Improving Patient Safety Culture Using the AHRQ Hospital Survey Theresa Famolaro, MPS Westat

1. Improving Patient Safety Culture Using the AHRQ Hospital Survey • Theresa Famolaro, MPS • Westat • Westat • 1650 Research Blvd. • Rockville, MD 20850 • TheresaFamolaro@westat.com • 301-738-3547

2. Objectives • Present an overview of the AHRQ Hospital Survey on Patient Safety Culture and its Comparative Database results • Discuss ways to improve patient safety culture using your survey results • Review success stories of using the survey for patient safety improvement • Discuss future survey activities

3. What is Patient Safety Culture? “The way we do things around here” Exists at multiple levels: System Organization Department Unit Shared by staff • What is • Rewarded • Supported • Expected Beliefs, values & norms

4. Why you should do a culture survey? • Raise staff awareness about patient safety • Diagnose and assess patient safety culture • Identify strengths and areas for improvement • Examine change over time • Evaluate the impact of patient safety initiatives • Conduct internal and external comparisons

5. Background • Hospital Survey on Patient Safety Culture (HSOPS) • Developed by Westat, funded by AHRQ • Survey development process: • Reviewed literature & existing surveys • Interviewed hospital staff • Identified key areas of safety culture • Developed survey items & pretested • Obtained input from researchers & stakeholders • Pilot tested in 21 hospitals with 1,437 respondents • Final survey released November 2004

6. HSOPS Patient Safety Culture Dimensions • 42 items assess 12 dimensions of patient safety culture • 1. Communication openness • 2. Feedback & communication about error • 3. Frequency of event reporting • 4. Handoffs & transitions • 5. Management support for patient safety • 6. Nonpunitive response to error • 7. Organizational learning--continuous improvement • 8. Overall perceptions of patient safety • 9. Staffing • 10. Supv/mgr expectations & actions promoting patient safety • 11. Teamwork across units • 12. Teamwork within units • Patient safety “grade” (Excellent to Poor) • Number of events reported in past 12 months

7. HSOPS Comparative Database

8. HSOPS Comparative Database • 2012 Report • 1,128 U.S. hospitals, 567,703 respondents • Average # respondents per hospital = 503 staff • 650 trending hospitals • Survey modes • Paper 21% • Web 66%, In 2007 was 25% • Both 13% • Average hospital response rate = 53% • Paper 61% • Web 51% • Both 49%

9. Hospital Work Areas • Medicine 12% (62,688) • Surgery 10% • Many areas/no specific area 8% • ICU 7% • Radiology 6% • Emergency 6% • Lab 5%

10. Staff Positions & Patient Contact • Nursing 35% (191,402) • Technicians (EKG, Lab, Radiology, etc) 11% • Management, administration 8% • Unit assistant/clerk/secretary 6% • Physicians, PAs, NPs 6% • 76% had direct interaction with patients

11. Hospital Strengths

12. Hospital Middle Composite Scores

13. Hospital Areas for Improvement

14. Patient Safety Grade

15. Number of Events Reported

16. How Do I Compare My Results? • Compare Percent Positive Results • Compare Results by Hospital and Respondent Characteristics

17. Improving Patient Safety Culture

18. Action Planning for Improvement Step #1: Understand Your Results Step #2: Communicate & Discuss Results Step #3: Create Focused Action Plans Step #4: Communicate Plans & Deliverables Step #6 and 7: Track Progress & Evaluate Impact and Share Step #5: Implement Action Plans

19. Actions Taken by Trending Hospitals

20. Examine Culture at the Unit Level • Culture clusters in units • Provide results to each unit • Empower units to identify areas to improve • Implement patient safety initiatives at the unit level • Measure improvement at the unit level

21. Improving Patient Safety Resource List Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture

22. What is the AHRQ Health CareInnovations Exchange? • Publicly accessible, searchable database of over 2,300 health policy and service delivery innovations and QualityTools • Successes and attempts • Innovators’ stories and lessons learned • Expert commentaries • Learning and networking opportunities

23. Evidence for Patient Safety Initiatives • March 2013 AHRQ Report • Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices • Lists Top 41 Patient Safety Improvement Strategies • Non-clinical initiatives • Team training in health care • Interventions to promote a culture of safety • Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html

24. TeamSTEPPS® • Developed by Department of Defense (DoD) and AHRQ • Teamwork training for health care professionals • Focuses on organizational culture of safety • Involves a three-phased process • A pretraining assessment for site readiness • Free training for onsite trainers and health care staff • Implementation and sustainment • Comprehensive curriculum

25. Success with TeamSTEPPS® • Northshore Long Island Jewish Health System • Implemented TeamSTEPPS® first in pilot unit • Administered AHRQ Hospital Survey at baseline and after TeamSTEPPS® training • Significant improvement in ALL survey results (2007 to 2010) • Nonpunitive response to error +15.9% • Staffing +15.8% • Teamwork within units +11.9% • Overall perceptions of safety +11.8% • Organizational learning +11.7% • Thomas, L. and Galla, C. Building a culture of safety through team training and engagement. BMJ Qual ity and Safety. 2013; 22::425–434.

26. Leadership WalkroundsTM • Developed by Allan Frankel, MD, Director of Patient Safety at Partners HealthCare • Face-to-face visits by leaders on units • Leaders discuss patient safety issues with clinical staff and physicians • Many concerns related to equipment, facilities, & communication • Concerns entered into a database, addressed by severity • Demonstrates leadership commitment to patient safety

27. Success With Leadership WalkroundsTM • Massachusetts hospitals (7) • WalkroundsTM training at each site • Weekly Walkrounds from August 2002-April 2005 • Initially 7 hospitals, only 2 hospitals complied • Assessed culture at baseline and 18 months later • Used SAQ survey • Showed significant increase in scores for 2 hospitals Frankel, Al. et al. Revealing and resolving patient safety defects: The impact of leadership. Walkrounds on frontline caregiver assessments of patient safety. Patient Safety and Medical Errors. Health Serv Res 2008 December; 43(6): 2050–2066.

28. Just Culture • Nonpunitive Response to Error lowest composite in hospital database (2007-2012) • Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture • Nonpunitive Response to Error: The Fair and Just Principles of the Aurora Health Care Culture • Patient Safety and the "Just Culture": A Primer for Health Care Executives • Patient Safety and the "Just Culture": A Presentation by David Marx, J.D. • Improving Patient Safety in Hospitals: A Resource List for Users of the AHRQ Hospital Survey on Patient Safety Culture. August 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/resourcelist/hospimpptsaf.html

29. Success With Just Culture Training • Aurora Healthcare System • HSOPS survey 2005 • Aurora hospitals, in 2005, Nonpunitive response to error: 33% • Implemented David Marx Just Culture Training • HSOPS survey 2008 • Nonpunitive Response to error: 40% • Leonhardt, K.(2008). Nonpunitive Response to Error” The Fair and Just Principles of the Aurora Culture . Presented at CAHPS®/SOPS User Group Meeting 2008. Scottsdale, Arizona.

30. Future AHRQ SOPS Activities • AHRQ Hospital Survey on Patient Safety Culture Comparative Database • Next Comparative Database Report, Spring 2014 • Next Hospital Data Submission, June 2015 • Revise Hospital Survey (Version 2.0)

31. Resources • AHRQ Hospital Survey on Patient Safety Culture: http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/index.html • AHRQ Innovations Exchange: www.innovations.ahrq.gov • Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices: http://www.ahrq.gov/research/findings/evidence-based-reports/ptsafetyuptp.html • TeamSTEPPS®: http://teamstepps.ahrq.gov/ • Leadership WalkroundsTM:http://www.hret.org/quality/projects/patient-safety-leadership-walkrounds.shtml

32. Questions? • SafetyCultureSurveys@westat.com, 1-888-324-9749 • DatabasesOnSafetyCulture@westat.com, • 1-888-324-9790