1. TEAMWORK AND COMMUNICATION IN SURGERY INITIATIVE SAFETY ATTITUDES QUESTIONNAIRE AND HEALTH BENCH DEMO November 18, 2011

2. Outline Why Teamwork and Communication? Dr. Craig Bosenberg Clinical Lead for Surgical Checklist and SSI, BC Patient Safety & Quality Council Logistics Marlies van Dijk Quality Leader, BC Patient Safety & Quality Council Safety Culture, SAQ, and Health Bench Demo Dr. Maleek Jamal Vice President, Client Development, Pascal Metrics

3. Why Teamwork and Communication?

4. Step-by-Step Breakdown

5. Timeline for Culture Survey Recruit Hospitals/Call to Action (October/ November 2011) Prepare PIA/Ethics application (October/ November 2011) Conduct Survey (December 2011/January 2012) 1. Feedback results to hospitals 2.Human Factors Training (March 2012) Initial wave deadline: November 30, 2011

6. Cost? No. of SitesBronzeSilver 5 to 10$3,900$5,500 11 to 15$3,750$5,300 16 to 20$3,600$5,100 21 to 26$3,200$4,600 Readiness elements: Leadership support and guidance (CEO and Board) Champions from all three disciplines (surgery, anesthesia and nursing) Resources to implement interventions Readiness elements: Leadership support and guidance (CEO and Board) Champions from all three disciplines (surgery, anesthesia and nursing) Resources to implement interventions

7. Dr. Maleek Jamal Safety Culture, SAQ, and Health Bench Demo

8. Makary et al. 2006 American College of Surgeons

9. PASCAL METRICS AND THE SAFETY ATTITUDES QUESTIONNAIRE PASCAL METRICS AND THE SAFETY ATTITUDES QUESTIONNAIRE DR. ALLAN FRANKEL

10. 10 Pascal serves ~800 hospitals and healthcare systems, has over 13,000 clinical areas in its industry-leading patient safety culture dataset

11. What is culture? “The way we do things around here.” –Shared perceptions about what is good, right, important, valued, rewarded, supported, and expected –Culture is shaped by: Policies, practices, and procedures The values and personalities of people in the organization Leadership –We can talk about specific pieces of culture, for example: Safety climate: To what extent is safety of patients a priority? Teamwork climate: To what extent is collaboration valued and supported?

12. 12 Why does culture matter?

13. 13 1. Nosochomial Infections 2. Readmissions 3. Medication errors 4. Wrong site surgeries / RFBs 5. Patient satisfaction 6. Nurse turnover & absenteeism 7. AHRQ Patient Safety Indicators 8. Nurse satisfaction 9. VAPs and BSIs 10. Malpractice claims...and more. Useful References for Culture-to- Outcomes Linkage: Jain et al. (2011) New Eng J Med Hansen et al. et (2011) Health Ser Res Leonard & Frankel (2011) Book Curry et al. (2010) Ann Int Med Singer et al. (2009) Health Ser Res Pettker et al. (2009) Am J Obs / Gyn Vogus & Sutcliffe (2010) Acad Manag Persp. Frankel & Leonard (2006) Health Ser Res Hoffman et al. (2006) Personnel Psych Sexton et al. (2006) BMC Safety Culture: Leading indicator of key clinical, operational, and financial outcomes

14. 14 Culture can be measured A survey instrument can most effectively distinguish between a “healthy” culture and an “unhealthy” culture when: –A valid instrument is used –All members of a unit are invited to complete the survey Including people of different roles ensures that each role’s piece of the patient care stream is taken into account –The survey response rate is high (at least 60%) A high response rate usually indicates that data are representative of everyone’s perceptions

15. 15 A Framework for Excellence: Examine a Patient – Examine a Unit Culture of Safety Learning Organization 1. Leaders who facilitate and mentor teamwork, improvement, respect and psychological safety 2. Teams who know the game plan and agree upon specific behaviors 3. Accountability that supports psychological safety because employees believe that they’ll be treated fairly 4. A Continuous Learning Process that generates reliable care by applying best evidence and minimizing variation, 5. Uses Measurement transparently, continuously, owned by frontline providers, and 6. Applies Formal Improvement Methods to generate quality and mitigate and eliminate defects.

16. 16 Nurses are the ‘Canaries in the Mine’ Nurse perceptions of care are leading indicators of harm ✓ Strong correlation of sentinel events with <50% RN perceptions of care

17. No BSI 21% No BSI = 5 months or more with no Blood Stream Infection No BSI 31%No BSI 44% 17 ✓ Strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care Michigan Keystone Initiative: Teamwork Climate Across ICUs Predicts Infection

18. Attribution: Doug Salvador, Maine Med Ctr Maine Medical Center

19. Quarterly cumulative SSI rate for all surgical procedures included in surveillance plan per 100 surgical procedures Attribution: Doug Salvador, Maine Med Ctr Maine Medical Center

20. 20 The usefulness of the survey is dependent on - Knowing which data to display - Knowing how to display the data - Knowing how to make the data actionable

21. OR/SPD SPD PACU/SACU Residents PreSurgical Eval SACU PACU OR PACU SPD Hospital A Hospital B Hospital C Residents

23. Debriefing culture data locally - CONFIDENTIAL- 23 © 2011 Pascal Metrics Local debrief sessions target improvement at the clinical area level Sessions empower caregivers to “own the data” Use the DEBRIEFer tool available via Pascal HealthBenchPascal HealthBench Tools >> DEBRIEFer

24. Change in survey scores ICUs with DeBRIEFer Reflected on SAQ scores and took action 1.Increased SAQ scores in 5 of 6 domains 2.Achieved 10.2% decrease in BSI (infection) rates 3.Achieved 15.2% decrease in VAP rates ICUs without DeBRIEFer Did not reflect on SAQ scores nor take action 1.Decreased SAQ scores in 5 of 6 domains 2.No significant decrease in BSI (infection) rates 3.Experienced 4.8% increase in VAP rates ✓ Silver-level Debriefing drives outcomes and performance improvement * * * * * Value of Silver-level?

25. Questions?

26. IMPLEMENTING THE SURVEY IN BC: LOGISTICS IMPLEMENTING THE SURVEY IN BC: LOGISTICS MARLIES VAN DIJK

27. Canadian Context – Patient Safety Tools Accreditation Canada Modified Stanford tool BC Culture Initiative: Safety Attitudes Questionnaire Quota set for number of employees organizationally wide Aiming for 80% of staff in Operating Rooms and Surgical units Starting unit level reporting in November 2011 Unit level and can compare yourself to 1000 ORs in the US/Canada Positively framed questions Example: - At work, my opinions seem to count - In my area, it is easy to speak up if I feel there is a problem related to safety Positive and negative framed questions Example: - In this work setting, if I perceive a problem it is difficult to speak up - In this work setting it is difficult to discuss errors No specific questions on how nurses and physicians as a team 2 specific questions - Nurse input is well received in this work setting - The physicians and nurses work as a well coordinated team Up to local sites/HA’s to interpret and support action Support to interpret and plan action at a local level across the province for interested sites 2 day workshop in March 2012

28. Survey Process? 1.Subscription Model – BCPSQC 2.Organizational Mapping, 2-3 weeks long Subscription Manager (10-15% of time) 3.Survey Administration, 4-6 weeks long Survey Lead (10-15% of time) 4.Data Scrub and Analytics, 4 weeks long 5.Leadership Briefing & Analytics and Action, * 6.Improvement and Debriefing, 9 months long

29. Cost? No. of SitesBronzeSilver 5 to 10$3,900$5,500 11 to 15$3,750$5,300 16 to 20$3,600$5,100 21 to 26$3,200$4,600 Readiness elements: Leadership support and guidance (CEO and Board) Champions from all three disciplines (surgery, anesthesia and nursing) Resources to implement interventions Readiness elements: Leadership support and guidance (CEO and Board) Champions from all three disciplines (surgery, anesthesia and nursing) Resources to implement interventions

30. Pascal Metrics Options Bronze Level o Survey Administration o Safety Culture Analytics and Reporting - Executive Summary and One Page Reports; - Basic Benchmarking; and - Downloadable Data Spreadsheets. o 2 Leadership briefings

31. Pascal Metrics Options Silver Level o Survey Administration o Safety Culture Analytics and Reporting - Interactive Analytics, Views and Tools including Heat Maps, Scatter Plots, Spike Charts, Drill Down Tables - DeBRIEFER Plus to develop, track, execute and communicate improvement plans; - Executive Summary and One Page Reports; - Basic Benchmarking; and - Downloadable Data Spreadsheets. o 5 Leadership briefings

32. Timeline for Culture Survey Recruit Hospitals/Call to Action (October/ November 2011) Prepare PIA/Ethics application (October/ November 2011) Conduct Survey (December 2011/January 2012) 1. Feedback results to hospitals 2.Human Factors Training (March 2012) Initial wave deadline: November 30, 2011

33. Next Steps Expression of Interest Surgical Quality Action Network (SQAN) will be recruiting sites till November 30, 2011 Please email Marlies van Dijk at mvandijk@bcpsqc.ca with any questions or to register for the survey.mvandijk@bcpsqc.ca