What Factors Influence Learning from PSEs?

1. What Factors Influence Learning from PSEs? Research Team: Liane Ginsburg, You-Ta Chuang Peter Norton, Whitney Berta, Deborah Tregunno, Peggy Ng and Julia Richardson

2. Learning in Context of Patient Safety • Learning from Patient Safety Events: • Identification & reporting of patient safety events • Analysis of the causes of these events, and • Taking appropriate corrective action to reduce reoccurrence of these events in the future

3. What we have known from our study Five factors influenced sampled 49 hospitals engaging in learning activities following PSEs • 1. Types of PSEs • 2. Patient safety culture • Organizational leadership for patient safety • Fear of repercussion • 3. Patient safety training • 4. Inter-organizational linkages • 5. Ease of reporting

4. 1. Types of Patient Safety Events • Major events • Event analysis • Dissemination of analysis and knowledge • Moderate events • Minor events • Major near misses • Differential learning responses among PSEs • Saliency, limited resource capacity

5. Event Types

6. Quick comparison

7. 2. Effects of Patient Safety Culture • Organizational leadership for patient safety • The degree of shared beliefs about senior management’s commitment to improve patient safety and quality of care • Example of 7 items: • Senior management has a clear picture of the risk associated with patient care • Fear of repercussion • A collective perception of potential negative reactions by others to patient safety failure events • Example of 4 items: • I will suffer negative consequences if I report a patient safety problem

8. Organizational leadership for patient safety

9. Fear of repercussion

10. 3. Effects of Patient Safety Training • Learning from experience depends upon learning capacity • Training is an avenue to improve learning capacity • Training has been found to be positively associated with organizational performance • Manager’s patient safety training • Promote “right” attitude toward patient safety failure • Help subordinates deal with patient safety failure • Items in the PCM survey • Receiving a formal quality/process improvement training program • Receiving a formal patient safety training program • Attending patient safety conferences

11. Effects of patient safety training

12. 4. Effects of Inter-organizational Linkages • Inter-organizational linkages facilitate information and experience transfer; as such they help organizations learn from others’ experiences. • Item in the PSO survey: • Please list the hospitals/organizations you frequently engage in discussion or information sharing regarding patient safety • The linkages tend to be: • Nearby hospitals/Teaching hospitals • Professional associations: Ontario Healthcare Risk Management Network, Safer Healthcare Now!, Quality Healthcare Network, Canadian Patient Safety Institute • Mean: 3 hospitals/organizations, min=0, max=10

14. Effects of interorganizational linkages

15. 5. Ease of reporting • Theoretically, ease of reporting systems should have positive effects on learning responses to PSEs • However, the effects are complicated – the effects are influenced by fear of repercussion

16. Moderate events

17. Minor events

18. Summary/Implications • Factors at organizational level influence learning from PSEs • Organizational leadership, fear of repercussion, training, inter-organizational linkages, and ease of report systems • These factors greatly influence learning from • Major event dissemination moderate events, minor events, and near misses • To improve patient safety, management may want to consider • Foster patient safety culture, provide training opportunities, and share information with other hospitals

19. Next Steps Unit-Level Factors Span of control Unit leadership Inter-unit linkage Group diversity Group norms Level of response to PLE Perceived PLE Characteristics Unit Salience Organization-Level Factors Leadership Safety Culture Org size Organization Inter-organizational networks Inter-organizational-Level Factors

20. Next Step • File out USB keys • Please leave mailing addresses with us • Pilot of unit-level learning • THANK YOU!