1. Inova Leadership Institute Quality Update and Safety Culture Results February 2015 1

2. Core Measures 2 2014 Overall Perfect Care = 96% 80% of Value Based Purchasing Core Measures at CMS Threshold Level Higher is better

3. Mortality 3 Overall 2014 Mortality O:E = 0.71, meeting 2014 Goal Lower is better

4. PSI-90 4 2014 All Medicare Patients PSI-90 is below CMS benchmark, meeting goal. Lower is better

5. Readmissions 5 2014 Inova Overall is meeting Readmission Goals for AMI (heart attacks) and COPD (chronic lung disease) Lower is better

6. Readmissions 6 2014 Inova Overall is not meeting, but very close, to Readmission Goals for heart failure & pneumonia 2014 Inova Overall is not meeting Readmission Goal for joint replacement

7. Hospital Acquired Infections 7 2014 Central Line Associated Blood Stream Infections (CLABSI) have decreased. 2014 Catheter Associated Urinary Tract Infections have mostly decreased. Opportunity for Improvement in IFH Adult ICUs. Lower is better

8. Multi-Drug Resistant Infections 8 2014 C.diff infections are mostly trending down. Some opportunity for improvement remains at IAH and IFH. Some spikes in 2014 MRSA infections, but remains at goal. Lower is better

9. Patient Safety Culture ILI 35

10. Patient Safety Culture Review “Virtually no one clearly defines what they mean by “culture,” and when they do they usually get it wrong.” -John Kotter 10

11. Safety Culture 11 Informed Reporting Just Flexible Learning

12. Safety Culture Journey 12 2011201220132014 Measure & Analyze Partial Administration Baseline Administration & Debrief 1 st Comparative Administration & Debrief 2 nd Comparative Administration & Debrief Focus Reporting and Just Culture Teamwork Staffing Act Set Targets for Improvement Planned for full administration Engagement of leaders Prep for improvements Safety Always Implementation TeamSTEPPS® Improve↑ 0.3%↑ 1.6%

13. Conclusions Overall, patient safety culture scores have improved slightly over 2013 Engagement of staff in the survey increased drastically in 2014 13 Nonpunitive Response to Error (+5.7%) and Hospital Handoffs and Transitions (+3.7%) had the greatest increase since 2012

14. Conclusions Since 2012, only Staffing has decreased consistently Hospital Management Support suffered a steep decline in 2013, improved in 2014, but not fully to the 2012 baseline The custom questions show a large increase in confidence around our new Safety Always event reporting system 14

15. Response Rate by Facility National Average (54%)

16. 90 th Percentile 75 th Percentile Average* 25 th Percentile 10 th Percentile or Less Non-Punitive Response to Error Handoffs and Transitions Staffing Teamwork in Unit Manager expectations around PS Management support for Patient Safety Communication Openness Event Reporting Teamwork Across Units Perceptions of Patient Safety Organizational Learning Feedback about Error N = 7,305 Inova 2014 HSOPS Results *Benchmarked against 2014 AHRQ Database (All Hospitals)

17. Inova HSOPS See-Saws Over Time 2012 2013 2014

18. National Percentiles

19. Operating Unit Results 19

20. Overall Percent Positive Response 20 300 – 399 Beds 100 – 199 Beds 500+ Beds 200 – 299 Beds 100 – 199 Beds

21. *Benchmarked against 2014 AHRQ Database (All Hospitals) Fairfax 2014 HSOPS Results 90 th Percentile 75 th Percentile Average* 25 th Percentile 10 th Percentile or Less Non-Punitive Response to Error Handoffs and Transitions Staffing Teamwork in Unit Manager expectations around PS Management support for Patient Safety Communication Openness Event Reporting Teamwork Across Units Perceptions of Patient Safety Organizational Learning Feedback about Error N = 3,413

22. 90 th Percentile 75 th Percentile Average* 25 th Percentile 10 th Percentile or Less Non-Punitive Response to Error Handoffs and Transitions Staffing Teamwork in Unit Manager expectations around PS Management support for Patient Safety Communication Openness Event Reporting Teamwork Across Units Perceptions of Patient Safety Organizational Learning *Benchmarked against 2014 AHRQ Database (All Hospitals) Feedback about Error Alexandria 2014 HSOPS Results N = 1165

23. 90 th Percentile 75 th Percentile Average* 25 th Percentile 10 th Percentile or Less Non-Punitive Response to Error Handoffs and Transitions Staffing Teamwork in Unit Manager expectations around PS Management support for Patient Safety Communication Openness Event Reporting Teamwork Across Units Perceptions of Patient Safety Organizational Learning *Benchmarked against 2014 AHRQ Database (All Hospitals) Feedback about Error Mt. Vernon 2014 HSOPS Results N = 687

24. 90 th Percentile 75 th Percentile Average* 25 th Percentile 10 th Percentile or Less Non-Punitive Response to Error Handoffs and Transitions Staffing Teamwork in Unit Manager expectations around PS Management support for Patient Safety Communication Openness Event Reporting Teamwork Across Units Perceptions of Patient Safety Organizational Learning *Benchmarked against 2014 AHRQ Database (All Hospitals) Feedback about Error Fair Oaks 2014 HSOPS Results N = 1074

25. 90 th Percentile 75 th Percentile Average* 25 th Percentile 10 th Percentile or Less Non-Punitive Response to Error Handoffs and Transitions Staffing Teamwork in Unit Manager expectations around PS Management support for Patient Safety Communication Openness Event Reporting Teamwork Across Units Perceptions of Patient Safety Organizational Learning *Benchmarked against 2014 AHRQ Database (All Hospitals) Feedback about Error Loudoun 2014 HSOPS Results N = 966

26. Difference from AHRQ Benchmark (50 th percentile) by Composite 26 HospitalLoudounFair OaksMt. VernonAlexandriaFairfax Benchmark100 - 199 Beds 200 - 299 Beds300 - 399 Beds500+ Beds Composite score exceeds respective benchmark. Composite score below respective benchmark. Safety Always

27. Difference from 2013 by OU 27 2014 Composite score exceeds 2013 score2014 Composite score below 2013 score

28. Composite Two Year Trends 28 ColorCriteria Green Above the 75th Percentile or a 5% increase from 2012 Yellow At least a 1% increase from 2012 (National Average rate of improvement) Red Less than a 1% increase from 2012 2012 to 2014 Difference Composite AlexandriaFair OaksMt. VernonFairfaxLoudoun Nonpunitive response to error0%4%1%7%11% Hospital handoffs & transitions-1%0%7%5%8% Frequency of events reported-1%3%7%1%5% Feedback & communication about error0%1%0%5%6% Teamwork across hospital units-3%0%3%4%6% Organizational learning - Continuous improvement-1%1% 6%4% Teamwork within units1%-1%1%5%3% Communication openness-3%0%1%5%4% Supervisor/manager expectations & actions promoting safety -1%0%1%3%2% Overall perceptions of safety-4%-2%1%2%5% Hospital management support for patient safety-5%-2%-1% 5% Staffing-9%-7%-3%1%2%

29. Staffing Perceptions 29

30. Staffing Questions Question2014 % Positive ResponseDifference from 2013 We have enough staff to handle the workload. (A2)38%0% Staff in this unit work longer hours than is best for patient care. (A5R)42%-1% We use more agency/temporary staff than is best for patient care. (A7R)58%-3% We work in "crisis mode" trying to do too much, too quickly. (A14R)42%0%

31. Common Barrier to Improvement Staffing QualityEngagement Patient Satisfaction Safety Culture

32. What Is Staffing Staffing Right NumberLeadershipTeamwork Individual Competencies

33. Leadership vs. Frontline 33

34. Differences in Perception 34 2014 Front Line Perceptions 2014 Leadership Perceptions Average gap between leaders and frontline has been 11% on all three surveys (2012, 2013, 2014)

35. Domain Breakout (System)

36. Domain Breakouts

37. Role Breakouts 37

38. System Wide Role Based Analysis

39. Safety Always Project 39

40. Issues with event reporting identified in safety culture survey (2012) Technology, process, and cultural factors identified as barriers to learning from error (2013) New technology vendor selected (Datix) with implementation partner (Synensis) –Rollout included: Assessment, System Configuration, ILI Training, Frontline Communications, and Reassessment Summary 40

41. Focused HSOPS Questions 41 Switched event reporting systems from Quantros (2013) to Safety Always (2014).

42. Safety Always Goals 42 * HSOPS dimensions include: “Frequency of Events Reported”, “Non- punitive Response to Error”, “Feedback and Communication about Error”, and “Management Support for Patient Safety” GoalProgress (as of Dec 2014) Increase reporting by 30%37.1% increase Reduce unclassified events from 25% to 15%17% of total are unclassified Decrease event entry time from 15-20 minutes to 5 minutesAverage entry time = 4 min Decrease anonymous reports from 12% to 6%11% of total are anonymous Track medical staff entering events into the system2.1% of total are Medical Staff

43. Positive Changes Safety Always is perceived significantly better than Quantros –Quicker data entry –More feedback to frontline “Great Catch” program continues to add positivity to reporting –Causes perceptions of the system to be “less punitive” Many units and departments are spending more time learning from individual events and near misses Internal communications have started to shift perceptions of reporting and have been a key to the success of the roll-out Leadership has increased transparency and learning by sharing more information regarding errors that occur and follow-up actions taken 43

44. Challenges & Opportunities Large opportunity to learn from events within Safety Always –System is used primarily for documentation –Middle management unsure how to use data and dashboards Workflow can continue to improve –Interdepartmental events are still difficult to complete and close –Reporters receive feedback inconsistently Anonymous reporting remains higher than expected –Partially attributed to speed of data entry –Reporters often feel uncomfortable reporting colleagues Further engage physicians –Increase utilization –Increase staff’s comfort with feedback 44

45. Closing Thoughts & Next Steps 45

46. Patient safety culture is improving, but slower than desired Successful roll-out of Safety Always has increased our ability to capture and learn from error –Improved behaviors need to be hardwired Focused action improves results Closing Thoughts 46

47. Patient Safety Culture Begin system-wide and OU-level action planning Safety Always Celebrate successes across the system Optimization of tool and our processes Continued work to clarify and improve manager workflow Increased utilization of reports and dashboards to learn from error Ongoing focus on actions to address root causes of events and great catches Next Steps – Starting in February