Challenges to Improving Safety at the Point of Care Building Infrastructure: Lessons Learned from Cr

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Challenges to Improving Safety at the Point of
CareBuilding Infrastructure Lessons Learned
from Critical Access Hospitals
AHRQ Annual Meeting Sept. 9, 2008

• Katherine Jones, PT, PhD
• And Team
• Supported by AHRQ Grant 1 U18 HS015822
• AHRQ Knowledge Transfer
• National Rural Health Association
• Nebraska Department of HHS

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Objectives

• Knowledge Patient safety infrastructure requires
  common knowledge of a theoretical framework to
  achieve sensemaking
• Skill Assess culture and implement change
  comply with Joint Commission Leadership Standards
  (LD.03.01.01)
• Attitude Believe that key safety culture
  practices create the infrastructure that
  organizations must use to support frontline
  workers who improve quality and keep patients safe

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Critical Access Hospitals (CAHs)

• Limited to
• 25 inpatient beds
• 96 hour average length of stay
• Receive cost-based reimbursement to maintain
  access to care in rural areas
• 1,289 CAHs concentrated in Midwest ¼ of general
  community hospitals in US

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What does a CAH look like?
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Chain of Impact at the Point of Care
Healthcare System Structures Processes
Organizational Structures Processes
Culture
Individual Provider Structures Processes
Interpersonal Care
Technical Care
Quality at Point of Care

• The quality, safety and value of care can be no
  better than the structures and processes used by
  providers in direct contact with the patient.
  Culture determines how organizations support
  providers at the point of care.
• Nelson et al. (2002) Joint Commission Journal on
  Quality Improvement, 28, 472-493.
• Swuste P. (2008). Human Factors and Ergonomics in
  Manufacturing, 18, 438-453.

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How can organizations effectively support
providers at the point of care?

• AHRQ-supported research with Critical Access
  Hospitals (CAHs) provides evidence consistent
  with Dr. Clancys message How to translate
  research into improvement
• Infrastructure
• Capacity
• Incentives
• Implementing a Program of Patient Safety in Small
  Rural Hospitals
• Evaluating the Effect of TeamSTEPPSTM Training on
  the Culture of Safety in Critical Access Hospitals

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Implementing a Program of Patient Safety in Small
Rural Hospitals

• One of 17 AHRQ PIPs grants funded 7/05 6/07
  (AHRQ Grant 1 U18 HS015822)
• Purpose To implement the patient safety
  practices of voluntary medication error reporting
  and organizational learning in 24 Critical Access
  Hospitals.
• Aim 1 Develop the organizational infrastructure
  for reporting and analyzing medication errors
  that is needed to identify system sources of
  error.

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Evaluating the Effect of TeamSTEPPSTM Training on
the Culture of Safety in Critical Access Hospitals

• Funding through AHRQ and Nebraska DHHS
• Purpose To implement the patient safety practice
  of teamwork and communication training in 25
  Critical Access Hospitals.
• Aim 1 Evaluate the impact of the TeamSTEPPS
  training program on safety culture using the
  rural-adapted version of the AHRQ Hospital Survey
  on Patient Safety Culture.

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The Components of an Effective Patient Safety
System

• The components are (1) monitoring
  progress/maintaining vigilance, (2) knowledge of
  epidemiology of patient safety risks and hazards,
  (3) development of effective practices and tools,
  (4) building infrastructure for effective
  practices, and (5) achieving broader adoption of
  effective practices
• Farley DO, Damberg CL, Ridgely MS, et al.
  Assessment of the AHRQ patient safety initiative
  final reportEvaluation report IV. Rand
  Organization 2008 Technical Report No. 563.
  http//www.rand.org/pubs/technical_reports/TR563/.

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Phase One Reporting in an Effective Patient
Safety System
1. Knowledge of Epidemiology of Medication Errors
2. Tool Process Maps Forms, Database
4. Building Infrastructure 14 CAHs report to
MEDMARX, Safety culture education
5. Achieving Broader Adoption 35 CAHs report to
MEDMARX, Ongoing NCPS RCA education
3. Monitor Progress Benchmarking
reports, Change management

• Four CAHs in Nebraska sought help from UNMC to
  make sense of their medication errors.
• Understand the epidemiology of medication errors
• Develop effective tools process maps, reporting
  forms, database
• Monitor progress benchmarking reports and
  assistance to manage process change
• AHRQ funding supported an infrastructuresubscript
  ions to MEDMARX,, education about disclosure of
  errors, just culture, root cause analysis
• AHRQ funding enabled broader adoption of these
  practices across 35 CAHs in three states

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Sensemaking Tools From PIPS Grant Process map,
Reporting Form
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Sensemaking Tools From PIPS Grant Transform data
into information
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Phase Two Assessing Progress in an Effective
Patient Safety System
2. Tools AHRQ HSOPS using Dillman tailored
design method, Benchmark Graphs, Unsafe Acts
Algorithm
1. Knowledge working definition, role of culture
in patient safety
4. Building Infrastructure Rural adaptation of
HSOPS to assess rural microcultures
5. Achieving Broader Adoption PIPS TOOLKIT,
Develop service to conduct HSOPS in CAHs for NRHA
3. Monitor Progress Assess change in
culture due to practices

• Second action research cycle of our PIPS Grant
• Knowledge that reporting is the foundation of a
  culture of safety working definition
• Need an effective tool to assess culture
• Monitor progress and assess change in culture due
  to reporting infrastructure
• Build rural quality improvement infrastructure by
  adapting HSOPS to the rural environment
• Achieved broader adoption of rural-adapted
  version of HSOPS by disseminating it to QIOs and
  contracting with the National Rural Health
  Association

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Working Definition of Safety Culture

• Enduring, shared beliefs and behaviors that
  reflect an organizations willingness to learn
  from errors
• Three beliefs present in a safe, informed
  culture
• Our processes are designed to prevent failure
• We are committed to detect and learn from error
• We have a just culture that disciplines based on
  risk

Wiegmann. A synthesis of safety culture and
safety climate research 2002. http//www.humanfac
tors.uiuc.edu/ReportsPapersPDFs/TechReport/02-03.
pdf
Institute of Medicine. Patient safety
Achieving a new standard of care. Washington,
DC The National Academies Press 2004.
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What are the components of safety culture?

• Reporting staff report their errors
• Just reporting is rewarded, clear line between
  acceptable unacceptable behavior
• Flexible authority patterns relax when safety
  information is exchanged
• Learning action is taken based on safety
  information systems

Reason, J. Managing the Risks of Organizational
Accidents. Hampshire, England Ashgate Publishing
Limited 1997.
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How can organizations effectively support
providers at the point of care?

• Use the AHRQ Hospital Survey on Patient Safety
  Culture (HSOSPS) to identify and monitor
  impairments in organizational learning at the
  level of units/departments and staff positions
• Implement effective practices within each of the
  four components of a safe culture that address
  impairments within microsystems
• Ensure interactions between the practices to
  engineer an infrastructurea culturethat
  supports organizational learning

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How does HSOPS identify impairments in
organizational learning?

• HOSPS measures staff perceptions of the beliefs
  and behaviors that support a safe culture
• HSOPS is a valid, reliable instrument comprised
  of 51 items categorized in 12 dimensions
• 12 dimensions reflect the four components of an
  informed, safe culture
• A tool to evaluate, plan, reevaluate patient
  safety programs
• Small rural hospitals require support to use it
  effectively
• Nieva, Sorra. (2003). Safety culture assessment
  a tool for improving patient safety in healthcare
  organizations. Qual Saf Health Care, 12(Suppl
  II), ii17-ii23.
• Jones, Skinner, Xu, Sun, Mueller. The AHRQ
  Hospital Survey on Patient Safety Culture a tool
  to plan and evaluate patient safety programs. In
  Henriksen et al., Advances in Patient Safety New
  Directions and Alternative Approaches. Vol. 2.
  Culture and Redesign . AHRQ Publication No.
  08-0034-1. Rockville, MD Agency for Healthcare
  Research and Quality August 2008.

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Benchmark HSOPS Graph of Aggregate Hospital
Results
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HSOPS Graph Comparing Nurse to Aggregate Hospital
Results
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Benchmark HSOPS Graph of Aggregate Results 2005
and 2007
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Interactions Between Components
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Execute Just Culture . . . UNSAFE ACTS
ALGORITHMwww.unmc.edu/rural/patient-safety
click on Just Culture
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Phase Three Integrating Team Training in an
Effective Patient Safety System
1. Knowledge that a culture of safety
is engineered from interacting practices
2. Tool TeamSTEPPSTM
4. Building Infrastructure Creating a rural
TeamSTEPPS community
3. Achieving Broader Adoption Train the trainer
in 25 CAHs
5. Monitor Progress Reassess change in
culture March 2009

• Third action research cycle
• Knowledge that a culture of safety in high
  reliability organizations is engineered from
  interacting practices of the four components of
  culture within microsystems (units/positions)
• HSOPS results indicated the need for training in
  teamwork and communication.
• We conducted the train the trainer course in 25
  CAHs in April 2008 will add 7 more in 2009
• We are building a community of TeamSTEPPS
  coaches/trainers across the state
• We will reassess safety culture in 25 CAHs in
  March 2009

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HSOPS Identifies Readiness for Teamwork Training

• TeamSTEPPS training must be supported by
  systematic error reporting, just culture
  practices, and use of learning tools such as
  individual and aggregate RCA, Leadership
  WalkRounds, and Safety Briefings

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ConclusionInfrastructure for Effective Practices

• Interaction between effective practices results
  in sensemaking within macro- and microsystems of
  care
• Sensemaking requires data, which is interpreted
  within the context of the lived experiences of
  those in direct contact with patients
• Sensemaking can not occur without data from
  reporting, trust and teamwork

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Infrastructure Lessons Learned from Dundy
County, Nebraska

• 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.

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Rural Adaptation of HSOPS

• Original HSOPS designed for large urban hospitals
• 14 different work areas
• 14 different staff positions
• Sort by work area or position if gt 11
• Rural-adapted HSOPS for hospitals with lt 50 beds
• 12 different work areas - 12 choose other
• Collapsed multiple departments to Acute/Skilled
  Care
• Added Long-term care, Home Health Care, Therapies
• 6 different job titles - 8 choose other
• Sort by work area or job title if gt 5

1/3 in national database choose other
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Rural Adaptation of HSOPS
2008 Comparative Database Report 33 of 160,196
respondents choose other
UNMC CAH Comparative Database 12 of 4,117
respondents choose
other
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Rural Adaptation of HSOPS
2008 Comparative Database Report 22 of 160,196
respondents choose other
UNMC CAH Comparative Database 8 of 4,117
respondents choose
other
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Where can I get the HSOPS?

• Original HSOPS From the AHRQ website
• http//www.ahrq.gov/qual/hospculture/
• Click on Hospital Survey Toolkit
• Rural-adapted version for CAHs with 25 or fewer
  beds from UNMC web site (see our poster in the
  mAHRQet Place Café )
• http//www.unmc.edu/rural/patient-safety
• Click on Hospital Survey on Patient Safety Cultur
  e Resources
• Contact information
• Katherine Jones, PT, PhD Anne Skinner, RHIA
• kjonesj_at_unmc.edu askinner_at_unmc.edu

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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
• Supported by AHRQ Grant 1 U18 HS015822
• National Rural Health Association
• Nebraska Department of HHS