J' Bryan Sexton, Ph'D'

1
Culture Eats Strategy for Lunch Safety Culture
Assessing Improving
J. Bryan Sexton, Ph.D. Johns Hopkins
University Quality and Safety Research
Group Anesthesiology and Critical Care
Medicine (School of Medicine), Health Policy and
Management (School of Public Health)
2
Disclosure

• Lotus Forum has licensed the rights to the SAQ
  described in this presentation. Dr. Sexton is the
  inventor of the SAQ and a paid consultant to
  Lotus Form. The terms of this arrangement are
  being managed by the Johns Hopkins University in
  accordance with its conflict of interest
  policies.

3
What of MI OR frontliners agree?

• OR Nurses I know the first and last names of all
  the personnel I worked with during my last shift
• Surgeons I know the first and last names of all
  the personnel I worked with during my last shift
• Anesthesiologists I know the first and last
  names of all the personnel I worked with during
  my last shift
• CRNAs I know the first and last names of all the
  personnel I worked with during my last shift

86 37 29 32
4
Familiarity with others is a critical component
of effective teamwork

• 74 of all commercial aviation accidents happen
  on the first day of a crew flying together
• Familiarity trumps fatigue (simulator studies)
• Highlights the importance of predictable patterns
  of behavior
• Many teamwork tools, e.g., briefings are a proxy
  for familiarity

5
My suggestions about safety would be acted upon
if I expressed them to management.
 
of respondents that agree
n657 Clinical Areas from MI 2007
6

• Tell me and I forget,
• Show me and I remember,
• Involve me and I understand.
• -Chinese Proverb

7
Central Mandate
Scientifically Sound
Feasible
Local Wisdom
Measurement Culture balance
8
Annual US Health
Research Funding
Millions of Dollars Spent
Sources ACP-ASIM Observer, 2001,
http//www.acponline.org/journals/news/feb01/clinr
esearch.htm Federal Funding and
Priorities for Health Services Research,
AcademyHealth, March 10, 2003.
9
We are just beginning to understand the context
and delivery of care
10
Safety Culture Primer

• The way we do things around here
• Measure of frontline caregiver consensus
• Predicts clinical and operational outcomes
• New field, evolving rapidly
• Assessing culture improvement is two-pronged
• Did the unit improve climate by 10 points or
  more?
• Did the unit maintain a good culture of 60 points
  or more?

11
Comparing Culture Surveys
SAQ 22 out of 23 characteristics
Qual. Saf. Health Care 200514364-366
12
Respecting the Wisdomof Frontline Caregivers
The way we do things around here
Frontline caregiver assessments of safety culture
are measurable using the Safety Attitudes
Questionnaire, which is the most widely used and
thoroughly validated instrument in healthcare.
SAQ results are reliable, responsive to
interventions, and predictive of clinical and
operational outcomes. Most research has involved
teamwork and safety climate domains, which have
been linked to

• Decubitus Ulcers in Med/Surg Units
• Delays in OR and ICU
• Bloodstream Infections in the ICU
• VAP in the ICU
• Wrong Site Surgeries
• Post-Op Sepsis
• Post-Op Infections
• PE/DVT per 1000 surgical discharges

• RN Turnover
• Absenteeism
• Incident Reporting Rates/Reporting Harm
• Burnout
• Spirituality
• Unit Size

13
SAQ Background

• The SAQ collects input from front-line
  personnel to determine the strengths and
  weaknesses of work settings.
• Used in medical, aviation, maritime, rail
  military settings
• Administered in over 2000 hospitals (USA, United
  Kingdom, Switzerland, Germany, Norway, Sweden,
  Spain, Portugal, Italy, Turkey, New Zealand, and
  Taiwan)
• SAQ is a reliable tool and formally validated
• Sexton J.B., Thomas E, Pronovost P Context of
  care and the patient care team The Safety
  Attitudes Questionnaire. National Academies of
  Science Report on Engineering in Healthcare.
  Washington, DC The National Academies Press,
  2005.
• Sexton J.B., Helmreich RL, Neilands TB, Rowan K,
  Vella K, Boyden J, Roberts PR, Thomas EJ. The
  Safety Attitudes Questionnaire Psychometric
  properties, benchmarking data, and emerging
  research. BMC Health Services Research. 2006 Apr
  36(1)44.
• Sexton J.B., Makary MA, Tersigni AR, Pryor D,
  Hendrich A, Thomas EJ, Holzmueller CG, Knight AP,
  Wu Y, and Pronovost PJ. Teamwork in the Operating
  Room Frontline Perspectives among Hospitals and
  Operating Room Personnel. Anesthesiology. 2006
  in press.
• Sexton J.B., Holzmueller CG, Pronovost PJ, Thomas
  EJ, McFerran S, Nunes J, Thompson DA, Knight AP,
  Penning DH, Fox HE. Variation in Caregiver
  Perceptions of Teamwork Climate in Labor and
  Delivery Units. J Perinat.2006 in press.
• Pronovost PJ and Sexton J.B., Assessing safety
  culture guidelines and recommendations. Qual Saf
  Health Care. 2005 14231-233

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SAQ items are grouped into 6 factors
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Teamwork Climate is the consensus of frontline
assessments of collaboration between caregivers
The Teamwork Climate Scale Items

• It is easy for personnel here to ask questions
  when there is something that they do not
  understand
• I have the support I need from other personnel to
  care for patients
• Nurse input is well received in this clinical
  area
• In this clinical area, it is difficult to speak
  up if I perceive a problem with patient care
• Disagreements in this clinical area are resolved
  appropriately (i.e. not who is right, but what is
  best for the patient)
• The physicians and nurses here work together as a
  well-coordinated team

16
SAQ Teamwork Climate Validity

• Sexton JB, Makary MA, et al. (2006) Teamwork in
  the Operating Room Frontline Perspectives among
  Hospitals and Operating Room Personnel.
  Anesthesiology
• Sexton JB, Holzmueller CG, et al. (2006)
  Variation in Caregiver Perceptions of Teamwork
  Climate in Labor and Delivery Units. Perinatology
• Sexton JB, Helmreich RL, et al. (2006) The Safety
  Attitudes Questionnaire Psychometric properties,
  benchmarking data, and emerging research. BMC
  Health Services Research

17
Hospital Wide Culture

• Interesting
• Not the best unit of analysis masks variability
  between work units

18
The Clinical Area is the Locus of Safety
Results using the Safety Attitude
Questionnaire Variance decompositions conducted
using nearly 15,000 responses from more than 700
clinical areas of approximately 50 hospitals
19
Teamwork Climate by MI Hospital
 
respondents reporting good teamwork climate
20
Teamwork Climate across 535 Units
 
respondents reporting good teamwork climate
21
JHH Culture SurveySafety Attitudes Questionnaire

• Participation is improving
• First robust signs of widespread improvement
• Average Response rates
• 2004 (75) 123 clinical areas 4965
• 2006 (77) 150 clinical areas 4497
• 2007 (75) 163 clinical areas 4798
• 98 clinical areas were linked from 2004 to 2007
  (same unit, good response rate)

22
Teamwork Climate across 100 Hospitals
 
of respondents reporting positive teamwork
climate
23
2007 Teamwork Climate Across Clinical Areas
NOTE Teamwork climate is negatively correlated
with annual nurse turnover rates, absenteeism,
BSI, PE/DVT, delays, and burnout
NOTE Teamwork climate is negatively correlated
with annual nurse turnover rates, absenteeism,
BSI, PE/DVT, delays, and burnout
Goal 80
 
of respondents reporting good teamwork climate
Needs improvement lt 60
24
Teamwork Climate Across Michigan ICUs
The strongest predictor of clinical excellence
caregivers feel comfortable speaking up if they
perceive a problem with patient care
of respondents within an ICU reporting good
teamwork climate
25
MI OR Teamwork Climate by Hospital
 
respondents reporting good teamwork
N69 sites from MI 2007
26
MI Operating Room Physician and RN Collaboration
 
of respondents reporting above adequate teamwork
OR RN/Surg CRNA/Anesth
27
Labor and Delivery Collaboration Map
Table 1 Labor Delivery Respondent
Demographics
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Reporting Good Collaboration
Makary MA, Sexton JB, Freischlag JA, et al.JACS.
2006 May202(5)746-52.
w/ each other 96
70
Anesthesiologists
84
87
89
88
48
75
92
58
63
76
68
29
Teamwork Climate Annual Nurse Turnover
 
reporting positive teamwork climate
30
Communication Breakdowns are frequently the root
cause of undesirable outcomes
31
Teamwork Disconnect

• RN Good teamwork means I am asked for my input
• MD Good teamwork means the nurse does what I say

32
May 2006 2135 OR respondents 60 hospitals 77
response rate
33
OR Teamwork Climate and Postoperative Sepsis
(per 1000 discharges)
May 2006 2135 OR respondents 60 hospitals 77
response rate
34
Safety Climate Across ORs
 
of respondents within an OR reporting good
safety climate
 
35
May 2006 2135 OR respondents 60 hospitals 77
response rate
36
Teamwork Climate Across Clinical Areas
NOTE Teamwork climate is negatively correlated
with annual nurse turnover rates, absenteeism,
BSI, PE/DVT, delays, and burnout (see slide 62,
refs 9, 10, 14, 15, 16, 18)
Goal 80
 
of respondents reporting good teamwork climate
Needs improvement lt 60
37
Disagreements In This Clinical Area Are Resolved
Appropriately (i.e. not who is right, but what is
best for the patient).
NOTE this item is typically negatively
correlated with annual nurse turnover rates
 
of respondents that agree
N69 sites from MI 2007
38
Conflict Resolution Tools and Techniques
39
Conflict Resolution in the OR

• Conflict was observed in 10 of flights and 10
  of surgeries

• Resolved in 80 of instances in cockpit

• Resolved in 20 of instances in operating room

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Communication ratings in the O.R.
Communication was rated as poor in one out of
five procedures but what does it mean to get
ratings of poor?

• failed communication of skin incision
• failure to communicate removal of the aortic
  cross-clamp
• implementation of trendelenburg position without
  notifying the surgeon
• failure to communicate insufficient regional
  anesthesia prior to incision.

43
Behavioral Markers by Phase Related to Pt Harm
Induction BM Briefing Inquiry Assertion
Intraop BM Vigilance Info Sharing
Handoff BM Contingency Management
Regression of these BMs onto Pt Outcome score
captures 20 of the variability R.445, plt.001
44
The Physicians And Nurses Here Work Together As
A Well-Coordinated Team.
NOTE this item is typically negatively
correlated with annual nurse turnover rates
 
of respondents that agree
N69 sites from MI 2007
45
Shared Mental Models
46
Communication breakdowns that lead to delays in
delivery of care are common.
 
of respondents that agree
N69 sites from MI 2007
47
Next Steps

• Harness the wisdom of frontline caregivers
• Provide them the tools and opportunities to take
  ownership of their local work environment
• Integrate culture, tools, and next steps into
  existing QI infrastructure, e.g. quality council,
  patient safety committee, executive walkrounds,
  etc.

48
Safety Culture Debriefing Action Tool

• Safety Culture Debriefing Action
• OBJECTIVE Use the Debriefing Guide to
• conduct a 30-60min structured discussion
• produce a specific data-driven next step to
• improve the local environment in this unit.
• Debriefing Guide
• Review SAQ results with particular attention to
  items with less than 60 agreement.
• Which item(s) seem most relevant (items/why)?
• Which item is of particular concern to this unit
  right now due to recent events or activities
  (item/score/why)?
• Share examples of how this item reflects your
  events or experiences in this unit?
• Envision an ideal unit what would it look like
  if 100 of the caregivers in this unit agreed
  strongly with the SAQ item (provide specific
  behaviors, processes, norms, policies)?
• Agree on one actionable step toward the ideal
  unit (agree on the task the person responsible
  the follow-up date the external committee or
  leader to whom this plan is disclosed)?

Adapted from Sexton, Paine, et al. A Checkup for
Safety Culture in My Patient Care Area, Jt Comm
J Qual Patient Saf. 2007 Nov33(11)
49
MI OR Teamwork Climate by Hospital
 
respondents reporting good teamwork
N69 sites from MI 2007
50
OR Teamwork Climate by Hospital
 
respondents reporting good teamwork
Sexton JB, Makary MA, et al. Anesthesiology.
2006 Nov105(5)877-84.
51
Setting the Stage Good Movie/Bad Movie

• The tone for communication and teamwork gets set
  in literally seconds
• Positive input is welcome, it feels safe, we all
  know what is going to happen
• Negative the plan is unclear, its hard to speak
  up, lots of hierarchy, doesnt feel safe

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Improving OR Teamwork Through Briefings

• OR Briefing Guide
• Do we know names and roles of team members (is
  there role clarity does each have experience w/
  this procedure)?
• Is the correct patient/procedure confirmed
  (TIME-OUT)?
• Were ABX given (if appropriate)?
• What are the critical steps of the procedure?
• What are the potential problems for this case
  (Nursing, Anesth, Surg)?

-vs.-
Evidence Based Briefing Fast Facts Purpose
Provide a simple structure in which the surgeon
can set expectations and make the surgical
procedure more predictable for everyone, while
improving the quality of information flow. Less
than 2 minutes, usually 90 seconds. Initiated by
Surgeon, but the circulating nurse can prompt if
surgeon forgets. Briefing comment examples If
something were to go wrong, what would it likely
be from your view? If anything doesnt look
right, let me know, and I will do the same for
you
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OR Teamwork Climate by Hospital
 
respondents reporting good teamwork
54
Culture Nuggets

• Size of unit matters units with fewer than 40
  caregivers often have a stronger consensus,
  better culture, and better implementation of
  innovations than units with over 80 caregivers
• Improvement is harder in teaching hospitals than
  faith based or community hospitals
• Losing a particularly ineffective or unpopular
  manager is a shock to many units transition is
  associated with a drop in safety climate which is
  the opposite of the expected improvement after
  what is often a long awaited departure
• Changes in geographic location, unit merging, and
  changes in managers each negatively impact
  teamwork and safety climate
• Introducing new technology to a unit is often
  associated with lower teamwork and safety climate
  scores
• E.g., POE, ORMIS, e-Mar, PAPR's and negative
  pressure rms, PYXIS supply
• This association appears to fade after 1 year
  
• What is going on in the low safety climate units?
• Changes in MD or RN leadership (not executive)
• had a facility redesign within existing unit
• Low safety climate units rely more on agency
  nurses

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Take Home

• Improving Quality You should know your culture
  to be effective stewards of limited quality
  resources
• Rigorous cultural assessment harnesses the wisdom
  of the front line workers
• Culture is related to clinical and operational
  outcomes
• Specifically teamwork climate and safety climate
• Culture is local work unit culture trumps
  hospital culture
• Beware of tagalong projects that piggyback on
  successful quality and safety efforts
• A little structure goes a long way to improve
  communication daily goals, briefing, SBAR
• Barriers to sustainability changes in
  management, structure, staffing, leadership
  attention span
• Extraordinary consensus about culture within
  units inter-rater reliability of over 80!
• Patient safety and quality with methodological
  rigor is a pioneering effort the science of
  safety is racing to keep pace
• Be ready to answer the question
• Are We Safer?

56
References for Culture, Teamwork, and Patient
Safety Tools and Resources

• Pronovost P, Berenholtz S, Dorman T, Lipsett PA,
  Simmonds T, Haraden C. Improving communication
  in the ICU using daily goals. J Crit Care. 2003
  18(2)71-75.
• Pronovost PJ, Weast B, Bishop K, Paine L,
  Griffith R, Rosenstein BJ, Kidwell RP, Haller KB,
  Davis R. Patient Safety, - Senior Executive
  Adopt-a-Work Unit A Model for Safety
  Improvement. Jt Comm J Qual Saf. 2004
  Feb30(2)59-68.
• Thompson D, Holzmueller C, Hunt D, Cafeo C,
  Sexton B, Pronovost P. A morning briefing
  setting the stage for a clinically and
  operationally good day. Jt Comm J Qual Patient
  Saf. 2005 Aug31(8)476-479.
• Sexton JB, Thomas E, Pronovost P. Context of care
  and the patient care team The Safety Attitudes
  Questionnaire. National Academies of Science
  Report on Engineering in Healthcare. Edited by
  Reid P, Compton W, Grossman J, Fanjiang G.
  Washington,DC, The National Academies Press,
  2005, pp 119-23.
• Pronovost PJ, Weast B, Rubin H, Rosenstein B,
  Sexton JB, Holzmueller C, Paine L, Davis R, Rubin
  H. Implementing and validating a comprehensive
  unit-based safety program. Journal of Patient
  Safety. 2005 1(1)33-40.
• Pronovost PJ, Sexton JB. Assessing safety
  culture guidelines and recommendations. Qual Saf
  Health Care 2005 14231-233.
• Thomas EJ, Sexton JB, Neilands TB, Frankel A,
  Helmreich RL. The effect of executive walk rounds
  on nurse safety climate attitudes A randomized
  trial of clinical units. BMC Health Serv Res.
  2005 Jun 85(1)4.
• Pronovost PJ, Holzmueller CG, Martinez E, Cafeo
  CL, Hunt D, Dickson C, Awad M, Makary,MA. A
  Practical Tool to Learn From Defects in Patient
  Care. Joint Commission Journal on Quality and
  Patient Safety, 2006 Feb 32 (2)102-108(7)
• Sexton JB, Helmreich RL, Neilands TB, Rowan K,
  Vella K, Boyden J, Roberts PR, Thomas EJ. The
  Safety Attitudes Questionnaire Psychometric
  properties, benchmarking data, and emerging
  research. BMC Health Services Research. 2006 Apr
  3644.
• Makary MA, Sexton JB, Freischlag JA, Holzmueller
  CG, Millman EA, Rowen L, Pronovost PJOperating
  room teamwork among physicians and nurses
  teamwork in the eye of the beholder. Journal of
  the American College of Surgeons. 2006
  May202(5)746-52.
• Makary MA, Holzmueller CG, Sexton JB, Thompson
  DA, Martinez E, Freischlag JA, Ulatowski JA,
  Heitmiller ES, Rowen L, Pronovost PJ. Operating
  Room Debriefings. Jt Comm J Qual Patient Saf.
  2006 Jul32(7)407-10, 357.
• Pronovost P, Holzmueller CG, Needham DM, Sexton
  JB, Miller M, Berenholtz S, Wu AW, Perl TM, Davis
  R, Baker D, Winner L, Morlock L. How will we know
  patients are safer? An organization-wide approach
  to measuring and improving safety. Crit Care Med.
  2006 Jul34(7) 1988-95.
• Rose JS, Thomas C, Tersigni A, Sexton J.B., Pryor
  D. A leadership framework for culture change in
  healthcare. Jt Comm J Qual Patient Saf. August
  200632(8)433-42.
• Pronovost PJ, Berenholtz SM, Goeschel CA, Needham
  DM, Sexton JB, Thompson DA, Lubomski LA,
  Marsteller JA, Makary MA, Hunt E. Creating high
  reliability in health care organizations. HSR.
  2006 Aug41(4Pt 2)1599-617.
• Sexton JB, Holzmueller CG, Pronovost PJ, Thomas
  EJ, McFerran S, Nunes J, Thompson DA, Knight AP,
  Penning DH, Fox HE. Variation in caregiver
  perceptions of teamwork climate in labor and
  delivery units. J Perinatol. 2006
  Aug26(8)463-70.
• Sexton J.B., Makary MA, Tersigni AR, Pryor D,
  Hendrich A, Thomas EJ, Holzmueller CG, Knight AP,
  Wu Y, and Pronovost PJ. Teamwork in the operating
  room frontline perspectives among hospitals and
  operating room personnel. Anesthesiology. 2006
  Nov105(5)877-84.
• Makary MA, Mukherjee A, Sexton JB, Syin D,
  Goodrich E, Hartmann E, Rowan L, Behrens DC,
  Marohn M, Pronovost PJ. Operating room briefings
  and wrong-site surgery. JACS. 2007
  Feb204(2)236-43.
• Thomas EJ, Taggart B, Crandell S, Lasky RE,
  Williams AL, Love LJ, Sexton JB, Tyson JE,
  Helmreich RL. Teaching teamwork during the
  Neonatal Resuscitation Program a randomized
  trial. J Perinatol. 2007 Jul27(7)409-414.
• Pronovost PJ, Needham D, Berenholtz SM, Sinopli
  D, Chu H, Cosgrove S, Sexton JB, Hyzy R, Welsh R,
  Roth G, Bander J, Diovine B, Kepros J, Goeschel
  C. A Multi-Faceted Intervention to Reduce
  Catheter-Related Blood Stream Infections in
  Michigan Intensive Care Units. NEJM 2006, in
  press.

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End Slide