Have Safety Culture Data, Will Travel? Sallie J. Weaver, PhD Assistant Professor Dept. of Anesthesiology & Critical Care Medicine, and Armstrong Institute for Patient Safety & Quality

Armstrong Institute for Patient Safety and Quality Roadmap What is patient safety culture? Why does it matter? I have data….but now what? Some food for thought regarding acting on data Armstrong Institute for Patient Safety and Quality

Sounding the Call for a Culture of Safety “Health care organizations must develop a culture of safety such that an organization’s care processes and workforce are focused on improving the reliability and safety of care for patients” Joint Commission Leadership Standard: Leaders create and maintain a culture of safety and quality throughout their organization NQF Safe Practice #2 Culture measurement, feedback, and intervention -While there were efforts to focus on culture in healthcare prior to 1999, the call to develop a culture of safety throughout the healthcare community was sounded most clearly in the seminal IOM report, To Err is Human. -The seminal IOM further articulated that “Safety should be an explicit organizational goal…demonstrated by strong direction and involvement of governance, management and clinical leadership” -The notion of safety culture has since been integrated into the Joint Commission Leadership standards and the NQF safe practices. -These calls to develop a culture of patient safety throughout all patient care environments Armstrong Institute for Patient Safety and Quality

The Armstrong Institute Model to Improve Care Comprehensive Unit based Safety Program (CUSP) Educate staff on science of safety Identify defects Recruit executive to adopt unit Learn from one defect per quarter Implement teamwork tools Translating Evidence Into Practice (TRiP) Summarize the evidence in a checklist Identify local barriers to implementation Measure performance Ensure all patients get the evidence Engage Educate Execute Evaluate Reducing preventable patient harm Emerging Evidence Local Opportunities to Improve Collaborative learning Pre-Work: Measure clinician and staff perceptions of safety culture (HSOPS Survey) Technical Work Adaptive Work

-Patient & Family Safety What is Safety Culture? Culture Behavior on the Job Outcomes -Patient & Family Safety - Care Provider Safety Perceived priority of safety relative to other goals Culture is the compass team members use to guide their behaviors, attitudes, & perceptions on the job What will I get praised for? What will I get reprimanded for? What is the “right” thing to do? Learned, shared, tacit assumptions among members of a meaningful social group Lens through which “reality” is viewed Colors perceptions of what is and what should be Continuously evolving --Balance positive and negative…highlight “right” Armstrong Institute for Patient Safety and Quality

What Are Core Aspects of Safety Culture… Culture of Safety Communication patterns & language Feedback, reward, and corrective action practices Formal and informal leader actions & expectations Teamwork processes (e.g., back-up behavior) Resource allocation practices Error-detection and correction systems -The notion of “bad” culture or “good” culture is somewhat of a myth. -As a multidimensional construct, there are several different things that contribute to culture…therefore, it is not that the entire culture is necessarily bad or good, rather that particular components may be areas of strength or may have room for improvement -When going through culture survey results then it is important to identify dimensions that are strong as well as those that need improvement in order to identify and leverage strengths to improve areas that need work. Armstrong Institute for Patient Safety and Quality

Why Safety Culture Matters Safety culture is related to outcomes Patient outcomes Patient care experience Infection rates, sepsis Postop. hemorrhage, respiratory failure, accidental puncture/laceration Treatment errors Clinician outcomes Incident reporting, burnout, turnover Safety culture influences the effectiveness of other safety and quality interventions Can enhance or inhibit effects of other interventions Safety culture can change through intervention Best evidence so far for culture interventions that use multiple components 1. Mardon et al., 2010; Weaver, 2011; MacDavitt et al., 2007; Singer et al., 2009; Sexton et al., 2011 2. Haynes et al., 2011; Van Nord et al., 2010 3. Weaver et a., in press Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality CUSP & Safety Culture Safety Culture is typically measured “Pre- CUSP”: Before interventions begin Provides a baseline to diagnose barriers and facilitators that can impact improvement efforts Then can be measured 12-18 months following start of improvement efforts Use reliable and valid survey instrument Hospital Survey on Patient Safety (HSOPS) CUSP is the intervention that you will use to help you improve culture results Armstrong Institute for Patient Safety and Quality

I have my daTa…but now what? Part II I have my daTa…but now what?

Armstrong Institute for Patient Safety and Quality Prepare your Elevator Speech: What is the Hospital Survey on Patient Safety (HSOPS)? Suite of survey tools = SOPS Hospital Medical office Nursing home Background & Frame of Reference: Sponsored by: Agency for Healthcare Research & Quality US federal agency charged with conducting and supporting research to improve patient safety and care quality Developed by Westat, public release in 2004 Participants are asked to choose 1 to 5 for each question: 1 Strongly Disagree 2 Disagree 3 Neither Agree nor Disagree 4 Agree 5Strongly Agree 1 Never 2 Rarely 3 Sometimes 4 Most of the time 5 Always Armstrong Institute for Patient Safety and Quality

HSOPS Questions & Composite Scores (“Dimensions”) Number of Questions Example Question 1. Supervisor/manager expectations & actions promoting patient safety 4 B1. My supervisor/manager seriously considers staff suggestions for improving patient safety. 2. Organizational learning-continuous improvement 3 A9. Mistakes have led to positive changes here 3. Teamwork within unit A1. People support one another in this unit. 4. Communication openness C4. Staff feel free to question the decisions or actions of those with more authority. 5. Feedback & communication about error C1. We are given feedback about changes put into place based on event reports. 6. Nonpunitive response to error A8. Staff feel like their mistakes are held against them. (negatively worded) Staffing A2. We have enough staff to handle the workload. Hospital management support for patient safety F8. The actions of hospital management show that patient safety is a top priority. Teamwork across hospital units F4.There is good cooperation among hospital units that need to work together. Hospital handoffs & transitions F5.Important patient care information is often lost during shift changes. (negatively worded)

HSOPS Questions & Composite Scores –continued- 4 Outcome variables Number of Questions Example Question 1. Overall perceptions of safety 4 A15. Patient safety is never sacrificed to get more work done. 2. Frequency of event reporting 3 D1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported? 3. Patient safety grade (of hospital unit) 1 E1. Please give your work area/unit in this hospital an overall grade on patient safety. 4. Number of events reported in the last 12 months G1. In the past 12 months, how many event reports have you filled out and submitted? Plus background questions about respondents Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality HSOPS Scoring Scoring guidelines created by AHRQ Scores represent the % of positive responses % who gave a score of 4 or 5 1 Strongly Disagree 2 Disagree 3 Neither Agree nor Disagree 4 Agree 5Strongly Agree 1 Never 2 Rarely 3 Sometimes 4 Most of the time 5 Always Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Your medical center Your medical center Your medical center Your medical center Your medical center Your medical center Your medical center Your medical center Your medical center Interpreting Composite Scores: The big picture view Higher is better Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Questions provide a deeper dive: For positively worded items, more green is better 15 Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Your medical center Your medical center Your medical center Your medical center Your medical center Your medical center Your medical center Your medical center Your medical center Interpreting Composite Scores: The big picture view Higher is better Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Questions provide a deeper dive: For negatively worded items, more RED is better Armstrong Institute for Patient Safety and Quality

Next Steps: Creating a Debriefing Plan Debriefing is… A semi-structured conversation among frontline clinicians and staff that is usually led by a designated facilitator Purpose… Encourage open communication, transparency, and interactive discussion about the survey results Across all levels To engage clinicians and staff in generating and implementing their ideas about how to create an effective safety culture in their work area Armstrong Institute for Patient Safety and Quality

Some points to cover in your debriefing plan Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Keep in mind…Culture Change can seem Hard Because Culture has Three Layers… (Schein, 2010; Scorzoni, 1982) Behaviors, norms, processes enacted on the job, feedback & reward systems Espoused values, goals, philosophies, formal policies -One the pitfalls of developing a culture of safety is to oversimplify it. For example, “the way we do things around here” has become a popular definition for the concept of safety culture. This is indeed one manifestation of culture, but it completely misses the definition of culture in terms of where culture matters according to Edgar Schein, one of the leading organizational scholars on organizational culture from MIT Sloan School of Business. -Conceptualizing culture in terms of three layers using lily example: -Flower: cultural artifacts…the behaviors, norms, structures, reward and punishment systems that are most easily perceived -Stem (under water): Espoused values….strategies, goals, and espoused justifications (what articulate in terms of why we do what we do) -Roots (under water, under soil): Underlying assumptions…unconscious beliefs we take for granted, perceptions, thoughts, feelings Underlying assumptions Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Keep in mind…Culture Change can seem Hard Because Culture has Three Layers… (Schein, 2010; Scorzoni, 1982) Behaviors, norms, processes enacted on the job Safety climate surveys focus diagnostic measurement here Espoused values, goals, philosophies, formal polices The differentiation between culture and climate is easier to understand when culture is defined in terms of layers. Each of the underlying layers helps to account for higher layers and underlying layers can help to explain why higher levels exist as they do Underlying assumptions Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Keep in mind…Culture Change can seem Hard Because Culture has Three Layers… (Schein, 2010; Scorzoni, 1982) Behaviors, norms, processes enacted on the job Espoused values, goals, philosophies, formal policies -Can get at underlying assumptions by identifying inconsistencies and conflicts between overt behaviors, enacted procedures and practices and espoused values, goals -For example, if your unit espouses an open door policy or a policy to speak up, but whistleblowers or others who bring up glitches are not listened to, not taken seriously, or informally punished in some way (e.g., ignored, labeled by colleagues)…than this suggests that at the deeper level of underlying assumptions that only positive communications are valued and that if you cannot solve the problem your self than you should not bring it up Deeper levels addressed by: Debriefing Involvement of unit members Leaders who model the values and align assumptions Underlying assumptions Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality Culture Change Can Seem Hard Because it Involves both Unlearning and Re-Learning Unfreeze Learn & Rebalance Refreeze There are three steps in Lewin's model. The first step is "unfreezing," which involves dismantling those things that support or maintain the previous behavior. In an organization, these elements of the old could be the compensation system or the approach to performance management. In the second step, the organization "presents a new alternative." This means introducing a clear and appealing option for a new pattern of behavior. The final step in this model is "freezing" which requires that changed behavior be reinforced both formally and informally in the organization. It is in this step that managers can have a great amount of influence through their use of positive reinforcement. Lewin's model does not explicitly state the notion that simply introducing change will result in the change being adopted or being sustained over the long run. If an attempt to create change in the organization is unsuccessful, it means that there is a problem in one of the three steps in the model. Lewin, 1951; Schein, 2009 Armstrong Institute for Patient Safety and Quality

Changing Culture in Practice: National CLABSI Project Example Baseline HSOPS survey Target non-punitive response to error What did they do? Clarified the language and definitions of events, errors, glitches with all unit clinicians & staff Education campaign to define and differentiate process errors (e.g., expected behavior not clear, not known) from intentional violations Created shared mental model about expected safety behavior, as well as what to report, when, and when/how to follow-up Follow up…hot off the presses! Non-punitive response, communication openness, supervisor support Armstrong Institute for Patient Safety and Quality

Armstrong Institute for Patient Safety and Quality In Sum Review the survey report for your unit Can be helpful to distill the report down into 3-5 key slides Decide when, how, and where to debrief your teammates (and leaders) on these results Be prepared to listen Ask for feedback Ask teammates to help come up with solutions Gather a small group together and use the “culture debriefing tool” to examine the roots of problem areas and begin to formulate strategies for improvement Next call with Jill Marsteller & Mike Rosen Aug 9 Armstrong Institute for Patient Safety and Quality

Thank you! Sallie J. Weaver, PhD ACCM, and Armstrong Institute for Patient Safety and Quality Sjweaver@jhu.edu