Challenges to Improving Safety at the Point of Care Building Infrastructure: Lessons Learned from Critical Access Hospitals Katherine Jones, PT, PhD And Team Supported by AHRQ Grant 1 U18 HS AHRQ Knowledge Transfer National Rural Health Association Nebraska Department of HHS AHRQ Annual Meeting Sept. 9, 2008

Objectives Knowledge: Patient safety infrastructure requires common knowledge of a theoretical framework to achieve sensemaking Skill: Assess culture and implement change; comply with Joint Commission Leadership Standards (LD ) Attitude: Believe that key safety culture practices create the infrastructure that organizations must use to support frontline workers who improve quality and keep patients safe

3 Critical Access Hospitals (CAHs) Limited to Limited to 25 inpatient beds 25 inpatient beds 96 hour average length of stay 96 hour average length of stay Receive cost- based reimbursement to maintain access to care in rural areas Receive cost- based reimbursement to maintain access to care in rural areas 1,289 CAHs concentrated in Midwest; ¼ of general community hospitals in US 1,289 CAHs concentrated in Midwest; ¼ of general community hospitals in US

4 What does a CAH look like?

5 Healthcare System Structures & Processes Organizational Structures & Processes Individual Provider Structures & Processes Quality at Point of Care Interpersonal Care Technical Care Chain of Impact at the 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 determines how 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, Culture

6 How can organizations effectively support providers at the point of care? AHRQ-supported research with Critical Access Hospitals (CAHs) provides evidence consistent with Dr. Clancy’s message: “How to translate research into improvement:” AHRQ-supported research with Critical Access Hospitals (CAHs) provides evidence consistent with Dr. Clancy’s message: “How to translate research into improvement:” Infrastructure Infrastructure Capacity Capacity Incentives Incentives Implementing a Program of Patient Safety in Small Rural Hospitals Implementing a Program of Patient Safety in Small Rural Hospitals Evaluating the Effect of TeamSTEPPS TM Training on the Culture of Safety in Critical Access Hospitals Evaluating the Effect of TeamSTEPPS TM Training on the Culture of Safety in Critical Access Hospitals

7 Implementing a Program of Patient Safety in Small Rural Hospitals One of 17 AHRQ PIPs grants funded 7/05 – 6/07 (AHRQ Grant 1 U18 HS015822) Purpose: To implement the patient safety practices of voluntary medication error reporting and organizational learning in 24 Critical Access Hospitals. Aim 1: Develop the organizational infrastructure for reporting and analyzing medication errors that is needed to identify system sources of error.

8 Evaluating the Effect of TeamSTEPPS TM Training on the Culture of Safety in Critical Access Hospitals Funding through AHRQ and Nebraska DHHS Purpose: To implement the patient safety practice of teamwork and communication training in 25 Critical Access Hospitals. Aim 1: Evaluate the impact of the TeamSTEPPS training program on safety culture using the rural- adapted version of the AHRQ Hospital Survey on Patient Safety Culture.

9 The Components of an Effective Patient Safety System* The components are: (1) monitoring progress/maintaining vigilance, (2) knowledge of epidemiology of patient safety risks and hazards, (3) development of effective practices and tools, (4) building infrastructure for effective practices, and (5) achieving broader adoption of effective practices *Farley DO, Damberg CL, Ridgely MS, et al. Assessment of the AHRQ patient safety initiative final report—Evaluation report IV. Rand Organization; 2008 Technical Report No

10 Phase One: Reporting in an Effective Patient Safety System Four CAHs in Nebraska sought help from UNMC to make sense of their medication errors. 1. Understand the epidemiology of medication errors 2. Develop effective tools: process maps, reporting forms, database 3. Monitor progress: benchmarking reports and assistance to manage process change 4. AHRQ funding supported an infrastructure—subscriptions to MEDMARX,, education about disclosure of errors, just culture, root cause analysis 5. AHRQ funding enabled broader adoption of these practices across 35 CAHs in three states 1. Knowledge of Epidemiology of Medication Errors 2. Tool: Process Maps Forms, Database 3. Monitor Progress: Benchmarking reports, Change management 4. Building Infrastructure: 14 CAHs report to MEDMARX, Safety culture education 5. Achieving Broader Adoption: 35 CAHs report to MEDMARX, Ongoing NCPS RCA education

11 Sensemaking Tools From PIPS Grant: Process map, Reporting Form

12 Sensemaking Tools From PIPS Grant: Transform data into information

13 Phase Two: Assessing Progress in an Effective Patient Safety System Second action research cycle of our PIPS Grant 1. Knowledge that reporting is the foundation of a culture of safety; working definition 2. Need an effective tool to assess culture 3. Monitor progress and assess change in culture due to reporting infrastructure 4. Build rural quality improvement infrastructure by adapting HSOPS to the rural environment 5. Achieved broader adoption of rural-adapted version of HSOPS by disseminating it to QIOs and contracting with the National Rural Health Association 1. Knowledge: working definition, role of culture in patient safety 2. Tools: AHRQ HSOPS using Dillman tailored design method, Benchmark Graphs, Unsafe Acts Algorithm 3. Monitor Progress: Assess change in culture due to practices 4. Building Infrastructure: Rural adaptation of HSOPS to assess rural microcultures 5. Achieving Broader Adoption: PIPS TOOLKIT, Develop service to conduct HSOPS in CAHs for NRHA

Working Definition of Safety Culture Enduring, shared beliefs and behaviors that reflect an organization’s willingness to learn from errors* Three 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 *Wiegmann. A synthesis of safety culture and safety climate research; **Institute of Medicine. Patient safety: Achieving a new standard of care. Washington, DC: The National Academies Press; 2004.

15 What are the components of safety culture? Reporting – staff report their errors Reporting – staff report their errors Just – reporting is rewarded, clear line between acceptable & unacceptable behavior Just – reporting is rewarded, clear line between acceptable & unacceptable behavior Flexible – authority patterns relax when safety information is exchanged Flexible – authority patterns relax when safety information is exchanged Learning – action is taken based on safety information systems Learning – action is taken based on safety information systems Reason, J. Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited; 1997.

16 How can organizations effectively support providers at the point of care? Use the AHRQ Hospital Survey on Patient Safety Culture (HSOSPS) to identify and monitor impairments in organizational learning at the level of units/departments and staff positions Use the AHRQ Hospital Survey on Patient Safety Culture (HSOSPS) to identify and monitor impairments in organizational learning at the level of units/departments and staff positions Implement effective practices within each of the four components of a safe culture that address impairments within microsystems Implement effective practices within each of the four components of a safe culture that address impairments within microsystems Ensure interactions between the practices to engineer an infrastructure—a culture—that supports organizational learning Ensure interactions between the practices to engineer an infrastructure—a culture—that supports organizational learning

17 How does HSOPS identify impairments in organizational learning? HOSPS measures staff perceptions of the beliefs and behaviors that support a safe culture HOSPS measures staff perceptions of the beliefs and behaviors that support a safe culture HSOPS is a valid, reliable instrument comprised of 51 items categorized in 12 dimensions HSOPS is a valid, reliable instrument comprised of 51 items categorized in 12 dimensions 12 dimensions reflect the four components of an informed, safe culture 12 dimensions reflect the four components of an informed, safe culture A tool to evaluate, plan, reevaluate patient safety programs; A tool to evaluate, plan, reevaluate patient safety programs; Small rural hospitals require support to use it effectively Small rural hospitals require support to use it effectively Nieva, Sorra. (2003). Safety culture assessment: a tool for improving patient safety in healthcare organizations. Qual Saf Health Care, 12(Suppl II), ii17-ii23. Jones, Skinner, Xu, Sun, Mueller. The AHRQ Hospital Survey on Patient Safety Culture: a tool to plan and evaluate patient safety programs. In Henriksen et al., Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 2. Culture and Redesign. AHRQ Publication No Rockville, MD: Agency for Healthcare Research and Quality; August 2008.

18 Benchmark HSOPS Graph of Aggregate Hospital Results

19 HSOPS Graph Comparing Nurse to Aggregate Hospital Results

20 Benchmark HSOPS Graph of Aggregate Results 2005 and 2007

21 Interactions Between Components HSOPS Items: Nurses at Dundy County Hospital 2005 and 2007 %+ 05 %+ 07 Effective Practices Outcome: Our procedures, systems are good at preventing errors. 31% 3%High Reliability Organization Learning: We are given feedback about changes put into place based on event reports. 44%72%QI, RCA, Leadership Walkrounds TM, Safety Briefings Flexible: Staff feel free to question the decisions and actions of those with more authority. 13%50%Structured Communication skills: SBAR, CUS, DESC Just: When an event is reported, it feels like the person is being reported and not the problem. 31%50%Education about human error, Unsafe Acts Algorithm Reporting: When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported. 25%65%Systematic reporting system using standard taxonomies

Known medical condition? NO YES NO YES NO YES NO YES NO Adapted from James Reason. (1997). Managing the Risks of Organizational Accidents. CulpableGray AreaBlameless NO 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 as intended? 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 violation Possible negligent behavior System induced error Blameless error, corrective training, counseling indicated Blameless error NO CulpableGray AreaBlameless NO 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 as intended? 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 violation Possible negligent behavior System induced error Blameless error, corrective training, counseling indicated Blameless error NO Execute Just Culture... UNSAFE ACTS ALGORITHM click on Just Culture

23 Phase Three: Integrating Team Training in an Effective Patient Safety System Third action research cycle 1. Knowledge that a culture of safety in high reliability organizations is engineered from interacting practices of the four components of culture within microsystems (units/positions) 2. HSOPS results indicated the need for training in teamwork and communication. 3. We conducted the train the trainer course in 25 CAHs in April 2008; will add 7 more in We are building a community of TeamSTEPPS coaches/trainers across the state 5. We will reassess safety culture in 25 CAHs in March Knowledge that a culture of safety is engineered from interacting practices 2. Tool: TeamSTEPPS TM 5. Monitor Progress: Reassess change in culture March Building Infrastructure: Creating a rural TeamSTEPPS community 3. Achieving Broader Adoption: Train the trainer in 25 CAHs

24 HSOPS Identifies Readiness for Teamwork Training TeamSTEPPS training must be supported by systematic error reporting, just culture practices, and use of learning tools such as individual and aggregate RCA, Leadership WalkRounds, and Safety Briefings

25 SENSEMAKINGSENSEMAKING TRUSTTRUST Conclusion: Infrastructure for Effective Practices Interaction between effective practices results in sensemaking within macro- and microsystems of care 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 from reporting, trust and teamwork

“Once the AHRQ survey identified areas for improvement, through the grant, we spent the next year working on those areas. The education and training on teamwork, communication, and RCA gave us tools we hadn’t heard of. We have seen our organization change from one that makes the same errors over and over to one that analyzes errors and attempts to learn from them.” Infrastructure: Lessons Learned from Dundy County, Nebraska

27 Rural Adaptation of HSOPS Original HSOPS designed for large urban hospitals Original HSOPS designed for large urban hospitals 14 different work areas 14 different work areas 14 different staff positions 14 different staff positions Sort by work area or position if > 11 Sort by work area or position if > 11 Rural-adapted HSOPS for hospitals with < 50 beds Rural-adapted HSOPS for hospitals with < 50 beds 12 different work areas - 12% choose “other” 12 different work areas - 12% choose “other” Collapsed multiple departments to Acute/Skilled Care Collapsed multiple departments to Acute/Skilled Care Added Long-term care, Home Health Care, Therapies Added Long-term care, Home Health Care, Therapies 6 different job titles - 8% choose “other” 6 different job titles - 8% choose “other” Sort by work area or job title if > 5 Sort by work area or job title if > 5 1/3 in national database choose “other”

28 Original AHRQ HSOPS Work Area Demographics Rural-Adapted HSOPS Work Area Demographics 2008 Comparative Database Report: 33% of 160,196 respondents choose “other” UNMC CAH Comparative Database: 12% of 4,117 respondents choose “other” Rural Adaptation of HSOPS

Comparative Database Report: 22% of 160,196 respondents choose “other” UNMC CAH Comparative Database: 8% of 4,117 respondents choose “other” Original AHRQ HSOPS Staff Position Demographics Rural-Adapted HSOPS Staff Position Demographics Rural Adaptation of HSOPS

30 Where can I get the HSOPS? Original HSOPS From the AHRQ website Original HSOPS From the AHRQ website Click on Hospital Survey Toolkit Hospital Survey ToolkitHospital Survey Toolkit Rural-adapted version for CAHs with 25 or fewer beds from UNMC web site (see our poster in the mAHRQet Place Café ) Rural-adapted version for CAHs with 25 or fewer beds from UNMC web site (see our poster in the mAHRQet Place Café ) Click on Hospital Survey on Patient Safety Culture Resources Hospital Survey on Patient Safety Culture Resources Contact information Katherine Jones, PT, PhDAnne Skinner, RHIA

31 Contact Information Katherine Jones, PhD, PT Anne Skinner Web site where tools are posted Supported by AHRQ Grant 1 U18 HS National Rural Health Association Nebraska Department of HHS