Building a Stronger Patient Safety Culture in a Community Hospital: Key Partnerships for Success

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Building a Stronger Patient Safety Culture in a
Community Hospital
Key Partnerships for Success
Michael Boucree, M.D. Vice President for
Outcomes Management Chief Quality Officer
Hurley Medical Center
Heather Reed Safety Culture Project
Manager Press Ganey Associates, Inc.
MHA Patient Safety and Quality Symposium April
15, 2009
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SESSION OBJECTIVES

• The Press Ganey Safety Culture Solution
• Press Ganey/MHA Keystone/Hurley Partnerships
• Appraise the significance of the collaborative
  role of employees, patients, and the community in
  successfully promoting a plan for improvement of
  the safety culture.
• Share critical successes of a patient safety
  culture assessment and implementation
• Identify patient safety effort measurements felt
  at the sharp end of implementation

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The Press Ganey Safety Culture
Solution

• A hospitals culture of safety grows out of its
  employees values, attitudes, perceptions, and
  behavior patterns.
• The Press Ganey Safety Culture Solution enables
  clients to create an environment of internal
  transparency in which team members feel
  comfortable and encouraged to talk about
  near-misses and potential risks to a patient's
  safety.
• Enables identification of strengths and
  weaknesses related to patient safety culture
• Enables measurement of organizational conditions
  that lead to adverse events and patient harm
• Provides insight and expert analysis that will
  provide guidance and support as you work to
  improve your safety culture

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The Press Ganey Safety Culture
Solution

• Support After the Report
• Report Interpretation webinar for senior
  leadership, directors and management
• Quality Improvement and Opportunity
  Identification
• Press Ganey Guided Solutions
• Online Action Planning
• Quality and Performance Improvement
• Improvement Monitoring
• Quarterly National Webinars and Additional
  Resources Provided

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The Press Ganey Safety Culture Survey

• Dimensions Measured
• Your Supervisor/Manager 
• Frequency of Events Reported
• Overall Ratings 
• Overall Perception of Safety 
• Organizational Learning 
• Teamwork Within Units 
• Communication Openness 
• Feedback/Communication About Errors
• Nonpunitive Response to Error
• Staffing 
• Hosp Management Support 
• Teamwork Across Units 
• Handoffs and Transitions

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Participating MHA Keystone Facilities

• Allegiance Health Jackson, MI
• Chelsea Community Hospital Chelsea, MI
• Covenant Medical Center Saginaw, MI
• Gratiot Medical Center Alma, MI
• Hurley Medical Center Flint, MI
• Marquette General Health System Marquette, MI
• Metro Health Hospital Wyoming, MI
• MidMichigan Medical Center-Gladwin Gladwin, MI
• Northern Michigan Regional Hospital Petoskey,
  MI
• Otsego Memorial Hospital Gaylord, MI

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MHA Keystone System Results

• Overall Mean 63.9
• n5,184

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Hurley Medical Center Press Ganey
Associates
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The Press Ganey Safety Culture Team
Robert Wolosin, PhD Research Product Manager
rwolosin_at_pressganey.com
Sarah Stawiski, PhD Research Associate
sstawiski_at_presganey.com
Amanda Holland Marketing Manager aholland_at_pressgan
ey.com
Heather Reed Project Manager hreed_at_pressganey.com
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Implementation

• Survey Distribution Packets were distributed to
  each pilot area by a study team member in sealed
  envelopes.
• Options Employees could return their completed
  surveys in a confidential envelope or access the
  survey online.
• Incentives Prizes were awarded to units with the
  highest participation rates.

Participants Solicited1,182 Overall Return
Rate 29 Staff Only (excluding physicians) 51
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Dimensions of Focus

• Nonpunitive Response to Error
• Overall Perception of Safety

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BUILDING A STRONGER PATIENT SAFETY CULTURE IN A
COMMUNITY HOSPITAL KEY PARTNERSHIPS
FOR SUCCESS Michael Boucree, M.D. Vice
President for Outcomes Management Chief Quality
Officer /Hurley Medical Center Principal
Investigator Tiffany Ceja, MSE Safety Grant,
Project Coordinator D. Kay Taylor,
Ph.D. Director of Research/Hurley Medical Center
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Background and Introduction

• Patients and their families have a vital interest
  in the safety of care received in hospitals.
• Although hospital personnel want to provide the
  best possible care, errors that harm patients
  still occur.
• Patient safety is mediated by cultural factors
  within hospital units such as communication
  practices and administrative response to errors,
  which can be modified with the help of system
  enhancements, addressing cultural and
  sub-cultural factors and engaging patients.

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DIMENSIONS OF PROJECT

• Hospital Setting
• Strategic Initiative
• Grant Opportunity
• Outcomes

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Hospital setting . . .

• Hurley Medical Center is a 443-bed public,
  non-profit, teaching medical
• center located in Flint, Michigan.

Established in 1908, last year we celebrated our
100th birthday of caring for the community!!!
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Strategic initiative . . .
QUALITY PILLAR
Improve patient satisfaction outcomes. Improve
perception of clinical quality and patient
safety. Achieve recognition as a premier public
hospital based on quality.
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Strategic initiative . . .
HEALTH STATUS PILLAR

• Leadership, integration and coordination of
  health status initiatives in the community and
  throughout hospital.
• Identify opportunities for grant funded
  programming and
• research to support public hospital initiatives.

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Grant opportunity . . .
A study team was formed. We worked with our
Grants Analyst and the Hurley Foundation to seek
possible funding sources. A study team member,
Marie Stewart, learned of the Press Ganey
opportunityand we forged ahead with the
development of a study proposal.     
We would like to acknowledge the efforts of
Kate Pate and Renee Shaw.
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A critical review of the published literature
provided essential insights into the shaping
of our plan. The study team proposed to use 5
key strategies to ensure success in building a
stronger hospital safety culture    1)
Utilization of a systems approach that would
serve to foster an atmosphere of trust
and facilitate change. 2) Engagement of
multiple players that allowed input at
all levels (including input from patients and
their families).   3) Provision of feedback to
staff. 4) Conduct of routine educationbased on
issues identified from reporting
datathat promotes targeted learning. 5) Use of
a proven tool for measurement, tracking, and
fostering positive change  
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The Hurley Foundation was notified in December
2007 that their investigator team (Dr. Michael
Boucree, Chief Quality Officer/ Principal
Investigator Dr. Kay Taylor, Director of
Research Tiffany Ceja, Project Coordinator)
would be the recipient of a 50,000.00 award
from Press Ganey to study methods for enhancing
the hospital safety environment. Their proposal,
Building a Hospital Safety Culture via a
Carefully Designed Voluntary Incident Reporting
System detailed the piloting of an innovative
reporting mechanism in eight hospital
units/areas.
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METHODS / ACTIVITIES

• Electronic Incident Reporting
• Speak-Up TM Campaign
• Patient Ambassadors
• Community Partners
• Patient Safety Feedback
• Employee Safety Culture Survey

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RESULTS AND OUTCOMES
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Electronic Reporting . . .

• PRIOR SYSTEM
• Paper
• Confidential

• NEW SYSTEM
• Computer form
• Confidentialbut may also be anonymous

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Training

• Four Safety Fairs
• March 2008,
• July 2008 (Employee Picnic)
• October 2008 (Wizard of Oz Theme Follow the
  Yellow Brick Road to Patient Safety),
• March 2009 Spring into Patient Safety)
• Computer Tutorials

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Benefits

• Time savings (3 vs. 1)
• Cost savings (.5 FTE)
• Increased compliance

In July 2008 and January 2009, there was a 100
entry or submission of employee incidents within
specified timeframes.
CHALLENGE HOW TO CAPTURE SAFETY OPPORTUNITIES.
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Problems Encountered

• Comfort level
• Clarity of information
• Training not adequate

We subsequently developed a tutorial that
appears on the 1st screen when you log in to
enter a report. Employees can choose to go
through the tutorialor they can bypass it and
proceed to the entry screen.
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Speak-Up Campaign . . .
TM
Goal To help patients become more informed and
involved in their health care.
Mechanism Greater patient involvement will help
identify potential errors in their care.
Challenge How to engage patients.
Provision of a pamphlet in the patient admission
packet will not produce significant change.
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Speak-Up Ambassadors

• Trained 135 employees to speak up for patients
• Documented several incidents of near misses
• Utilize these individuals as immediate feedback
  as to whats going well, and whats not
• Crosses the bridge from management to employees
• Helps to reduce the blame culture

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Ambassadors Program

• Problems encountered
• Level of interest higher than anticipated
• Not enough organizational resources to maintain
  high level support
• Positive outcomes
• Became extensions of the Patient Advocate/Patient
  Representative Office
• Are there more ways we can utilize these
  individuals as Ambassadors for Safety, Service,
  Compliance and Complaint managment?
• Yesbut we have to be able to support them

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Community Partners . . .

• F.A.C.E.D. (Faith Access to Community Economic
  Development) E. Yvonne Lewis Director
• R.U.T.H. (Resources United To Help) Earline
  Hill Director

These organizations share a similar mission and
vision as each strive to reach out and provide
needed services to low-income residents of Flint
and Genesee County with the goal of enhancing the
health and well-being of the community. Each
group is committed to engaging our most
vulnerable or high-risk community members in this
process.
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Types of collaborative undertakings with
F.A.C.E.D. and R.U.T.H.

• Conduct of focus groups with community members
• to reveal and/or address safety concerns.
• Assistance in developing strategies/mechanisms
• for engaging patients.
• Working with hospital staff to help develop
  educational
• programs for both employees and the
  community.
• CHALLENGE Providing timely feedback to the
  community on suggested improvements.

This grant project has resulted in our
facilitating there two organizations to work
together.
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Patient Safety Feedback . . .
Customized Patient Safety questions were added to
our Press Ganey Patient Satisfaction tool.
 


SAFETY OF CARE

1. Hospitals commitment to patient safety . .
. . . . . . . . . . . . . . . . . . . . . . . . .
. . . 2. Openness to discussing concerns
. . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 3. Efforts to improve
patient safety . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . .  
Very
Very Poor Poor Fair Good
Good
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2,000 responses between May 1st and August 31st.
gt6600 responses to date (February 2009)
reflecting gt2300 unduplicated respondents

• Hospitals commitment to patient safety.
• Very Poor 1 Poor 2 Fair 9
  Good 35 Very Good 53
• 2. Openness to discussing concerns .
• Very Poor 1 Poor 2 Fair 8
  Good 34 Very Good 55
• Efforts to improve patient safety
• Very Poor 1 Poor 2 Fair 9
  Good 34 Very Good 54

- reflects 1st trimester response rate
subsequent trimesters have reflected similar
trends in responses, with a increase in the
Good response rate
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Responses through December, 2008 and February,
2009

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Press Ganey Employee Safety Culture Survey
KEY STRATEGY Use of a proven tool for
measurement, tracking, and fostering positive
change.

• Informing and engaging our employees
• Display boards
• Patient safety fair booth/station
• Manager Meeting presentation
• GroupWise e-mail reminder(s)

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Pilot Units . . .

• 7E General Medicine
• 6E Rehabilitation
• 2N Obstetrics
• Emergency Department

• 4E ICU
• 4N Surgery
• 2E Pediatrics
• 5E Neurovigil/Trauma

Baseline data was collected in March 2008
Intermediate Survey conducted October,
2008 Annual Survey to be conducted late
April/early May 2009.
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Positive Area 1

• Teamwork Within Units
• People support one another in this unit.
• When a lot of work needs to be done quickly, we
  work together as a team to get the work done.
• In this unit, people treat each other with
  respect.
• When one area in this unit gets really busy,
  others help out.

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Positive Area 2

• Overall, I am satisfied with my job.
• I would feel safe being treated as a patient
  here.
• I would recommend the healthcare services
  provided here to my friends and relatives.
• Overall, the culture at this facility encourages
  patient safety.

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Focus Areas
Two performance dimensions revealed multiple low
scoring items.

• Non-Punitive Response to Error
• Overall Perception of Safety

There were 1,182 participants solicited. We
received a total of 343 completed surveysfor a
29 overall return rate. Howeverif you exclude
the physician targetswe achieved a 51 response
rate.
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Non-Punitive Response to Error

• When an event is reported, it feels like the
  person is being written up, not the problem.
• Staff worry that mistakes they make are kept in
  their personnel file.

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Overall Perception of Safety

• We have safety problems in this unit.
• It is just by chance that more serious mistakes
  dont happen around here.

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With the administration of the post or follow-up
Press Ganey Employee Safety Culture Surveywe
will be able to test how well our strategies have
worked for enhancing the patient safety culture
in our hospital.
According to the views or perceptions of our
nurses, physicians, etc.
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Advantages of incorporating an evaluation
plan when building a stronger patient safety
culture

• Allows us to track or monitor the status of our
  efforts.
• We can make needed changes to enhance our
  efforts.
• We can demonstrate the success of our efforts.
• The evaluation process itself can increase our
  chances of success.
• 
  
  
•  

Whatever we measure we tend to improve.
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An unintendedbut importantoutcome of the
project and its evaluation plan has been a
meshing of divergent systems within our
hospital. The major strategies that we tackled
to strengthen our safety culture cross over
many different departments or areasthus we came
together to accomplish key objectives. This
cooperation or synergy has resulted in other
changes . . .
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Sample of Recent Initiative HAND HYGIENE
AUDIT
The hospital was preparing to conduct hand
inspections to ensure compliance with length of
fingernailsas well as with the ban on artificial
nails. When a study team member read a
house-wide e-mail announcing an upcoming auditit
was suggested that we first conduct a survey to
capture employee knowledge and attitudes.

• Approximately 800 employees completed the
  survey.
• We identified two focus areas
• There was a lack of understanding of the link
  between artificial nails and infection risk.
• There was a concern that policies were not
  uniformly enforced.
• We have now developed key strategies to address
  these areas!

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Sample of Recent Initiative Safety Culture
Intranet Site

• This is still under construction, but we added a
  Safety Culture
• link on our intranet. There are currently 7
  buttons
• Surveys
• Safety Goals
• Speak Up Campaign
• Electronic Incident Reporting
• Community Partners
• Training
• Contacts

In addition to expanding and enhancing this link,
we intend to later include a SAFETY link on the
hospitals internet site!
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Sample of Recent Initiative Patient Speak-Up
Ambassador University

• This is our most recent brainstorming product.
• Components discussed to date include development
  of
• A curriculum
• Levels or status
• Recognition or incentives

This endeavor could serve as a national model for
engaging employees in the process of improving
the safety culture!
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Possible Future Grant Collaborative with
Press-Ganey

• Based on excellent work
• Second phase implementation
• Bringing together of two cultures for Research on
  an important topic
• Publication
• Look at Cost of Care changes based on safety
  culture results

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CONCLUDING REMARKS
This project or undertaking had at its core the
implementation of an electronic incident
reporting systemalong with the Speak-UpTM
Campaign, community partner engagement, and the
use of a proven tool to track our progress. It
is important to note, however, that the project
has expanded beyond its initial boundaries or
parameters.
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Significance of Collaborative Efforts
With our community . . .

• We have created a positively-charged
  atmosphere in which our community partner
  organization members are genuinely interestedand
  excitedabout improving health care delivery to
  our citizens.

A re-engagement with the community at an ideal
time (our 100th year of providing health care
services).
With our employees . . .

• We have initiated a process whereby the fabric
  of our safety
• culture is being challenged. We are poised for
  change.

A movement from a sense of apprehension or
mistrust, to a Reporting Culture, to a Just
Culture.
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HURLEY PATIENT SAFETY CULTURE STUDY TEAM

• Michael Boucree, M.D. Vice President for
  Outcomes Management Chief Quality Officer and
  Principal Investigator
• D. Kay Taylor, Ph.D. Director of Research
• Tiffany Ceja, M.S.E. Grants Project Coordinator
• Marie Stewart, M.B.A. Director of Customer
  Experience
• Colette Stearns, M.S.A. Director, Clinical
  Effectiveness

• Valerie Petrich, B.S.N. Nursing Quality and
  Patient Safety Officer
• Johnetta Prosser, R.N. Patient Representative
  
• Desiree Blake, B.S.N. Chief Nursing Educator
  Professional Development
• Aimee Boettcher, RHIT Decision Suppoprt
  Analyst

Thank you!