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Title: Build a Foundation for Quality: Interpreting HSOPSC Results and Action Planning


1
Build a Foundation for Quality Interpreting
HSOPSC Results and Action Planning
  • Katherine Jones, PT, PhD
  • Anne Skinner, RHIA

NRHA Quality and Clinical Conference July 15,
2008
Supported by AHRQ Grant 1 U18 HS015822 and NRHA
2
Objectives
  • What you should know (knowledge)
  • What you should do (skills)
  • What you should believe/value (attitudes)
  • Acronyms
  • AHRQ Agency for Healthcare Research and Quality
  • HRO High Reliability Organization
  • HSOPSC Hospital Survey on Patient Safety Culture

3
Skills Objectives (What you do)
  • Use examples of HSOPSC results to
  • Identify safety culture strengths weaknesses
  • Aggregate across an organization
  • Within work areas
  • Within job titles
  • Identify gaps between beliefs behaviors within
    dimensions
  • Describe key practices to address weakness
  • Create an action plan to engineer key practices

4
Knowledge Objectives (What you know)
  • Build on previous knowledge
  • Recognize that HSOPSC dimensions measure four
    components of an informed, safe culture
  • Compare beliefs and behaviors within HSOPSC
    dimensions
  • Identify relationships between HSOPSC dimensions
  • Recognize that culture varies within an
    organization
  • Define active learning transformative learning
  • List four stages of active learning
  • Describe three attitudes toward transformative
    learning
  • Describe key organizational practices that
    support four components of an informed, safe
    culture

5
Attitudes Objectives (What you think is
important)
  • Believe that active learning in teams leads to
    transformative learning in organizations
  • Value the cumulative effect of the interaction of
    key practices that support organizational learning

6
Active and Transformative Learning
  • Active Learning
  • An approach to working with and developing
    people which uses work on a real project or
    problem as the way to learn.
  • Transformative Learning
  • The use of critical reflection to transform
    taken-for-granted frames of reference
    (assumptions) reframe the problem

Mezirow et al. (1990). Learning as
Transformation. San Francisco Josey-Bass.
7
Characteristics of Transformative Learners
  • Seek more accurate and complete information
  • Free from coercion
  • Open to alternative points of view
  • Objectively consider evidence
  • Critically reflect on own assumptions
  • Have an opportunity to participate in discussion
    and problem solving
  • Willing to accept a new frame of reference that
    is validated through evidence and discussion

Mezirow et al. (1990). Learning as
Transformation. San Francisco Josey-Bass, pp.
13-14.
8
Frame of Reference? Think Pair Share
  • 1 not at all 2 to some extent 3
    a great deal
  • There is an organization wide sense of
    susceptibility to the unexpected.
  • Everyone feels accountable for reliability.
  • Leaders pay as much attention to managing
    unexpected events as they do to achieving formal
    organization goals.
  • We spend time identifying how our activities
    could potentially harm patients, employees, the
    organization.
  • We pay attention to when and why our patients and
    our employees might feel frustrated or
    disenfranchised.
  • There is widespread agreement about how things
    could go wrong.

Weick Sutcliffe (2001). Managing the
Unexpected. p. 90
9
What is your frame of reference?
  • Employees should be more careful and
    professional.
  • My organization could better support employees
    with the infrastructure they need to be a high
    reliability organization.

10
Stages of Active Learning
  • Expand an existing frame of reference
  • Communication could be improved lets try SBAR
  • Learn a new frame of reference
  • Human beings easily misunderstand each other so
    communication should be structured lets use
    SBAR
  • Transform your point of view
  • Hospitals should embrace concepts of high
    reliability because human error is inevitable
    HROs use structured communication lets use SBAR
  • Transform your habits of mind
  • Because human beings are imperfect, I can use
    structured communication in my professional and
    personal communication to decrease likelihood of
    misunderstandings

Mezirow et al. (1990). Learning as
Transformation. San Francisco Josey-Bass.
11
Attitudes toward Transformative Learning
  • Embrace and absorb
  • Skeptical then connect
  • Resistant and defensive

Mezirow et al. (1990). Learning as
Transformation. San Francisco Josey-Bass.
12
Solution
Change belief system
Difficulty of Implementation
Modify existing behavior
13
(No Transcript)
14
Measurement To Identify Impairments
Interventions To Improve Practices
ENGINEERING A CULTURE OF SAFETY Inventory of
Tools www.unmc.edu/rural/patient-safety/tools/Inve
ntory.htm
15
A Reporting culture is engineered by implementing
practices . . .
  • Any safety information system depends crucially
    on the willing participation of the workforce,
    the people in direct contact with the hazards. To
    achieve this, it is necessary to engineer a
    reporting culturean organization in which people
    are prepared to report their errors and
    near-misses. (Reason, p. 195)

16
A Reporting culture is engineered by implementing
practices . . .
  • Practices/Tools
  • Reporting Form
  • Near miss log
  • Chart audit
  • Secret Shopper
  • Safety Briefings
  • Leadership WalkRoundsTM
  • Bulletin board/ suggestion box/telephone hotline
  • Successful reporting systems (Leape, 2002)
  • Nonpunitive
  • Confidential
  • Independent
  • Expert analysis
  • Timely
  • Systems-oriented
  • Responsive

17
Characteristics of Successful Reporting Systems
  • Nonpunitive reporters do not fear punishment
  • Confidential reporter not revealed to those who
    discipline
  • Independent reporting system independent of
    discipline
  • Expert analysis reports analyzed by those with
    systems knowledge
  • Timely reports are analyzed promptly
    recommendations disseminated rapidly
  • Systems-oriented recommendations focus on
    systems
  • Responsive those receiving reports are capable
    of disseminating/implementing recommendations

Leape, LL. (2002). Reporting of adverse events.
NEJM, 347, p. 1636.
18
www.MEDMARX.com
19
Systematic Data Collection in Medication Error
Reporting
  • Description of the error
  • Error severity based on the outcome to patient
  • Phase of the medication use process in which the
    error originates
  • Type of the error
  • Cause of the error
  • Contributing factors to the error
  • Information about the drug(s) involved

20
NCC MERP Taxonomy of Error Severity
  • A capacity to cause error
  • B error occurred, did not reach patient
  • C error reached patient, no harm
  • D error reached patient, monitoring and
    intervention required
  • E temporary harm requiring intervention
  • F temporary harm requiring initial or prolonged
    hospitalization
  • G permanent harm
  • H intervention required to sustain life
  • I error contributed to or resulted in death

http//www.nccmerp.org/pdf/taxo2001-07-31.pdf
21
Near-miss Log Sheet
22
Reporting Error Severity
23
Reporting Where Errors Originate
24
Reporting Types of Errors
Jones et al. (2006). http//www.unmc.edu/rural/doc
uments/pr06-08.pdf
25
Reporting Causes
26
Reporting Contributing Factors
27
What we heard about using MEDMARX as the
foundation for reporting in Critical Access
Hospitals
  • Before the project, we just counted errors. We
    never went past the type of error.
  • Without the language of errors associated with
    MEDMARX, all we could talk about was who did it
    and not what happened and why. MEDMARX created a
    standardized process that allowed us to collect
    more information. The use of MEDMARX and its
    graphs and charts contributes to the perception
    of errors as having a system source.

28
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, in the
    context of daily work

http//www.ihi.org/IHI/Topics/PatientSafety/Safety
General/Tools/SafetyBriefings28IHITool29.htm
29
Ground Rules for Briefings
  • All gather in a designated area
  • Be brief…5 minutes and stick to it!
  • Remember the purpose increase awareness of
    safety issues
  • Remember non-punitive information for patient
    care only…never used in performance appraisal
  • All opinions have equal value
  • Ask open-ended questions

30
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?

31
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?

32
Improvements in nurse perceptions of reporting
culture 2005 vs. 2007 as a result of systematic
reporting of medication errors using MEDMARX
33
Nurse 05
Aggregate 05
Nurse 07
34
A Just culture is engineered by implementing
practices . . .
  • The willingness of workers to report depends on
    their belief that management will support and
    reward reporting and that discipline occurs based
    on risk-taking…there is a clear line between
    acceptable and unacceptable behavior
    organizational practices support a just culture.

35
A Just culture is engineered by implementing
practices . . .
  • Practices/Tools
  • Understanding human error (Reason 2003, 2006)
  • Active errors (sharp end)
  • Latent errors
  • Just Culture and behavior (Marx, 2001)
  • Conduct human error, negligence, reckless,
    intentional rule violation
  • Disciplinary decision-making outcome-based,
    rule-based, risk-based
  • Unsafe Acts Algorithm
  • Disruptive Behavior Policy/Standards

36
A just culture requires an understanding of the
nature of human error.
Just Culture Engage Educate
Missed exit XR not reg
Run stop sign Adult dose vs. flush
Cell phone drunk Refuse time out
U Turn No 5 Rights
Marx, D. (1997). Patient safety and the just
culture A primer for health care executives.
Reason, J. (1997). Managing the risks of
organizational accidents.
37
Execute Just Culture . . . UNSAFE ACTS ALGORITHM
NO
NO
NO
YES
NO
YES
YES
YES
YES
NO
Known medical condition?
NO
YES
YES
YES
NO
YES
NO
Culpable
Gray Area
Blameless
Adapted from James Reason. (1997). Managing the
Risks of Organizational Accidents.
38
Importance of Just Culture
  • The single greatest impediment to
  • error prevention in the medical
  • industry is that we punish people
  • for making mistakes.
  • Dr. Lucian Leape
  • Professor, Harvard School of Public Health
  • Testimony before Congress on
  • Health Care Quality Improvement

39
Improvements in nurse perceptions of just culture
2005 vs. 2007 as a result of systematic reporting
of medication errors using MEDMARX and education
about human error
40
Nurse 07
41
A Flexible culture is engineered by implementing
practices . . .
  • The willingness of workers to report depends on
    their belief that authority patterns relax when
    safety information is exchanged because managers
    respect the knowledge of front-line
    workersorganizational practices support a
    flexible culture, which adapts to changing
    demands.

42
A Flexible culture is engineered by implementing
practices . . .
Team Strategies Tools to Enhance Performance
Patient Safety
http//teamstepps.ahrq.gov
43
Outcomes of Team Competencies
  • Knowledge
  • Shared Mental Model
  • Attitudes
  • Mutual Trust
  • Team Orientation
  • Performance
  • Adaptability
  • Accuracy
  • Productivity
  • Efficiency
  • Safety

http//teamstepps.ahrq.gov
44
Importance of Team Structure
  • Team Structure
  • Complementary skills
  • Interdependent tasks
  • Clear role expectations
  • Common purpose
  • Performance goals
  • Mutual accountability
  • Curriculum
  • Train the Trainer
  • Fundamentals
  • Essentials

http//teamstepps.ahrq.gov
45
Skill Overview Leadership
  • Organize the team
  • set clear goals delegate tasks
  • manage resources
  • Ensure team members share information
  • Formal team meetings informal exchange sessions
  • Make decisions through collective input
  • Empower team members to speak up
  • Resolve conflict
  • Actively model and facilitate good teamwork
  • May be designated or situational

http//teamstepps.ahrq.gov
46
Skill Overview Situation Monitoring
Situation Monitoring (Individual Skill)
Situation Awareness (Individual Outcome)
Status of the patient Team Members Environment Pro
gress toward Goal
Shared Mental Model (Team Outcome)
47
Skill Overview Mutual Support
  • Back up behavior to prevent work overload
  • Task assistance is sought and offered
  • Provide effective feedback Timely, Respectful,
    Specific, Directed towards improvement,
    Considerate
  • Advocate for the patient through conflict
    resolution
  • CUS to solve information conflicts
  • Im concerned ( I need clarity)
  • Im uncomfortable
  • Consequences in terms of patient safety
  • DESC Script to solve personal conflicts
  • Describe the behavior
  • Express how the situation makes you feel
  • Suggest alternatives
  • Consequences stated in terms of patient safety

48
TeamSTEPPS Mutual Support Two-Challenges
Rule
49
Skill Overview Communication
  • Exchange of information between a sender and a
    receiver
  • Effective communication
  • Brief
  • Clear
  • Timely
  • Complete Know the plan, share the plan, review
    risk
  • JCAHO National Patient Safety Goals require
    improvement in communication

Salisbury Hohenhous (2008)
50
Communication Skills
  • SBAR
  • Situation what is going on with the pt.
  • Background clinical background
  • Assessment what do I think is the problem
  • Recommendation how can we correct it
  • Call-out
  • Inform all team members simultaneously
  • Check-back
  • Close the loop as receiver accepts a message,
    sender double-checks to ensure message was
    received

http//teamstepps.ahrq.gov
51
Communication Skills
  • Handofftransfer of information (along with
    authority and responsibility) during transitions
    in care must include opportunity to ask
    questions, clarify, and confirm
  • Introduction
  • Patient
  • Assessment
  • Situation
  • Safety Concerns
  • Background
  • Actions
  • Timing
  • Ownership
  • Next

http//teamstepps.ahrq.gov
52
TOOLS and STRATEGIES Brief Huddle
Debrief STEP Cross Monitoring Feedback Advocacy
and Assertion Two-Challenge Rule CUS DESC
Script Collaboration SBAR Call-Out Check-Back Hand
off
  • OUTCOMES
  • Evidence-based Shared Mental Model
  • Adaptability
  • Team Orientation
  • Mutual Trust
  • Team Performance
  • Patient Centered
  • Patient Safety!!
  • BARRIERS
  • Inconsistency in Team Membership
  • Lack of Time
  • Lack of Information Sharing
  • Hierarchy
  • Defensiveness
  • Varying Communication Styles
  • Conflict
  • Lack of Coordination and Follow-Up with
    Co-Workers
  • Distractions
  • Fatigue
  • Workload
  • Misinterpretation of Cues
  • Lack of Role Clarity

53
Disruptive Behavior
  • Old frame of reference
  • Tolerate the behavior as a way of doing business
  • Shrug off the problem minor occurrence with no
    ill effects to patients or staff
  • New frame of reference
  • Disruptive behaviors have profound effect on
    patient safety and quality of care
  • Not unique to physicians or healthcare
  • Consequences permeate the organization
  • Affect staff morale, patient and family
  • Community perceptions and hospital reputation.
  • Hospitals can no longer take a passive approach
    to disruptive behaviors

Rosenstein O'Daniel (2008). Neurology, 70,
1564-1570.
54
Disruptive Behavior Calls for Leadership
  • Joint Commission Standard LD.03.01.01 (1/09)
  • Leaders create and maintain a culture of
    safety and quality throughout the organization.
  • Elements of Performance for LD.03.01.01
  • Leaders regularly evaluate the culture of safety
    and quality using valid and reliable tools.
  • Leaders prioritize and implement changes
    identified by the evaluation.
  • . . .3 - 11

55
Improvements in nurse perceptions of flexible
culture 2005 vs. 2007 as a result of systematic
reporting of medication errors using MEDMARX,
education about human error, introduction of SBAR
56
Nurse 07
57
Nurse 07
58
Nurse 07
59
The Problem…
  • Absence of team-related skills such as
    leadership, structured communication,
    adaptability to changing workloads, planning,
    team performance improvement
  • The Solution…
  • People make fewer errors when they work in
    teams.
  • To Err is Human Building a Safer Health System

60
Current Intervention TeamSTEPPS
  • Knowledge
  • Shared Mental Model of Team Skills
  • Attitudes
  • Mutual Trust
  • Team Orientation
  • Performance
  • Adaptability
  • Accuracy
  • Productivity
  • Efficiency
  • Safety

61
Reporting, Just, and Flexible practices support
organizational Learning
  • Practices/Tools
  • Individual RCA
  • Aggregate RCA
  • FMEA
  • Safety Briefings
  • Leadership WalkRounds
  • Close the loop with reporting
  • Ultimately, the willingness of workers to report
    depends on their belief that the organization
    will analyze reported information and then
    implement appropriate changeorganizational
    practices support a learning culture.

62
Five Basic Steps of Root Cause Analysis
  • 1. Gather the facts using a timeline
  • 2. Understand what happened
  • 3. Identify root causes using causal statements
  • 4. Determine system improvements to minimize risk
    of repeating the error
  • 5. Create action plans to implement and monitor
    effectiveness of changes

http//www.unmc.edu/rural/patient-safety/Toolbox/I
nteraction/Interaction.htm http//www.unmc.edu/r
ural/patient-safety/tools/Conducting20Individual
20RCA.pdf
63
Aggregate RCA
  • Staff may be more receptive to change
  • Process change based on multiple events
  • Focus on potentially serious events--close calls
    and errors that reached the patient
  • Staff may be less defensive because focus not on
    a harmful event...blame less prevalent
  • May be used in any setting
  • Inpatient, outpatient, long term care, acute
    care, home care
  • Use in all types of reported events
  • Falls, pressure ulcers, employee events, lab

http//www.unmc.edu/rural/patient-safety/Toolbox/I
nteraction/Interaction.htm
64
(No Transcript)
65
Leadership WalkRoundsTM
  • Senior leaders demonstrate commitment to safety
    and learn about safety issues by making regular
    rounds to discuss safety with staff
  • Communication is two-way, leaders and staff talk
    honestly and listen carefully (reporting)
  • Unannounced or announced but must be regular
    (weekly)
  • Focus on systems not individuals (just)
  • Close the loop on communication (flexible)
  • use a notebook and database to track reported
    events and their resolution (learning)
  • Digital camera can capture unsafe
    equipment/environment

http//www.unmc.edu/rural/patient-safety/Toolbox/I
nteraction/Interaction.htm
66
Were interested in focusing on the system and
not individuals
  • Can you think of any events in the past day or
    few days that have resulted in prolonged
    hospitalization for a patient?
  • Have there been any near misses that almost
    caused patient harm but didnt?
  • Have there been any incidents lately that you
    can think of where a patient was harmed?
  • What aspects of the environment are likely to
    lead to the next patient harm?
  • Is there anything we could do to prevent the
    next adverse event?
  • Can you think of a way in which the system or
    your environment fails you on a consistent
    basis?
  • How are we actively promoting a just culture and
    a non-punitive, confidential reporting policy?

67
(No Transcript)
68
Improvements in nurse perceptions of learning
culture 2005 vs. 2007 as a result of systematic
reporting of medication errors using MEDMARX,
education about human error, introduction of
SBAR, quarterly aggregate RCAs of falls and
nonharmful medication errors, and individual RCA
of harmful medication errors
69
Nurse 07
70
Nurse 05
Nurse 07
71
Nurse 05
Nurse 07
72
Nurse 05
Nurse 07
73
The Importance of Teams in Organizational Learning
  • Teams are the fundamental learning units in
    modern organizations. Unless teams can learn,
    organizations cannot learn.
  • Peter Senge (1990). The Fifth Discipline The Art
    and Practice of the Learning Organization. New
    York Doubleday Currency, p. 10.

74
Active Learning
  • Form groups of 5
  • Review the Benchmark Graph
  • What are the strengths and weaknesses revealed by
    the aggregate data?
  • What practices are needed to support an informed,
    safe culture?
  • Do you need additional information?
  • Premier Excel Data Tool
  • What are the top three practices you would
    recommend?

75
(No Transcript)
76
What is a learning culture?
  • It observes and collects data
  • It reflects and draws correct conclusions from
    information systems
  • It creates and plans change based on information
  • It has the will to act and implement change
  • Learning disabilities are tragic in children,
    but they are fatal in organizations. -- Peter
    Senge

Reason, J. (1997). Managing the Risks of
Organizational Accidents. Hampshire, England
Ashgate Publishing Limited.
77
8 Steps of Change
ENDURE
EXPAND
EVALUATE
EXECUTE
EDUCATE
ENGAGE
John Kotter
78
Lessons Learned
  • HSOPSC is a strategic management tool
  • Identifies practices needed to support an
    informed, safe culture
  • Rural-adapted survey reveals culture variation
    within small rural hospitals
  • Detects and evaluates change in culture over time
  • Reassessment with HSOPSC reveals
  • How leaders use information
  • If organizations engineered practices to support
    four components of culture in response to
    baseline survey
  • Presence/absence of change strategy

79
Lessons Learned
  • Behaviors that support an informed safe culture
  • Assess safety culture using effective data
    collection methods
  • Create an infrastructure that supports systematic
    error reporting…reporting is the foundation of an
    informed, safe culture
  • Adhere to principles of just culture
  • Implement team training to support a flexible
    culture
  • Learn from error in the context of daily work
    (Safety Briefings and Leadership WalkroundsTM)
  • Systematically learn from events using individual
    RCA and aggregate RCA to learn from multiple
    non-harmful errors

80
  • 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 hadnt 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.

Lessons Learned from Dundy County, Nebraska
81
Contact Information
  • Katherine Jones, PhD, PT
  • kjonesj_at_unmc.edu
  • Anne Skinner
  • askinner_at_unmc.edu
  • Web site where tools are posted
  • www.unmc.edu/rural/patient-safety

82
The AHRQ Hospital Survey on Patient Safety
Culture A Service Offered by the University of
Nebraska Medical Center and the National Rural
Health Association
  • Administration
  • Interpretation
  • Action Planning
  • For more information, please contact Anne
    Skinner askinner_at_unmc.edu 402-559-8221
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