Patient Safety Culture in West Virginia’s Rural Hospitals

In the beginning….

West Virginia Medical Institute

Background

The IOM Report. To Err is Human, focused attention on patient safety and medical errors

However, rural West Virginia hospitals did not have systems or infrastructure in place to improve processes as suggested by IOM

WVMI saw opportunity to assist and implemented the WV Patient Safety Improvement Program, initially with corporate funds

We received an AHRQ grant 9/2004 to expand the scope of the original project

Objectives

Improve patient safety and the culture of patient safety in rural West Virginia hospitals by:1. Offering a free, confidential event reporting

system protected from legal discovery2. Developing a collaborative network to share

information and best practices

Barriers to Implementation

Lack of IT Infrastructure in rural areas of West Virginia

Peer Review Statutes- Hospital legal staff feared data could be discoverable

Computer Literacy of hospital staff Lack of trained IT staff

Today

23 hospitals are participating in the AHRQ project to date, 13 of these are CAH

Baseline evaluation question: What is the patient safety culture in West Virginia’s critical access hospitals?

Critical Access Hospitals

There are 1013 CAHs across the nation Small rural hospitals differ from larger urban

facilities in many different ways that can impact on their ability to implement and sustain patient safety initiatives.

Do they differ with respect to the patient safety culture in their facilities?

Hospital Survey on Patient Safety Culture: Methodology

• Distributed to staff designated by hospital administration at time of system training.*

• Completed surveys turned in at end of training session.

• Data scanned into an Excel database and analyzed used SAS.

• Data collection is ongoing as hospitals are still being recruited.

Hospital Survey: Results

Through April 2005, 860 surveys have been completed representing staff at 16 hospitals

10 of the 16 (62.5%) are CAHs

Demographic Data about Respondents

1. Primary hospital work area, department or clinical area where respondents spend most of their work time:

14.9% Many different hospital units / No specific unit 0.3% Psychiatry / mental health11.1% Medicine (non-surgical) 3.8% Rehabilitation1.9% Surgery 2.2% Pharmacy0.6% Obstetrics 4.8% Laboratory0.3% Pediatrics 4.4% Radiology9.5% Emergency department 0.3% Anesthesiology0.3% Intensive care unit (any type) 45.4% Other

2. Staff position in the hospital:

21.2% Registered nurse 2.6% Dietician0.3% Physician assistant / Nurse practitioner 8.3% Unit assistant / Clerk / Secretary6.0% LVN / LPN 0.6% Respiratory therapist6.1%Patient care assistant / Hospital aide / Care partner 1.3% Physical, occupational, or speech therapist0.3% Attending / Staff physician 6.1% Technician (e.g., EKG, Lab, Radiology)0.0% Resident physician / Physician in training 24.4% Administration / Management6.1% Pharmacist 20.5%Other

AHRQ Staff Survey Summary Results

Cat

egor

y

Val

ue

Freq

uenc

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Eve

nt R

epor

ting

Ove

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Perc

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f Saf

ety

Supe

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anag

er e

xpec

tatio

ns

& a

ctio

ns p

rom

otin

g sa

fety

Org

aniz

atio

nal L

earn

ing-

Con

tinuo

us im

prov

emen

t

Team

wor

k W

ithin

Hos

pita

l Uni

ts

Com

mun

icat

ion

Ope

nnes

s

Feed

back

and

Com

mun

icat

ion

Abo

ut E

rror

Non

puni

tive

Res

pons

e To

Err

or

Staf

fing

Hos

pita

l Man

agem

ent S

uppo

rt fo

r Pa

tient

Saf

ety

Team

wor

k A

cros

s Hos

pita

l Uni

ts

Hos

pita

l Han

doff

s & T

rans

ition

s

All Hospitals 10th Percentile 41% 50% 63% 59% 73% 55% 51% 30% 47% 61% 34% 23%All Hospitals Median 55% 66% 76% 76% 83% 68% 71% 47% 57% 71% 53% 42%All Hospitals 90th Percentile 64% 77% 83% 90% 88% 88% 85% 56% 74% 87% 70% 51%

Non CAH Hospital 10th Percentile 49% 55% 71% 66% 77% 66% 64% 37% 50% 62% 33% 23%Non CAH Hospital Median 55% 64% 77% 76% 83% 77% 70% 47% 58% 70% 46% 30%Non CAH Hospital 90th Percentile 59% 77% 81% 89% 85% 88% 82% 52% 67% 79% 59% 43%

CAH Hospital 10th Percentile 34% 49% 58% 53% 71% 50% 47% 26% 48% 55% 46% 32%CAH Hospital Median 51% 67% 75% 74% 81% 66% 72% 44% 56% 73% 59% 45%CAH Hospital 90th Percentile 65% 75% 83% 88% 92% 75% 86% 63% 78% 90% 74% 53%

Demographic Data (continued)

3. Time worked--in the hospital 8.4% Less than 1 year 33.6% 1 to 5 years 24.9% 6 to 10 years (years)

8.7% 11 to 15 years 9.9% 16 to 20 years 14.4% 21 years or more

--in their current hospital work area 10.2% Less than 1 year 40.7% 1 to 5 years 23.1% 6 to 10 years (years)

9% 11 to 15 years 7.2% 16 to 20 years 9.9% 21 years or more

--in their current 4.5% Less than 1 year 24.5% 1 to 5 years 17.6% 6 to 10 yearsspecialty (years)

16.1% 11 to 15 years 11.3% 16 to 20 years 26% 21 years or more

4. Percentage of respondents with direct interaction or contact with patients: 73.2%

22

23

19

74

22

14

13

55

63

12

65

18

Overall Perceptions of Safety

R Indicates reversed-worded items.NOTE: The item letter and number in parentheses indicate the item’s survey location.

Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree

1. Patient safety is never sacrificed to get more work done. (A15)

2. Our procedures and systems are good at preventing errors from happening. (A18)

R3. It is just by chance that more serious mistakes don’t happen around here. (A10)

R4. We have patient safety problems in this unit. (A17)

34

29

20

35

6613

27

31

44

Frequency of Events Reported

1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported? (D1)

2. When a mistake is made, but has no potential to harm the patient, how often is this reported? (D2)

3. When a mistake is made that could harm the patient, but does not, how often is this reported? (D3)

% Never/ % Sometimes % Most of the Rarely time/AlwaysSurvey Items

NOTE: The item letter and number in parentheses indicate the item’s survey location.

6

5

13

13

84

74

26

13

7

10

62

88

Teamwork Within Units

NOTE: The item letter and number in parentheses indicate the item’s survey location.

Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree

1. People support one another in this unit. (A1)

2. When a lot of work needs to be donequickly, we work together as a team to get the work done. (A3)

3. In this unit, people treat each other withrespect. (A4)

4. When one area in this unit gets really busy, others help out. (A11)

Communication Openness

1. Staff will freely speak up if they see something that may negatively affect patient care. (C2)

2. Staff feel free to question the decisions or actions of those with more authority. (C4)

R3. Staff are afraid to ask questions when something does not seem right. (C6)

R Indicates reversed-worded items.NOTE: The item letter and number in parentheses indicate the item’s survey location.

% Never/ % Sometimes % Most of the Rarely time/Always

Survey Items

9

18

12

78

2265

37

13

46

21

13

13

51.1

77

28

19

10

67.5

Feedback and Communication About Error

1. We are given feedback about changes putinto place based on event reports. (C1)

2. We are informed about errors that happen in this unit. (C3)

3. In this unit, we discuss ways to prevent errors from happening again. (C5)

NOTE: The item letter and number in parentheses indicate the item’s survey location.

% Never/ % Sometimes % Most of the Rarely time/Always

Survey Items

Nonpunitive Response to Error

R1. Staff feel like their mistakes are held

against them. (A8)R2. When an event is reported, it feels like

the person is being written up, not the problem. (A12)

R3. Staff worry that mistakes they make are kept in their personnel file. (A16)

R Indicates reversed-worded items.NOTE: The item letter and number in parentheses indicate the item’s survey location.

Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree

24

21

23

35

4631

38

42

41

Hospital Management Support for Patient Safety

R Indicates reversed-worded items.NOTE: The item letter and number in parentheses indicate the item’s survey location.

Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree

11

17

21

83

21

6

9

58

75

1. Hospital management provides a work climate that promotes patient safety. (F1)

2. The actions of hospital management show that patient safety is a top priority. (F8)

R3. Hospital management seems interested in patient safety only after an adverse event happens. (F9)

21

22

14

22

58

45

57

41

11

21

21

67

Teamwork Across Hospital Units

R Indicates reversed-worded items.NOTE: The item letter and number in parentheses indicate the item’s survey location.

Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree

1. There is good cooperation among hospital units that need to work together. (F4)

2. Hospital units work well together to provide the best care for patients. (F10)

R3. Hospital unites do not coordinate well with each other. (F2)

R4. It is often unpleasant to work with staff from other hospital units. (F6)

Hospital Handoffs & Transitions

R Indicates reversed-worded items.NOTE: The item letter and number in parentheses indicate the item’s survey location.

32

30

30

35

25

32

17

43

52

38

48

18

Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree

R1. Things “fall between the cracks” when transferring patients from one unit to another. (F3)

R2. Important patient care information is often lost during shift changes. (F5) R3. Problems often occur in the exchange of information across hospital units. (F7)

R4. Shift changes are problematic for patients in this hospital. (F11)

How Does CAH Pt. Safety Culture Differ from Larger Hospitals in WV?

At the level of composite scores the differences are minimal, with the exceptions of:

Communication Openness, Teamwork Across Hospital Units, and Hospital Handoffs and Transitions.

Culture differences continued

Differences appear in specific questions 74% v 57% strongly agree/agree that patient safety

is NEVER sacrificed to get more work done. 64% v 44% strongly agree/agree that they have

enough staff to handle the workload. 29% v 44% strongly agree/agree that they work in

“crisis mode” trying to do too much, too quickly 58% v 42 SA/A there is good cooperation among

hospital units that need to work together

Discussion: So What?

Reminder: Convenience sample, reflecting the opinions of those chosen or choosing to participate in training.

The patient safety culture in WV rural hospitals of all sizes still have areas needing improvement, e.g., attention to near misses, non-punitive response.

Some of the ways in which CAH culture may differ, e.g., better teamwork, better transitions could theoretically support the ease with which patient safety interventions could be implemented.

Time will tell

Contact Information

Gail Bellamy, Principal Investigator, gbellamy@wvmi.org

Patricia Ruddick, Project Manager, pruddick@wvmi.org

David Lomely, Analyst, dlomely@wvmi.org