Re-measuring Safety Culture: The Follow-up HSOPS Survey Sallie Weaver, PhD Kristina Weeks, MSH, DrPH (c) Nasir Ismail, MS, PhD(c) ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY

Polling Question #1 What is your current role? Surgeon Quality improvement practitioner Infection preventionist OR nurse OR technician Anesthesiologist OR manager Other

Polling Question #2 Have you presented the HSOPS results to your unit staff/management? Yes No

Learning Objectives Describe the value of HSOPS data List steps to complete the HSOPS survey Increase HSOPS response rate Download and debrief HSOPS report

Can my hospital still take the survey if we have not completed a baseline survey? YES

When will the follow-up HSOPS survey be available for Cohort 1 and Cohort 2 teams? Survey period opens: July 1st, 2014 12noonEDT Survey period closes: September 3rd, 2014 5pmEDT

Today’s Agenda Why should you complete the HSOPS Survey? How do you complete the HSOPS survey? How can you increase the response rate? How do you download the HSOPS final report? Why should you debrief that report?

Why Should You Complete HSOPS Survey? Hospital Survey On Patient Safety Culture (HSOPS) Measures safety culture within the units of hospital What does Safety Culture mean? Perceived priority of safety relative to other goals Attitudes, beliefs, perceptions, and values related to safety within an organization

Core Aspects of Safety Culture1

Safety Culture Is Related To Outcomes2,3,4,5,6,7,8 Patient outcomes Patient care experience Infection rates, sepsis Postoperative hemorrhage Respiratory failure, accidental puncture / laceration Treatment errors Clinician outcomes Incident reporting Burnout and turnover

HSOPS Dimensions Supervisor / manager expectations and actions promoting patient safety Nonpunitive response to error Staffing Organizational learning- continuous improvement Hospital management support for patient safety Teamwork within unit Teamwork across hospital units Communication openness Hospital handoffs and transitions Feedback and communication about error

HSOPS Sample Questions 10 Composite Scores (“Dimensions”) Sample Question 1. Supervisor/manager expectations & actions promoting patient safety B1. My supervisor/manager seriously considers staff suggestions for improving patient safety. 2. Organizational learning-continuous improvement 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.

HSOPS Sample Questions 10 Composite Scores (“Dimensions”) Sample Question 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. Cooperation is good 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 Sample Questions 4 Outcome Variables Example Question 1. Overall perceptions of safety A15. Patient safety is never sacrificed to get more work done. 2. Frequency of event reporting 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) 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?

How Do You Complete The HSOPS Survey? OPTION 1 Collect the email addresses of all clinicians and staff (including physicians) that worked in the unit at least 3 months Enter email addresses into an Excel spreadsheet Upload the Excel spreadsheet file into the SUSP online portal https://armstrongresearch.hopkinsmedicine.org/susp.aspx

Contact susp@jhmi.edu for more information. How Do You Complete The HSOPS Survey? OPTION 2 Alternate Method: Work Area ID Some clinical areas prefer to submit surveys via a central pc located in within the unit Request a work area id Set up a workstation in the clinical area Instruct staff to use the provided link and ID Contact susp@jhmi.edu for more information.

HSOPS Response Rate Polling Question #3 What was your response rate on the initial HSOPS survey? 80-100% 60-80% 40-60% 20-40% 0-20% Unit did not complete 1st HSOPS survey What did you do to motivate team members to participate?

Set a goal Make a plan! Flyers & posters How Can You Increase The Response Rate? Set a goal Make a plan! Flyers & posters

Checking Response Rate & Getting Reports

HSOPS Reports

HSOPS Reports

Debrief survey results with all your team members What is Debriefing? Debrief survey results with all your team members Debriefing is a semi-structured conversation among frontline clinicians and staff that is usually led by a designated facilitator Encourages open communication, transparency, and interactive discussion across all levels of the work area between disciplines Engages clinicians and staff in generating and implementing their ideas about how to create an effective safety culture in their work area Slide. What is Debriefing? Say: Using your safety culture survey results means debriefing them with your work area team members and leaders.   Debriefing is a process. It refers to having a semi-structured conversation (or series of conversations) among frontline clinicians and staff that is usually led by a designated facilitator. The goal of debriefing your safety culture survey results is to encourage open communication, transparency, and interactive discussion about the survey results across all levels of your work area and between disciplines. Debriefing is really about using your safety culture data as a starting point to engage clinicians and staff in generating and implementing their ideas about how to create an effective safety culture in their work area. Encourages ownership that facilitates change management.

Work units that debrief around safety culture perform better Making HSOPS Data Meaningful Work units that debrief around safety culture perform better Data is data. Debriefing turns data into information. Debriefing accelerates improvement.9 Units who used semi-structured debriefing of culture survey achieved 10.2% Reduction in Infection Rates YES NO Units who did not debrief survey results achieved 2.2% Reduction in Infection Rates Slide. Making HSOPS Data Meaningful Say: Debriefing is important because it turns data into information and helps to accelerate improvement. It helps to address the adaptive work (e.g., improving teamwork, communication, and strengthening behavioral norms around new processes) that is critical to making technical changes (e.g., new care bundles or algorithms) stick.   Studies show that debriefing survey results matters for improvement. For example, a study of Rhode Island ICUs found that those teams who used a semi-structured method similar to the method we will share with you today to debrief their safety culture survey results reduced their infection rates by 10.2%. The teams who took a safety culture survey, but did not actively utilize their culture data also saw reductions, but they were much smaller. On average these teams only reduced their infection rates by 2.2%.

How do I use the CUSP culture check-up tool? Making HSOPS Data Meaningful How do I use the CUSP culture check-up tool? Share culture results with everyone on the unit during a survey debriefing Bring together team members from your work area Follow your debriefing plan Take notes and recognize recurring themes Encourage open, honest discussion about making the culture of your work area the best it can be Slide. Making HSOPS Data Meaningful - CUSP Culture Check-up Tool Say: The CUSP Culture Check-up Tool is available to help you debrief your safety culture survey results with all members of your team and leaders. The tool is designed to be used during a debriefing session or meeting or over the course of several sessions. It will help to provide focus, identify areas for potential improvement, and guide efforts to brainstorm improvement plans.   A debriefing facilitator, often someone external to the unit or work area, that takes notes and organizes recurring themes, uses this tool. The goal of these debriefings is to have open, honest discussion about ideas to make the culture of your work area the best it can be.

How do I use the CUSP culture check-up tool? Making HSOPS Data Meaningful How do I use the CUSP culture check-up tool? Focus on identifying system issues that the group can work on improving together instead of as individuals. Don’t use it to point fingers at specific individuals Use the tool to structure meetings and guide conversation. As a group, complete all steps in this worksheet. Slide. Making HSOPS Data Meaningful - CUSP Culture Check-up Tool Say: The Culture Check-up tool includes specific questions that the facilitator can ask in order to ensure that the focus is on identifying system issues that the group can work on improving together. The role of the debriefing facilitator is to help participants to complete all steps in the tool as a group and to keep conversation constructive.

HSOPS debriefings with CUSP culture check-up tool Making HSOPS Data Meaningful HSOPS debriefings with CUSP culture check-up tool What is the Purpose of this Tool? Understand the unit culture Use teammates’ feedback to predict and avoid barriers Use feedback to leverage the team’s strengths Who Should Use this Tool? Safety culture debriefing facilitators Helps to guide the discussion and record group decisions Slide. Making HSOPS Data Meaningful - Debriefings with the CUSP Culture Check-Up Tool Say: The purpose of the Culture Check-up Tool is to understand how team members currently perceive the culture of safety in their work area, to gain their insight into potential barriers to change and to make the most of current cultural strengths.   The tool is designed to be used by a designated safety culture debriefing facilitator whose role is to help guide these debriefing sessions, ensure that discussions are constructive, and record group decisions.

Steps in CUSP Culture Check-Up Tool Identifies general strengths and weaknesses of your unit culture Get specific about behaviors and attitudes that make up those strengths and weaknesses Select opportunities for growth Develop a strategy for addressing growth opportunities Put plan into action Evaluate results and share progress during SUSP team meetings Steps in the CUSP Culture Check-up Tool SAY: There are 6 key steps included in the Culture Check-up Tool. In step 1, the debriefing facilitator helps team members to identify the general cultural strengths and opportunities for improvement based upon your work area’s safety culture survey results. In steps 2 and 3, your team works collectively to identify the specific behaviors and attitudes that make up those strengths (i.e., what might we want to continue doing) and weaknesses (i.e., what may we want to stop doing). In step 3 in particular, the facilitator encourages group reflection using a series of questions included in the tool. Understand that cultural strengths can help fix cultural weaknesses. For example, after your team identifies a cultural area they would like to target for improvement, the facilitator will ask them to envision and describe what the unit or work area would look like if the culture was at 100% or if team members scored very highly in that area. In step 4, the team makes decisions about how they will get to the “ideal” culture that they described in Step 3. There are many tools and methods for improving your work areas culture of safety. AHRQ recommends creating ‘safety briefings’ – short updates for frontline teammates about patient safety issues in the work are. For more ideas, go to: http://www.ahrq.gov/qual/patientsafetyculture/hospimpdim.htm. In Step 5, the team works on laying out a specific strategy for implementing those changes or strategies identified in Step 4. Finally, in Step 6, the team evaluates progress on the culture improvement plans that they have identified as part of their team meetings moving forward. It can be helpful to include a discussion of efforts that the team is making to improve the culture of safety in their work area as a standing item that is discussed at every team meeting.

Tip: Download the Culture Check UpTool at Culture Check Up Tool is a document used by Debriefing Facilitator to guide conversation and improvement planning Download from the SUSP portal or the AHRQ website Slide. CUSP Culture Check-up Tool (-con’t) Say: The Culture Check-up Tool itself is a MS Word document that you can download from the AHRQ website. The first two pages, shown here, offer specific directions for how to use the tool. Tip: Download the Culture Check UpTool at https://armstrongresearch.hopkinsmedicine.org/susp.aspx www.ahrq.gov/professionals/education/curriculum- tools/cusptoolkit/toolkit/culturecheckup.html

Culture Check-up Tool https://armstrongresearch.hopkinsmedicine.org/susp

Culture Check up tool

Brainstorming culture discussion items Culture Check Up Tool Brainstorming culture discussion items Statement To Be Discussed Unit Safety Assessment Score % What does this statement mean to you? How accurately does the unit score reflect your experience on this unit? Share examples. How would it look (what behaviors or processes would we see) in this unit if 100% of staff responded “agree strongly” with this item? Identify at least one actionable idea to improve unit results in this area. What are the next steps and how will we accomplish them? Slide. CUSP Culture Check-up Tool (-con’t) Say: The third page of the tool is title “the culture item discussion form.” This page can actually be filled out by debriefing facilitators and includes specific questions that they can ask during the discussion to help team members brainstorm.

Debriefing Plan Highlights Decision Points For Project Team Debriefing Plan How many debriefing sessions will be held? Who will facilitate each debriefing session? When will debriefing(s) be held? Who is responsible for taking notes and recording ideas from each session? If you conduct more than one debriefing session, who is responsible for collating notes and ideas for improvement from the different sessions? How will the CUSP team ensure there is follow-up on the action items from the debriefing session(s)? Slide. Debriefing Plan Highlights Say: Before your team or your debriefing facilitator can use the Culture Check-up Tool, it is important for your team to make some decisions about your debriefing approach. It is important for as many clinicians and staff to participate in the survey debriefing process as possible. For many work areas, this may mean holding more than one survey debriefing discussion. As a team, it will be important to come to a consensus about several things, including: How many debriefing sessions will be held? How will you ensure evening or night clinicians and staff have an opportunity to participate? Who will facilitate each debriefing session? When will debriefings be held? Where will debriefings be held? Who is responsible for taking notes and recording ideas from each session? If you conduct more than one session, who is responsible for collating notes and ideas for improvement from the different sessions? How will the CUSP team ensure that there is follow-up on the action items or plans from the debriefing sessions?

What’s Next? Plan debriefing strategy to share results with team 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 Slide. What’s Next? Say: In summary, debriefing your safety culture survey results refers to having a semi-structured conversation about the survey results and brainstorming improvement ideas. It is a critical part of accelerating your team’s improvement efforts. As a team you will need to decide when, how, and where to debrief all members of your work area and your work area leadership. In these debriefing discussions it is critical that you set some ground rules. Some example ground rules include: all participants agree to be prepared to listen, to ask for feedback, and to be open to creative ideas. During these debriefings a facilitator can use the Culture Check-up Tool to help team members examine the roots of problem areas and begin to formulate strategies for improvement.

Where to find the old webinars? The link: https://armstrongresearch.hopkinsmedicine.org/susp

Cohort 1 & 2 Project End Date Project End August 31, 2014

Activities Still Open for Participation Affinity group calls SUSP webpage (webinars, toolkits, etc.) SUSP data portal HSOPS reports SSI reports Medconcert SUSP help desk (SUSP@jhmi.edu)

What Now? Does your hospital want to continue using the data portal to track your SSI data? Or rather, do you want Sept 2014- Aug 2015 SSI data to be entered into portal? If yes, contact your CE to confirm data will continue to be uploaded routinely If no, your CE will complete one final upload in February 2015 to complete the 2 years of project data Review the data manual on how to create SSI reports in NHSN and NSQIP SUSP generating reports using the SSI data registry Poll question- If your hospitals want to continue tracking are you (the CE) willing to continue uploading data routinely through Aug 2015?

Want To Continue Beyond August 2014? Does your hospital want to stay involved in SUSP activities (cohorts 3, 4 & 5 project calls, affinity groups, etc.) ? If yes, contact your CE and let them know your plans to continue your participation and which ones. Poll question: If your hospitals want to stay involved are you willing to continue sending the weekly update and other information?

Thank you for your willingness to participate and learn together on how to prevent surgical site infections. The journey continues….. Questions?

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