1. 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

2. 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

3. 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

4. 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

5. -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”
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6. 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

7. 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
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8. 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 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

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

10. 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

11. 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.
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)

12. 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
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13. 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
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14. 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
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15. 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

16. 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

17. Armstrong Institute for Patient Safety and Quality
Questions provide a deeper dive:
For negatively worded items, more RED is better
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18. 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
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19. Some points to cover in your debriefing plan
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20. 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
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21. 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

22. 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
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23. 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
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24. 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
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25. 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

26. Thank you! Sallie J. Weaver, PhD ACCM, and
Armstrong Institute for Patient Safety and Quality