as intended?
Known medical condition?
Were procedures available, workable,
intelligible, correct and routinely used?
Deficiencies in training, selection, or
inexperienced?
Blameless error
YES
NO
YES
Blameless error, corrective training, counseling
indicated
Substance abuse without mitigation
NO
YES
System induced violation
YES
YES
Possible reckless violation
System induced error
NO
Sabotage, malevolent damage
Substance use with mitigation
Possible negligent behavior
Culpable
Gray Area
Blameless
James Reason (1997). Managing the Risks of
Organizational Accidents
49
Patient Safety Model (USP, 2004)
Culture
Sources of Data Voluntary reporting Trigger
Tool Customer Satisfaction Incident
Reports Interviews Focus Groups
Data Collection
Data Analysis
Plan Change
Implement Change
Assess Impact of Change
50
Role of Voluntary Reporting in Culture
  • Purpose learn from experience (Leape, 2002)
  • All parties aware of hazards
  • Share lessons with others
  • Identify latent system causes of medication error
  • Implement change in processes through quality
    improvement projects
  • Monitor impact of quality improvement projects
  • Measure of mindfulnessawareness of staff about
    safety

51
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52
Characteristics of Successful Reporting Systems
(Leape, 2002)
  • Nonpunitivereporters free from fear
  • Confidentialidentities of reporters not
    important
  • Independentfirewall exists between those
    receiving error reports those with disciplinary
    power
  • Systems-oriented
  • Expert analysisrecognize underlying system
    causes
  • Timelyprompt analysis and dissemination
  • Responsivedisseminate and implement

53
Systems-oriented Reporting
  • Describe the errormost important!
  • Categorize the error (e.g. medication errors)
  • Severity
  • Phase of origination (node)
  • Type
  • Identify causes and contributing factors
  • Identify level of staff making/reporting
  • Identify interventions/monitoring needed if the
    error reached the patient
  • Identify actions to avoid future errors

54
Action Plan to Improve Hospital Management
Support
  • Findingmanagement and front line staff have
    different views of the culture of safety
  • ToolPatient Safety Leadership WalkRoundsTM
  • Senior leaders talk with front line staff
    informally but regularly to understand their
    perceptions
  • Use the scripted opening statements to get
    started
  • Follow-up! Use GLITCH book, database

Available from www.ihi.org
55
Action Plan to Improve Hospital Management Support
  • Finding the attitudes of senior leaders
    determine the flow of critical information
  • Tool American Hospital Association Strategies
    for Leadership Hospital Executives and their
    Role in Patient Safety
  • A self-assessment tool for leaders to increase
    visibility and activity in patient safety

Available from http//www.coloradopatientsafety.o
rg/Hosp_Exec_Patient_Safety_MA.pdf
56
Action Plan to Improve Communication
  • Findinglack of communication opennessa majority
    of nurses did not feel free to question decisions
    or actions of those with more authority
  • Tools
  • SBARA structured framework for communication
    that ensures all parties have the same mental
    model of the situation, concerns about the
    situation, and potential solutions
  • CUSSacronym for two challenges to clearly
    indicate concern

Available from www.ihi.org
57
Barriers to CommunicationHaig (2006). Joint
Commission Journal on Quality and Patient Safety.
  • Lack of structure and standardization
  • Uncertain who is responsible for care management
  • Differences in authority, gender, and race
  • Physicians and nurses have different
    communication styles
  • physicians seem to favor bulleted summaries
  • nurses often use detailed, descriptive narratives

58
SBAR
  • S - Situation - what is happening at the present
    time?
  • B - Background - what are the circumstances
    leading up to the situation?
  • A - Assessment - what do I think the problem is?
  • R - Recommendation - what should we do to correct
    the problem?

59
CUSS
  • Two Challenges and then Stop the line!
  • Im Concerned.
  • Im uncomfortable.
  • Stop. Patient safety is at risk!

60
What to do if CUSS doesnt work
  • http//video.google.com/videoplay?docid1882664901
    133929840

61
Action Plan to Improve Teamwork
  • FindingNearly one-fourth of RNs agree that
    hospital units do not coordinate well
  • Tool TeamSTEPPS (Team Strategies and Tools to
    Enhance Performance and Patient Safety)
  • Teams make fewer mistakes than individuals
  • TeamSTEPPS teaches core components of teamwork
    Leadership, Situation Monitoring, Mutual
    Support, and Communication

Available from /www.usuhs.mil/cerps/teamstepps.ht
ml
62
Action Plan to Improve Communication and Teamwork
  • Findinglack of communication and teamwork within
    and across departments shift change is
    problematic, information falls through the cracks
  • Tool Patient Safety BriefingsTM
  • Increase awareness of safety within departments
  • Provide a structured means of communication
    within and across departments

Available from www.ihi.org
63
Safety Briefings Background
  • Based on briefings developed in aviation to
    overcome barriers to communication
  • All staff are equal when voicing safety concerns
  • Safety is discussed routinely, 24/7

64
Ground Rules for Briefings
  • All gather in a designated area
  • Be brief5 minutes and stick to it!
  • Remember the purpose increase awareness of
    safety issues
  • Remember non-punitive information for patient
    care onlynever used in performance appraisal
  • All opinions have equal value
  • Ask open-ended questions

65
Start of Shift Briefing
  • What safety issues should staff be aware of
    today?
  • Are there patients with similar names ?
  • Non-formulary drugs ordered?
  • Elderly patients at risk for falls?
  • New equipment?
  • Changes in the work environment?
  • Changes in work flow?
  • Any staff assigned work that is not routine?
  • Any staff doing work usually performed by others?
  • Any staff working unusual shifts?

66
End of Shift Debriefing
  • Who encountered a safety issue related to
    medications?
  • Who had a near miss with a medication today?
  • How many staff had patients who asked questions
    or made comments about medications today?
  • How many were near misses that a patients
    comment prevented?
  • Are there safety issues (staff or patient) that
    should prompt action?
  • Are there process changes that should be made?

67
Action Plan to Improve Hospital Handoffs
Transitions
  • Findingshift change is problematic, information
    falls through the cracks
  • Tool IPASSTHEBATON (Strategies and Tools to
    Improve Healthcare Handoffs and Transitions)
  • Captures key elements to be communicated in a
    structured method with the opportunity to ask
    questions, clarify and confirm

Available from https//patientsafety.satx.disa.mi
l/
68
I Introduce yourself and your role/job P
Patient Name, identifiers, age, sex, location A
Assessment Presenting chief complaint S
Situation Current status/ circumstances, S
Safety Concerns Critical lab values/reports,
allergies, alerts (falls, isolation,
etc.) THE B Background Co-morbidities, current
medications, family history A Actions
taken or required AND provide brief rationale T
Timing Level of urgency and prioritization of
actions O Ownership Who is responsible
(nurse/doctor/team), patient family
responsibilities? N Next What will happen next?
What is the PLAN?
69
Elements of a Culture of Safety Singer et al.
(2003). Quality and Safety in Healthcare.
  • Commitment to safety articulated at highest
    levels
  • Resources, incentives, rewards provided
  • Safety is the primary priority at the expense of
    production
  • Communication across all organizational levels is
    frequent and candid
  • Unsafe acts are rare despite high production
  • Errors and problems are reported when they occur
  • Organizational learning is valued

70
Lessons Learned
  • Core patient safety values of nonpunitive
    response, communication openness, and feedback
    are lagging
  • Perceptions of safety culture can vary by
    department position within hospitals of all
    sizes and across systems
  • Management has more positive perception of safety
    culture than front-line
  • Hospitals should provide anonymous means to
    communicate patient safety concerns
  • Collaborate to implement tools and learn from
    peers...tool time conference call discussions

71
Lessons Learned Patient Safety/QI Critical
Success Factors
  • Shared goal is widely communicated
  • Senior management engaged and supportive
  • Follow principles of CQIvisualize processes, use
    rapid cycle change
  • Clinical leadership/champion
  • Collaborative multidisciplinary teams
  • Timely feedback to staff regarding use of data
  • Non-punitive organizational culture

Bradley, E. (2005). Improving complex systems
Top performing hospitals in door-to-balloon
times for patient with AMI. Presented at 2005
meeting of AcademyHealth.
72
Never doubt that a small group of thoughtful,
committed citizens can change the world.
Indeed, it is the only thing that ever has.
Margaret Mead
Florence Nightingale
73
Contact information kjonesj_at_unmc.edu 402-558-8913
74
References
  • American Hospital Association. (2001). Strategies
    for leadership hospital executives and their
    role in patient safety. Retrieved March 9, 2006
    from http//www.coloradopatientsafety.org/Hosp_Exe
    c_Patient_Safety_MA.pdf
  • Agency for Health Care Research and Quality.
    Hospital Survey on Patient Safety Culture.
    Retrieved March 9, 2006 from http//www.ahrq.gov/q
    ual/hospculture/
  • Bradley, E. (2005). Improving complex systems
    Top performing hospitals in door-to-balloon times
    for patient with AMI. Presented at 2005 meeting
    of AcademyHealth.
  • Carroll, J.S. and Edmondson, A.C. Leading
    organizational learning in health care. Quality
    and Safety in Health Care, 2002 11 p. 51-56.
  • Carroll, J.S. and Quijada, M.A.. Redirecting
    traditional professional values to support
    safety changing organizational culture in health
    care. Quality and Safety in Health Care, 2004
    13 p.16-21.
  • Department of Defense. (2005). Healthcare
    communications toolkit to improve transitions in
    care. Retrieved March 30, 2006 from
    https//patientsafety.satx.disa.mil/

75
References
  • Firth-Cozens, J. Cultures for improving patient
    safety through learning the role of teamwork.
    Quality and Safety in Health Care, 2001 10 p.
    26-31.
  • Frankel, A. Patient safety leadership walkrounds.
    Institute for HealthCare Improvement. Retrieved
    March 9, 2006 from http//www.ihi.org/ihi.
  • Haig KM, Sutton S, Whittington J. (2006). SBAR A
    shared mental model for improving communication
    between clinicians. Joint Commission Journal on
    Quality and Patient Safety, 32 (3) 167-175.
  • Hudson, P. Applying the lessons of high risk
    industries to health care. Quality and Safety in
    Health Care, 2003 12 p. 7-12.
  • Institute for HealthCare Improvement. (2003).
    Safety briefings. Retrieved March 9, 2006 from
    http//www.ihi.org/ihi.
  • Institute of Medicine. Crossing the quality
    chasm a new health system for the 21st century.
    Washington, DC National Academies Press 2001.

76
References
  • Institute of Medicine. Patient Safety Achieving
    a New Standard of Care. Washington, DC National
    Academies Press, p. 174 2004.
  • Marx, D. Patient safety and the Just Culture A
    primer for health care executives. New York
    Columbia University, 2001.
  • Nieva, V.F. and Sorra, J. Safety culture
    assessment a tool for improving patient safety
    in healthcare organizations. Quality and Safety
    in Healthcare, 2003 12 p. 17-23.
  • Pronovost, P. J., Weast, B, et al. Evaluation of
    the cultures of safety survey of clinicians and
    managers in an academic medical center. Quality
    and Safety in Healthcare, 2003 12 p. 405-410.
  • Singer, S.J. , Gaba, D.M., et al. The culture of
    safety results of an organization-wide survey in
    15 California hospitals. Quality and Safety in
    Healthcare, 2003 13 p. 52-56.
  • Weingart, S.N. and Page D. Implications for
    practice challenges for healthcare leaders in
    fostering patient safety. Quality and Safety in
    Healthcare, 2004 vol. 13 p. 52-56.
  • Westrum, R. A typology of organizational
    cultures. Quality and Safety in Healthcare,
    2004 vol. 13 p. 22-27.
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