1. Interpreting Safety Culture Survey Results and Action Planning
Katherine Jones, PT, PhD
Anne Skinner, RHIA
June 17, 2011

2. Acronyms AHRQ = Agency for Healthcare Research and Quality
HRO = High Reliability Organization
HSOPS = Hospital Survey on Patient Safety Culture

3. Objectives Define “culture of patient safety” (safety culture)
Identify four components of safety culture
Use tools and reports from survey results to:
Identify change over time associated with patient safety interventions and benchmark results to the national database
Identify variation in safety culture by work area and job title in HSOPS results
Compare beliefs and behaviors within HSOPS dimensions to identify practices needed to support safety culture
Describe key practices that support safety culture
Recognize potential for response shift bias among when evaluating impact of patient safety interventions
Recognize role of leadership in engineering culture change
Develop an action plan to engineer key practices that support safety culture

4. The Problem and Challenge…
“The problem is not bad people; the problem is that the system needs to be made safer . . .”
IOM (2000). To Err is Human: Building a Safer Health System
“The biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm.”
IOM (2001). Crossing the Quality Chasm: A New Health System for the 21st Century, p. 79

5. Chain of Impact at the Point of Care
Healthcare System
Structures & Processes
Organizational
Structures & Processes
Beliefs -- Culture – Behaviors
Individual Provider
Structures & Processes
Interpersonal
Care
Technical
Care
Quality has been defined by the IOM as “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”*
We make three fundamental assumptions about the structure of the health system:
The healthcare macrosystem is made up of various regulatory, professional, and market-oriented organizations;
Organizations that deliver healthcare services are made up of structures and processes that must support those in direct contact with patients
3. It is the providers in direct contact with patients that comprise the microsystems, which produce quality, safety, and cost outcomes at the point of care.
Ultimately the outcomes of our healthcare system can be no better than the microsystems of which it is composed. Organizations must engineer specific practices to support learning within microsystems at the point of care.
Quality at Point of Care
The quality, safety and value of care can be no better than the structures and processes used by providers in direct contact with the patient. Culture is a lens through which organizations support providers at the point of care.
Nelson et al. (2002) Joint Commission Journal on Quality Improvement, 28,
Swuste P. (2008). Human Factors and Ergonomics in Manufacturing, 18, 5 5

6. What did you measure with HSOPS?
Enduring, shared, LEARNED* beliefs and behaviors that reflect an organization’s willingness to learn from errors**
Four beliefs present in a safe, informed culture***
Our processes are designed to prevent failure
We are committed to detect and learn from error
We have a just culture that disciplines based on risk
People who work in teams make fewer errors
Understanding results from the AHRQ HSOPS requires that you first understand the construct that the survey is measuring.
The survey is measuring the construct of safety culture which can be defined as the enduring, shared beliefs and practices (think behaviors) that reflect an organization’s willingness to learn from errors. The IOM identified four beliefs present in a safe, informed culture:
Healthcare processes can be designed to prevent failure
There is an organizational commitment to detect, learn from error
There is a just culture that disciplines based on risk
People who work in teams make fewer errors
A safe, informed culture should be a high reliability organization, which is an organization that is
HRO:
preoccupied with failure
sensitive to how each team member affects a process
allows those who are most knowledgeable about a process to make decisions, and
resists the temptation to blame individuals for errors within complex processes
What you believe
Changing values and attitudes of adults is difficult if not impossible
What you do
Behavior reflects beliefs, knowledge and skills
Gap can exist between beliefs and behaviors due to lack of knowledge, lack of skills
Management has ability to implement new policies and procedures; teach new skills to guide behavior
*Schein, E. Organizational Culture and Leadership. 4th ed. San Francisco, CA:
John Wiley & Sons; 2010.
**Wiegmann. A synthesis of safety culture and safety climate research; 2002.
***Institute of Medicine. Patient safety: Achieving a new standard of care.
Washington, DC: The National Academies Press; 2004.

7. Beliefs Assessed with HSOPS
Our processes are designed to prevent failure
“Our procedures and systems are good at preventing errors from happening.”—national db 62% - 82%*
We are committed to detect and learn from error
“When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?”— national db 44% - 67%*
“Mistakes have led to positive changes here.”— national db 54% - 74%*
We have a just culture—discipline is based upon risk taking
“Staff worry that mistakes they make are kept in their personnel file.”R— national db 25% - 47%*
People who work in teams make fewer errors
“People support one another in this department.” – national db79% - 92%
“When one area in this department gets really busy, others help out.”— national db 59% - 78%*
This slide illustrates how items from the AHRQ HSOPS measure the four beliefs present in an informed, safe culture as identified by the IOM.
*10th%ile and 90th%ile for 1032 hospitals reporting to AHRQ 2011 national comparative database

8. Three Levels of Culture
Behaviors
Beliefs & Values
Underlying Assumptions
Three Levels of Culture
“…in many organizations, values reflect desired behavior but are not reflected in observed behavior.”
Artifacts
Visible structures and processes
Observed behavior
Espoused beliefs and values
Goals, values, aspirations
May/may not be consistent with behavior
Basic underlying assumptions
Unconscious, taken for granted beliefs & values
Determine behavior, thought, feeling
Schein, E.H. Organizational Leadership and Culture 4th ed. San Francisco:
John Wiley & Sons; 2010, p.24, 27.

9. Goals of Culture Assessment…why did you measure safety culture?
Identify areas of culture in need of improvement
Increase awareness of patient safety concepts
Evaluate effectiveness of patient safety interventions over time
Conduct internal and external benchmarking,
Meet regulatory requirements
Identify discrepancies between beliefs and observed behaviors within subcultures and microcultures
Nieva, Sorra. (2003). Safety culture assessment: a tool for improving patient safety in healthcare organizations. Qual Saf Health Care, 12(Suppl II), ii17-ii23.

10. Regulatory Requirement
Conduct HSOPS to meet Joint Commission Leadership Standards (Standard LD )
Leaders regularly evaluate the culture of safety and quality using valid and reliable tools
Leaders prioritize and implement changes identified by the evaluation

11. Four Components of Safety Culture
SENSEMAKING
TRUST
A culture of safety is informed. It never forgets to be afraid…
= Flexible
Reason, J. (1997). Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited.
Battles et al. (2006). Sensemaking of patient safety risks and hazards. HSR, 41(4 Pt 2),
The shared beliefs and practices that comprise safety culture can be categorized to facilitate measurement, action planning, and change. Psychologist James Reason categorized safety culture into four components, which reflect his assertion that an informed culture is a safe culture. These components can be used to identify the beliefs and practices that interact to produce an organization that is informed about risks and hazards, takes action to become safe, and provides feedback about the effect of those actions.
Reporting
“Any safety information system depends crucially on the willing participation of the workforce, the people in direct contact with the hazards. To achieve this, it is necessary to engineer a reporting culture—an organization in which people are prepared to report their errors and near-misses.”
Just
“What is needed is a just culture, an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information—but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior.”
Flexible
“A flexible culture takes a number of forms, but in many cases it involves shifting from the conventional hierarchical mode to a flatter professional structure, where control passes to task experts on the spot, and then reverts back to the traditional bureaucratic mode once the emergency has passed.”
Learning
“An organization must possess a learning culture—the willingness and the competence to draw the right conclusions from its safety information system, and the will to implement major reforms when their need is indicated. . . In most important respects, an informed culture is a safety culture.”
Interaction between effective practices results in sensemaking within macro- and microsystems
Sensemaking requires data, which is interpreted within the context of the lived experiences of those in direct contact with patients*
Sensemaking can not occur without data, trust and teamwork

12. How to Become an HRO: Engage in Continuous Improvement
Plan
Action
Practices
Implement
Behaviors
Beliefs and
Measure
Becoming a high reliability organization that seeks to learn from its mistakes requires a continuous cycle of measurement of the beliefs and behaviors that support learning, action planning, implementation, and reassessment.

13. Measure Beliefs and Behaviors with HSOPS
Developed by AHRQ to provide healthcare organizations with a valid tool to assess safety culture
42 items categorized in 12 dimensions
2 dimensions are outcome measures at dept/unit level
7 dimensions measure culture at dept/unit level
3 dimensions measure culture at hospital level
2 additional items are outcome measures at dept/unit level
Number of Events Reported
Patient Safety Grade
The HSOPS consists of 42 items that are categorized in 12 dimensions. Two dimensions are outcome measures at the level of the unit/department : overall perceptions of safety and frequency of events reported. Seven dimensions measure safety culture at the unit/department level: supervisor/manager expectations and actions promoting patient safety, organizational learning, teamwork within departments, communication openness, feedback and communication about error, nonpunitive response to error, and staffing. Three dimensions measure safety culture at the hospital level: hospital management support for patient safety, teamwork across hospital departments, and hospital handoffs and transitions. Two additional items are outcome measures that the respondent assesses at the department level: patient safety grade and number of events reported.

14. HSOPS
Original AHRQ Survey available
AHRQ Comparative Database for HSOPS
2011 Comparative Database for Benchmarking
1032 hospitals; 472,397 respondents
Stratis will submit your results to database
Report comparing your hospital to national data
Trending hospitals asked to describe interventions 14

15. UNMC Rural HSOPS Available at www.unmc.edu/rural/patient-safety
Developed by UNMC as part of AHRQ Partnerships in Implementing Patient Safety Grant
Collapses work areas and position to reflect CAH environment
Allows sorting by Work Area/Position if > 5 respondents
Creates valid benchmark data for CAHs
Allows valid tracking of safety culture over time within a CAH to evaluate patient safety interventions
10 additional items added by UNMC to evaluate TeamSTEPPS

16. Original AHRQ HSOPS
32%
Rural-Adapted AHRQ HSOPS
3.3%

17. Rural-Adapted AHRQ HSOPS
Original AHRQ HSOPS
21%
Rural-Adapted AHRQ HSOPS
3.2%

18. Reason’s Components Frequency of Events Reported (O)
HSOPS Dimensions or Outcome Measures
Reporting Culture - a safe organization is dependent on the willingness of front-line workers to report their errors and near-misses
Frequency of Events Reported (O)
Number of Events Reported (O)
Just Culture - management will support and reward reporting; discipline occurs based on risk-taking
Nonpunitive Response to Error (U)
Let’s see how Reason’s components of culture are measured by the AHRQ survey….
Reporting Culture - a safe organization is dependent on the willingness of front-line workers to report their errors and near-misses is measured by the unit level outcomes Frequency of Events Reported and Number of Events Reported
Just Culture - management will support and reward reporting; discipline occurs based on risk-taking is measured at the level by Nonpunitive Response to Error
O = Outcome measure
U = Measured at level of unit/department
H = Measured at level of hospital

19. Reason’s Components HSOPS Dimensions or Outcome Measures
Flexible Culture - authority patterns relax when safety information is exchanged because those with authority respect the knowledge of front-line workers
Teamwork w/in Units (U)
Staffing (U)
Communication Openness (U)
Teamwork ax Units (H)
Hospital Handoffs (H)
Learning Culture - organization will analyze reported information and then implement appropriate change
Hospital Mgt Support (H)
Manager Actions (U)
Feedback & Communication (U)
Organizational Learning (U)
Overall Perceptions (O)
Patient Safety Grade (O)
Flexible Culture - authority patterns relax when safety information is exchanged because those with authority respect the knowledge of front-line workers is measured at the unit level by Teamwork w/in Units, Staffing, and Communication Openness; and at the hospital level by Teamwork Across Units and Hospital Handoffs and Transitions
Learning Culture - organization will analyze reported information and then implement appropriate change is measured at the hospital level by Hospital Mgt Support and at the unit level by Manager Actions, Feedback & Communication about Error, Organizational Learning, Overall Perceptions or Safety, and Patient Safety Grade

20. Your Results Resource Purpose Reports from Excel Tool
ANALYSIS - Contains raw data
Generates spreadsheet to upload for national database
Instructions for interpretation
Demographics of respondents
Contains dimension and item level results in the aggregate, by department, position, direct patient care, action planning sheet
Benchmark Tool
COMMUNICATION
Compare aggregate results to peer group (external benchmark)
Compare aggregate results over time
Compare results by work area and job title to the aggregate
Item Level Over Time
COMPARISONS AND COMMUNICATION
Compare item level results over time and to peer group
Includes responses to teamwork questions
Comments Coded by Theme
CONTEXT
Open ended comments coded by culture-related themes
Provides respondents’ direct feedback
Action Plan
PLAN - Work sheet to anchor action plan in history, mission and strategic goals; identify practices needed to support safe culture

21. Action Planning: What is needed
Principle-drive NOT event-driven
Planned approach NOT piecemeal
Proactive NOT reactive
Understand latent conditions
Anticipate the next error
Focus on performance/behavior
Reason, J. (1997). Managing the Risks of Organizational Accidents.
Hampshire, England: Ashgate Publishing Limited.
Schein, E.H. Organizational Leadership and Culture 4th ed. San Francisco:
John Wiley & Sons; 2010.

22. Interpreting Results to Develop an Action Plan
Anchor plan in history, mission, strategic goals
Understand response rate (> 60% best)…are results generalizable?
Identify organization-wide areas
In need of improvement
Improved due to specific interventions
Wrap your mind around reverse worded items
Identify gaps between beliefs and behaviors within 4 components

23. Interpreting Results to Develop an Action Plan
Identify variation in microcultures by work area/job title
Relate open-ended comments to results
Recognize potential for response shift bias in repeat reassessments
Consider how management uses information
Explicit plan to strengthen 4 components within depts by implementing specific practices that close the gap between beliefs and behaviors
Communicate results and plan

26. Organization Wide Areas in need of improvement
Lowest Scores
Handoffs and Transitions (35%)
Teamwork Ax Depts (40%)
Nonpunitive Response (45%)
Significant Changes
Feedback & Communication about Error (+13%)
Teamwork W/in Units (+10%)
Overall Perceptions (+7%)
Teamwork Ax Units (-5%
Handoffs & Transitions (-5%)
Organization Wide Areas in need of improvement

27. Reverse worded items Gaps between beliefs & behaviors
Percent Positive 2011 HSOPS Database (n=1032 Hospitals)

28. Gaps Between Beliefs & Behaviors Percent Positive 2011 HSOPS Database (n=1032 Hospitals)
Reporting Culture
Just Culture
These two graphs provide item results for the dimensions communication openness and teamwork within units for nurses from a specific hospital.
For communication openness, 63% of nurses responded positively that they believed, “Staff will freely speak up if they see something that may negatively affect patient care.” However, only 13% indicated that “Staff feel free to question the decisions or actions of those with more authority,” – a behavior.
For Teamwork with Units, 88% of nurses responded positively that they believed, “People support one another in this department.” However, 63% indicated, “When one area in this department gets really busy, others help out,” – a behavior consistent with supporting one another.

29. Teamwork Culture
These two graphs provide item results for the dimensions communication openness and teamwork within units for nurses from a specific hospital.
For communication openness, 63% of nurses responded positively that they believed, “Staff will freely speak up if they see something that may negatively affect patient care.” However, only 13% indicated that “Staff feel free to question the decisions or actions of those with more authority,” – a behavior.
For Teamwork with Units, 88% of nurses responded positively that they believed, “People support one another in this department.” However, 63% indicated, “When one area in this department gets really busy, others help out,” – a behavior consistent with supporting one another.

30. Teamwork Culture http://www.ahrq.gov/qual/hospsurvey11/hospsurv111.pdf
These two graphs provide item results for the dimensions communication openness and teamwork within units for nurses from a specific hospital.
For communication openness, 63% of nurses responded positively that they believed, “Staff will freely speak up if they see something that may negatively affect patient care.” However, only 13% indicated that “Staff feel free to question the decisions or actions of those with more authority,” – a behavior.
For Teamwork with Units, 88% of nurses responded positively that they believed, “People support one another in this department.” However, 63% indicated, “When one area in this department gets really busy, others help out,” – a behavior consistent with supporting one another.

31. Learning Culture
These two graphs provide item results for the dimensions communication openness and teamwork within units for nurses from a specific hospital.
For communication openness, 63% of nurses responded positively that they believed, “Staff will freely speak up if they see something that may negatively affect patient care.” However, only 13% indicated that “Staff feel free to question the decisions or actions of those with more authority,” – a behavior.
For Teamwork with Units, 88% of nurses responded positively that they believed, “People support one another in this department.” However, 63% indicated, “When one area in this department gets really busy, others help out,” – a behavior consistent with supporting one another.

32. In this graph, the 12 dimensions of the survey are along the x axis
In this graph, the 12 dimensions of the survey are along the x axis. The graph illustrates that HSOPS results for the work areas acute/skilled care and surgery are less positive than the aggregate for the hospital.

33. Why are microcultures different?
Quantity, relevance, timeliness of information available differs due to leadership
Methods of information sharing differ
Personal
Through standard channels
Teams do whatever it takes to get the right information to the right people at the right time
These methods reveal what is important to leaders
My personal power and glory (pathologic)
Maintenance of positions, rules, turf (bureaucratic)
Mission of organization (generative)
Why are cultures in organizations different? Through actions, rewards, & punishments, Leaders communicate what is important
Personal power (my needs and glory)
Positions (rules and departmental turf)
Mission of organization
Patterns of information flow--the Quantity Relevance Timeliness Appropriateness of information available --reflect the climate set by the leader
Westrum, R. A typology of organizational cultures. Quality and Safety in Healthcare 2004;13:22-27.

34. In this graph, the 12 dimensions of the survey are along the x axis
In this graph, the 12 dimensions of the survey are along the x axis. The graph illustrates that HSOPS results for the work areas acute/skilled care and surgery are less positive than the aggregate for the hospital.

35. Action Planning: A Reporting culture is engineered by implementing practices
Practices/Tools
Reporting Form
Near miss log
Chart audit
Secret Shopper
Safety Briefings
Leadership WalkRoundsTM
Bulletin board/ suggestion box/telephone hotline
Successful reporting systems (Leape, 2002)
Nonpunitive
Confidential
Independent
Expert analysis
Timely
Systems-oriented
Responsive
Reporting, obtaining information about the processes and outcomes of care, is the foundation of a safe, informed culture. Psychologist James Reason states, “Any safety information system depends crucially on the willing participation of the workforce, the people in direct contact with the hazards.” To achieve this, it is necessary to engineer a reporting culture—an organization in which people are prepared to report their errors and near-misses.” The practices that support a reporting culture include formal reporting systems that are
Nonpunitive
Confidential
Independent
Expert analysis
Timely
Systems-oriented
Responsive
And informal forms of reporting that include Chart Audit, Secret Shopper, Safety Briefings, Leadership WalkRounds

36. Reporting Action Plan & Aims
We need to strengthen our REPORTING CULTURE because: Just 1/3 of all respondents agreed that “near misses” are frequently reported. Comment: “There is a strong belief by some staff that errors are recorded and held against staff….” We can do this by: (1) educating all employees about the role of near miss reporting—learning about risks and hazards in systems without harming patients; ( 2) implementing use of a “near miss” reporting log in all departments; (3) including discussion of near misses at departmental briefs (including sift change), huddles, and debriefs; and (4) including discussions of near misses in regular Leadership WalkRounds.

37. Action Planning: A Just culture is engineered by implementing practices
Practices/Tools
Understanding human error (Reason 2003, 2006)
Active errors (sharp end)
Latent errors
Just Culture and behavior (Marx, 2001)
Conduct: human error, negligence, reckless, intentional rule violation
Disciplinary decision-making: outcome-based, rule-based, risk-based
Unsafe Acts Algorithm
Disruptive Behavior Policy/Standards
The willingness of workers to report depends on their belief that management will support and reward reporting and that discipline occurs based on risk-taking…there is a clear line between acceptable and unacceptable behavior —organizational practices support a just culture.
Discipline does not take place in response to human error but in response to knowingly increasing the risk to patients or peers. These practices include….

38. Execute Just Culture . . . UNSAFE ACTS ALGORITHM
Were the actions
as intended?
Evidence of illness or substance use?
Knowingly violated safe procedures?
Pass substitution
test? (Could someone else have done the same thing)?
History of
unsafe acts?
Were the consequences
Were procedures
available, workable, intelligible, correct and routinely used?
Deficiencies in training, selection, or inexperienced?
Substance abuse
without mitigation
Sabotage, malevolent damage
Substance use
with mitigation
Possible reckless
violation
System induced
Possible negligent
behavior
error
Blameless error, corrective training, counseling indicated
Blameless error NO NO NO NO
YES NO
YES
YES
YES NO
YES
Known medical
condition? NO
YES
YES NO
YES
YES NO
This slide illustrates the Unsafe Acts Algorithm, which can be used by front line managers to operationalize just culture. Front line managers can use the algorithm as a guide for determining when to hold an individual accountable for a patient safety event and when to investigate latent causes of error within the system.
Culpable
Gray Area
Blameless
Adapted from James Reason. (1997). Managing the Risks of Organizational Accidents.

39. Just Culture Action Plan & Aims
We need to strengthen our JUST CULTURE because:
35% of all respondents DISagreed with the reverse-worded statement, “Staff worry that mistakes they make are kept in their personnel file.”
Comment: “There is a strong belief by some staff that errors are recorded and held against staff….”
We can do this by:
(1) educating all staff about the impact of human error on patient safety and the role of just and fair culture in patient safety program; (2) implementing the use of the Unsafe Acts Algorithm by all managers to transparently determine individual vs. system accountability in adverse events.

40. Action Planning A Flexible culture is engineered by implementing practices
“Could definitely use more TeamSTEPPS training. Some questions difficult to answer.”
“TeamSTEPPS has brought some very positive changes in the hospital…we do Huddle each morning before the hospital Huddle..”
“TeamSTEPPS training has changed the way I think about my job, and the communication processes in my department.”
“TeamSTEPPS and Service Excellence is working. Did create chaos for a short time.”
“I don't feel very comfortable with the TeamSTEPPS program. It’s a great program; we just haven't practiced using it enough to make us comfortable with all the strategies or tools.”
Team Strategies & Tools to Enhance Performance & Patient Safety
Psychologist James Reason states, “A flexible culture takes a number of forms, but in many cases it involves shifting from the conventional hierarchical mode to a flatter professional structure, where control passes to task experts on the spot, and then reverts back to the traditional bureaucratic mode once the emergency has passed.”
TeamSTEPPS stands for Team Strategies and Tools to Enhance Performance and Patient Safety. TeamSTEPPS is an evidence-based team training program developed by the Department of Defense and the Agency for Healthcare Research and Quality. It builds on 25 years of research on teams and team performance in high-risk areas such as aviation, the military, nuclear power, and healthcare in which poor performance may lead to serious consequences or death. TeamSTEPPS is designed to optimize team performance across the healthcare delivery system by focusing on specific skills supporting team performance that empowers ‘experts on the spot’ to ensure all have a shared mental model.

41. Flexible Action Plan & Aims
We improved/need to strengthen our FLEXIBLE (Teamwork-Oriented) CULTURE : 91% of acute/skilled respondents agree that they support one another; 71% help each other out when it gets busy 84% of all respondents agree they will speak up but only 53% will do so to those with more authority 23% of all respondents DISagreed with the reverse-worded statement, “Problems often occur in the exchange of information across hospital units.” We can continue to improve by: Ensuring consistent use of briefs, huddles, debriefs and seeking/offering task assistance within departments; use of the Two Challenge Rule and CUS to make it psychologically safe for staff to speak up to those with more authority; and use of structured communication during hand-offs and transitions (SBAR, I PASS the BATON) across hospital departments.

42. Action Planning: Reporting, Just, and Flexible practices support Learning
Practices/Tools
Individual RCA
Aggregate RCA
FMEA
Safety Briefings
Leadership WalkRoundsTM
Close the loop with reporting…feedback
Ultimately, the willingness of workers to report depends on their belief that the organization will analyze reported information and then implement appropriate change—organizational practices support a learning culture.
A learning culture takes action based on information about its systems. A learning culture is driven to improve through constant feedback about the successes and failures of its processes. The foundation of a learning culture is information systems…reporting. Ultimately, the willingness of workers to report depends on their belief that the organization will analyze reported information and then implement appropriate change—organizational practices support a learning culture. Root cause analysis, individual and aggregate, FMEA, Safety Briefings, and Leadership WalkRounds are the tools that organizations use to learn from their experience.

43. Learning Action Plan & Aims
We improved/need to strengthen our LEARNING CULTURE 61% of all respondents agree they are given feedback about changes put into place based upon event reports 70% agree that “Mistakes have led to positive changes here.” We can continue to improve by :(1) including front line staff in retrospective (root cause analysis) and prospective (failure mode and effect analysis) organizational learning, (2) conducting Leadership WalkRounds focused on proactive discussion of risks and hazards, (3) use of briefs, huddles, and debriefs in all departments to integrate organizational learning into daily work.

44. Response Shift Bias
Definition: tendency for an individual to overestimate their knowledge, skills, and behaviors in a pretest because their understanding of a concept is limited prior to the program intervention.
We have patient safety problems in this department. (73% before TS “shift” to 67% after)
(R)Problems often occur in the exchange of information across hospital departments. (45% before TS “shift” to 36% after)

45. Conclusion: HSOPS Guides Implementation of an Infrastructure for Patient Safety
Interaction between effective practices results in sensemaking
Sensemaking requires data, which is interpreted within the context of the experiences of those in direct contact with patients*
Sensemaking can not occur without data, trust and teamwork
Leaders drive sensemaking
*Battles et al. (2006). Sensemaking of patient safety risks and hazards. HSR, 41(4 Pt 2),
SENSEMAKING
TRUST 45 45

46. Shift Towards a Culture of Safety46

47. Lessons Learned Behaviors support an informed safe culture
Measure safety culture using appropriate survey and effective data collection methods
Create an infrastructure that supports reporting
Adhere to principles of just culture
Implement team training to support a flexible culture
Learn from error in the context of daily work (Safety Briefings and Leadership WalkRounds)
Teams must systematically learn from events using individual RCA and aggregate RCA to learn from multiple non-harmful errors

48. Lessons Learned Leaders manage culture or it manages them….
Create a compelling positive vision
Define the change goal as solving a performance problem…not “changing culture”
Provide formal training in groups
Ensure new behaviors lead to success, satisfaction
Provide opportunities for practice, coaching, feedback
Provide positive role models
Provide support groups for learning problems
Create structures consistent with new way of thinking/working/behaving
Culture impacts performance, focus on where the performance needs to be improved.
Create the motivation to change
Learn new concepts
Role models
Learning by doing
Internalize new concepts
Leaders must create, embed, manage culture or the culture will manage the leader.
Schein, E.H. Organizational Leadership and Culture 4th ed. San Francisco: John Wiley & Sons; 2010.

49. Diffusion of Innovations…
“Getting a new idea adopted, even when it has obvious advantages, is difficult. Many innovations require a lengthy period of many years from the time when they become available to the time when they are widely adopted.” – Rogers in Diffusion of Innovations, p. 1

50. The Responsibility of Leadership
“Our systems are too complex to expect merely extraordinary people to perform perfectly 100% of the time. We as leaders have a responsibility to put in place systems to support safe practice.”
James Conway,
former VP and COO Dana Farber Cancer Institute

51. Contact Information
Katherine Jones, PT, PhD Anne Skinner Web site where tools are posted