Have Safety Culture Data, Will Travel?

Sallie J. Weaver, PhDAssistant Professor

Dept. of Anesthesiology & Critical Care Medicine, and

Armstrong Institute for Patient Safety & Quality

Armstrong Institute for Patient Safety and Quality2

Roadmap

1. What is patient safety culture?

2. Why does it matter?

3. I have data….but now what?

4. Some food for thought regarding acting on data

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Sounding the Call for a Culture of Safety• “Health care organizations must develop a

culture of safety such that an organization’s care processes and workforce are focused on improving the reliability and safety of care for patients”

• Joint Commission Leadership Standard:– Leaders create and maintain a culture of safety

and quality throughout their organization• NQF Safe Practice #2

– Culture measurement, feedback, and intervention

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The Armstrong Institute Model to Improve Care

Comprehensive Unit based Safety Program

(CUSP)

1. Educate staff on science of safety

2. Identify defects

3. Recruit executive to adopt unit

4. Learn from one defect per quarter

5. Implement teamwork tools

Translating Evidence Into Practice

(TRiP)

1. Summarize the evidence in a checklist

2. Identify local barriers to implementation

3. Measure performance

4. Ensure all patients get the evidence

• Engage• Educate• Execute• Evaluate

Reducing preventable patient harm

• Emerging Evidence

• Local Opportunities to Improve

• Collaborative learning

Technical Work Adaptive Work

Pre-Work: Measure clinician and staff perceptions of safety culture (HSOPS Survey)

Culture

Behavior on the Job

Outcomes-Patient & Family

Safety- Care Provider

Safety

• Perceived priority of safety relative to other goals

• Culture is the compass team members use to guide their behaviors, attitudes, & perceptions on the job

• What will I get praised for?• What will I get reprimanded for?• What is the “right” thing to do?

What is Safety Culture?

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What Are Core Aspects of Safety Culture…

Culture of

Safety

Communication patterns & language

Feedback, reward, and corrective

action practices

Formal and informal leader

actions & expectations

Teamwork processes

(e.g., back-up behavior)

Resource allocation practices

Error-detection and correction

systems

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1. Safety culture is related to outcomes Patient outcomes

Patient care experience Infection rates, sepsis Postop. hemorrhage, respiratory failure, accidental puncture/laceration Treatment errors

Clinician outcomes Incident reporting, burnout, turnover

2. Safety culture influences the effectiveness of other safety and quality interventions Can enhance or inhibit effects of other interventions

3. Safety culture can change through intervention Best evidence so far for culture interventions that use multiple

components

Why Safety Culture Matters

CUSP & Safety Culture

Safety Culture is typically measured “Pre-CUSP”: Before interventions begin• Provides a baseline to diagnose barriers and

facilitators that can impact improvement efforts

• Then can be measured 12-18 months following start of improvement efforts

Use reliable and valid survey instrument• Hospital Survey on Patient Safety (HSOPS)

CUSP is the intervention that you will use to help you improve culture results

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I HAVE MY DATA…BUT NOW WHAT? Part II

Prepare your Elevator Speech:What is the Hospital Survey on Patient Safety (HSOPS)?

Suite of survey tools = SOPS• Hospital• Medical office• Nursing home

Background & Frame of Reference:• Sponsored by: Agency for Healthcare Research & Quality

• US federal agency charged with conducting and supporting research to improve patient safety and care quality

• Developed by Westat, public release in 2004

Participants are asked to choose 1 to 5 for each question:1 Strongly Disagree 2 Disagree 3 Neither Agree nor Disagree 4 Agree 5Strongly Agree1 Never 2 Rarely 3 Sometimes 4 Most of the time 5 Always

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HSOPS Questions & Composite Scores

10 Composite Scores (“Dimensions”)

Number of Questions

Example Question

1. Supervisor/manager expectations & actions promoting patient safety

4 B1. My supervisor/manager seriously considers staff suggestions for improving patient safety.

2. Organizational learning-continuous improvement

3 A9. Mistakes have led to positive changes here

3. Teamwork within unit 4 A1. People support one another in this unit.

4. Communication openness 3 C4. Staff feel free to question the decisions or actions of those with more authority.

5. Feedback & communication about error 3 C1. We are given feedback about changes put into place based on event reports.

6. Nonpunitive response to error 3 A8. Staff feel like their mistakes are held against them. (negatively worded)

7. Staffing 4 A2. We have enough staff to handle the workload.

8. Hospital management support for patient safety

3 F8. The actions of hospital management show that patient safety is a top priority.

9. Teamwork across hospital units 4 F4.There is good cooperation among hospital units that need to work together.

10. Hospital handoffs & transitions 4 F5.Important patient care information is often lost during shift changes. (negatively worded)

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HSOPS Questions & Composite Scores –continued-

4 Outcome variables Number of Questions

Example Question

1. Overall perceptions of safety 4 A15. Patient safety is never sacrificed to get more work done.

2. Frequency of event reporting 3 D1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?

3. Patient safety grade (of hospital unit)

1 E1. Please give your work area/unit in this hospital an overall grade on patient safety.

4. Number of events reported in the last 12 months

1 G1. In the past 12 months, how many event reports have you filled out and submitted?

Plus background questions about respondents

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HSOPS Scoring

• Scoring guidelines created by AHRQ• Scores represent the % of positive responses

– % who gave a score of 4 or 5

1 Strongly Disagree 2 Disagree 3 Neither Agree nor Disagree 4 Agree 5Strongly Agree

1 Never 2 Rarely 3 Sometimes 4 Most of the time 5 Always

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Your medical center

Your medical center

Your medical center

Your medical center

Your medical center

Your medical center

Your medical center

Your medical center

Your medical center

Interpreting Composite Scores: • The big picture view• Higher is better

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Questions provide a deeper dive:• For positively worded items, more green is

better15

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Your medical center

Your medical center

Your medical center

Your medical center

Your medical center

Your medical center

Your medical center

Your medical center

Your medical center

Interpreting Composite Scores: • The big picture view• Higher is better

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Questions provide a deeper dive:• For negatively worded items, more RED

is better

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Next Steps: Creating a Debriefing Plan

• Debriefing is…– A semi-structured conversation among frontline

clinicians and staff that is usually led by a designated facilitator

• Purpose…1. Encourage open communication, transparency,

and interactive discussion about the survey results

• Across all levels2. To engage clinicians and staff in generating and

implementing their ideas about how to create an effective safety culture in their work area

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Some points to cover in your debriefing plan

Decision points for project team Debriefing plan How many debriefing sessions will be held?

Who will facilitate each debriefing session?

When will debriefing(s) be held?

Where will debriefing(s) be held?

Who is responsible for taking notes and recording ideas from each session?

If you conduct more than one debriefing session, who is responsible for collating notes and ideas for improvement from the different sessions?

How will the CUSP team ensure there is follow-up on the action items from the debriefing session(s)?

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Keep in mind…Culture Change can seem Hard Because Culture has Three Layers… (Schein, 2010; Scorzoni, 1982)

1. Behaviors, norms, processes enacted on the job, feedback & reward systems

2. Espoused values, goals, philosophies, formal policies

3. Underlying assumptions

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Keep in mind…Culture Change can seem Hard Because Culture has Three Layers… (Schein, 2010; Scorzoni, 1982)

1. Behaviors, norms, processes enacted on the job

2. Espoused values, goals, philosophies, formal polices

3. Underlying assumptions

Safety climate surveys focus diagnostic measurement here

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Keep in mind…Culture Change can seem Hard Because Culture has Three Layers… (Schein, 2010; Scorzoni, 1982)

1. Behaviors, norms, processes enacted on the job

2. Espoused values, goals, philosophies, formal policies

3. Underlying assumptions

Deeper levels addressed by: Debriefing Involvement of unit members Leaders who model the values and

align assumptions

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Culture Change Can Seem Hard Because it Involves both Unlearning and Re-Learning

Unfreeze

Learn & Rebalance

Refreeze

Lewin, 1951; Schein, 2009

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Changing Culture in Practice: National CLABSI Project Example

• Baseline HSOPS surveyTarget non-punitive response to error

• What did they do?– Clarified the language and definitions of events,

errors, glitches with all unit clinicians & staff• Education campaign to define and differentiate process

errors (e.g., expected behavior not clear, not known) from intentional violations

• Created shared mental model about expected safety behavior, as well as what to report, when, and when/how to follow-up

• Follow up…hot off the presses!Non-punitive response, communication openness, supervisor support

In Sum

1. Review the survey report for your unit2. Can be helpful to distill the report down into 3-5 key slides 3. Decide when, how, and where to debrief your teammates

(and leaders) on these results• Be prepared to listen• Ask for feedback • Ask teammates to help come up with solutions

4. Gather a small group together and use the “culture debriefing tool” to examine the roots of problem areas and begin to formulate strategies for improvement

• Next call with Jill Marsteller & Mike Rosen Aug 9

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Thank you!

Sallie J. Weaver, PhDACCM, and

Armstrong Institute for Patient Safety and QualitySjweaver@jhu.edu