Connecting the Dots: Improving Unit Safety Culture to Stop HAI

1. Connecting the Dots: Improving Unit Safety Culture to Stop HAI Katherine J. Jones, PT, PhD University of Nebraska Medical Center

2. Supported By • AHRQ Partnerships in Implementing Patient Safety Grants (1 U18 HS015822, 1R18HS021429) The content is solely the responsibility of the author and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. • National Rural Health Association • Nebraska Department of Health and Human Services • AHRQ Office of Communications and Knowledge Transfer • Hospitals in Nebraska, Iowa, Louisiana, Washington, Oregon, Alaska

3. Learning Objectives • Define safety culture • Describe how to measure safety culture • Explain the relationship between prevention and healthcare-associated infections and safety culture

4. What is Safety Culture • Definition • Role of Organizational Culture • Categories of Culture • 3 Levels of Culture • 4 Components of Culture

5. Definition of Safety Culture • Enduring, shared, LEARNED1 beliefs and behaviors that reflect an organization’s willingness to learn from errors2 • Four beliefs present in a safe, informed culture3 • 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 taking • People who work in teams make fewer errors

6. The Role of Organizational Culture Safety Culture4 • A cross cutting contextual factor • Moderates effectiveness of patient safety interventions • Associated with adverse events and patient satisfaction Organizational Culture1 • Allows us to make sense of environment • Reflects common language… is heard and observed • Leaders create/teach culture • Share information • Reward, provide feedback • Hold people accountable

7. Negative Correlation: HSOPS and Patient Safety Events5 Higher HSOPS scores are associated with fewer adverse events, which validates patient safety culture assessment as a meaningful indication of the safety of patients.

8. Positive Correlation: HSOPS and Patient Satisfaction6 “….behaviors and attitudes [of hospital employees] can directly affect the pain, discomfort, health, and recovery of patients.”

9. Categories of Culture1 • Macroculture • Organizational Culture • Subculture • Microculture

10. Three Levels of Organizational Culture1 “…values reflect desired behavior but are not reflected in observed behavior.” (Schein, 2010, pp. 24, 27)

11. Four Components of Safety Culture7 • Reporting Culture • Just Culture • Flexible (Teamwork) Culture • Learning Culture • Effective reporting and just cultures create atmosphere of trust • Sensemaking8 of patient safety events and high reliability result from an explicit plan to engineer behaviors from each component of safety culture

12. Action Plan Measure Beliefs and Behaviors Implement Practices Continuous Quality Improvement HROs Engage in Continuous Improvement We can not change what we do not measure!

13. How Do you Measure Safety Culture?1 • Qualitative • Focus Groups • Structured Interviews • Observation • Quantitative Survey Tools…use best tool for your setting • Goals of assessment

14. Goals of Culture Assessment 1,9,10 • Identify areas of culture in need of improvement • Identify impairments in organizational learning • Increase awareness of patient safety concepts • Evaluate effectiveness of patient safety interventions over time • Conduct internal and external benchmarking, • Meet regulatory requirements • Identify gaps between beliefs and observed behaviors within subcultures and microcultures

15. When Should you Measure Safety Culture?11 • Baseline prior to patient safety intervention • 12 – 24 month intervals to monitor change over time

16. Hospital Survey on Patient Safety Culture12 • Survey tool kit available http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm • Comparative Database for Benchmarking http://www.ahrq.gov/qual/hospsurvey12/ • 1,128 hospitals; 567,703 respondents in 2012 database • 42 items categorized in 12 composites/dimensions • 9 dimensions measure culture at dept/unit level • 3 dimensions measure culture at hospital level • 2 additional outcome measures at dept/unit level (Patient Safety Grade, Number of Events Reported) • Comments

17. How Do you Interpret HSOPS Results? • Reason’s Components of Safety Culture7 • Identify unit-wide areas in need of improvement • Conduct external benchmarking9 • State Averages • National Database ICU • Conduct internal benchmarking9 • Nurse vs. Non-nurse (professional subcultures) • Understand Reverse-worded Items • Identify beliefs & behaviors in composites1

18. Crosswalk Reason’s Components7 Reason’s Components4 Reporting Culture – a safe organization is dependent on the willingness of front-line workers to report their errors and near-misses Just Culture – management will support and reward reporting; discipline occurs based on risk-taking HSOPS Dimension or Outcome Measure • Frequency of Events Reported (U) • Number of Events Reported (O) • Nonpunitive Response to Error (U) O=Outcome Measure, U=Unit, H=Hospital

19. Crosswalk Reason’s Components7 Reason’s Components4 Flexible Culture - authority patterns relax when safety information is exchanged because those with authority respect the knowledge of front-line workers Learning Culture - organization will analyze reported information and then implement appropriate change HSOPS Dimension or Outcome Measure • Teamwork w/in Units (U) • Staffing (U) • Communication Openness (U) • Teamwork ax Units (H) • Hospital Handoffs (H) • Hospital Mgt. Support (H) • Manager Actions (U) • Feedback & Communication (U) • Organizational Learning (U) • Overall Perceptions (U) • Patient Safety Grade (O, U)

20. Unit-Wide Areas in Need of Improvement • Below State or National average • Less than 75% positive • Large “gap” between beliefs and behaviors within the composites

21. External Benchmarking

22. Internal Benchmarking

23. Reverse-Worded Items • Score reported is “percent positive” • Percentage of responses rated 4 or 5 (Agree/Strongly agree or Most of the Time/Always) for positively-worded items, or 1 or 2 (Disagree/Strongly Disagree or Rarely/Never) for reverse-worded items • Positive is positive for patient safety, higher score better • We work in “crisis mode” trying to do too much, too quickly. (A14R) • 8 of 12 composites have at least 1 reverse-worded item • 2 Composites all items reverse-worded • Handoffs & Transitions • Nonpunitive Response to Error

24. Reporting Culture Frequency of Events Reported Three items elicit perceptions of reporting BEHAVIOR.

25. Action Planning: Interventions Support Reporting Successful reporting systems13 Nonpunitive Confidential Independent Expert analysis Timely Systems-oriented Responsive Formal Reporting of adverse events with standardized taxonomies (e.g. National Coordinating Council for Medication Error Reporting and Prevention A – I Error Severity Taxonomy) Near misses are frequently reported, valued, and learned from using anonymous log Non-harmful errors that reach the patient are frequently reported, valued, and learned from Informal Reporting – Safety Briefings14 Informal Reporting – Leadership WalkRounds,15Leveraging Frontline Expertise16

26. Just Culture Non-punitive Response to Error Three items elicit perceptions of response to error. Last item “R3. Staff worry that mistakes they make are kept in their personnel file.”…always least positive.

27. Action Planning: Interventions to Support Just Culture • Understand human error,7 human factors • Active errors (sharp end) • Latent errors • Just Culture and behavior17-19 • Conduct: human error, negligence, reckless, intentional rule violation • Disciplinary decision-making: outcome-based, rule-based, risk-based • Unsafe Acts Algorithm7 • Disruptive Behavior Policy/Standards20

28. Pass substitution test? (Could someone else have done the same thing)? Were the actions as intended? Evidence of illness or substance use? Knowingly violated safe procedures? History of unsafe acts? NO Were procedures available, workable, intelligible, correct and routinely used? Were the consequences as intended? Deficiencies in training, selection, or inexperienced? Blameless error Blameless error, corrective training, counseling indicated Substance abuse without mitigation NO System induced violation Possible reckless violation System induced error Sabotage, malevolent damage Substance use with mitigation Possible negligent behavior Unsafe Acts Algorithm7 NO NO NO YES NO YES YES YES NO YES Known medical condition? NO YES YES YES YES NO Culpable Gray Area Blameless Adapted from James Reason. (1997). Managing the Risks of Organizational Accidents.

29. Flexible Culture Teamwork within Units Four items elicit perceptions of teamwork within units. TeamSTEPPS Tools to bridge gap between belief and behavior: Briefs, Huddles, Debriefs; Situational Awareness, Mutual Support, Seeking & Offering Task Assistance

30. Flexible CultureCommunication Openness Three items elicit perceptions of communication openness. TeamSTEPPS Tools to Bridge the Gap between belief and behavior : Advocacy and Assertion, Two Challenge Rule, CUS

31. Flexible CultureHandoffs & Transitions Four items elicit perceptions of handoffs & transitions. TeamSTEPPS Tools to Structure Communication: SBAR, Check Back, Call Out, I PASS the BATON

32. Action Planning: Interventions to Support Flexible (Teamwork) Culture Team Strategies & Tools to Enhance Performance & Patient Safety 21 http://teamstepps.ahrq.gov Adopting team behaviors positively impacts all components of safety culture because teamwork supports learning.22

33. Mutual Support Tool: CUS…Graded Assertiveness • I’m CONCERNED that Mr. Johnson has a urinary catheter. It was put in in the ICU without an order. • No response… • I’m UNCOMFORTABLE leaving it in because he does not currently have any evidence-based indications for a catheter. • No response… • This is a SAFTEY issue. Mr. Johnson is at risk for a CAUTI if we do not remove the catheter.

34. Communication Tool: SBAR…Brief, Clear, Timely, Complete Communication • At shift change: • S: Mr. Johnson still has a urinary catheter. • B: It was put in in the ED without an order. I have a call in to Dr. Smith, the hospitalist, to remove it. • A: Mr. Johnson does not currently have any indications for a catheter. • R: Call Dr. Smith again, if he does not return the call within an hour.

35. Learning CultureSupervisor Manager Expectations Four Items elicit perceptions of leadership behavior. Interventions: TeamSTEPPS Leadership Tools (Briefs, Huddles, Debriefs; Feedback; Resource Management; Conflict Resolution); Frontline engagement15, 16

36. Learning CultureFeedback & Communication about Error Four items elicit perceptions of feedback about error. Interventions: TeamSTEPPS Briefs, Huddles, Debriefs; Frontline engagement; 15, 16 Communication Notebook; Bulletin Board; Unit Newsletter; Formal In-services & Unit meetings

37. Learning CultureOrganizational Learning—Continuous Improvement Learning Tools : Briefs, Huddles, Debriefs; Leadership WalkRounds,15Leveraging Frontline Expertise;16 Individual and Aggregate RCA; Failure Mode and Effects Analysis

38. Action Planning: Reporting, Just, and Flexible Practices Support Learning • Ultimately, the willingness of workers to report depends on their belief that the organization will analyze reported information and then implement appropriate change—organizational practices support a learning culture.7 Practices/Tools • Individual RCA23 • Aggregate RCA24 • FMEA25 • Safety Briefings14 • Leadership WalkRounds,15Leveraging Frontline Expertise16 • Close the loop with reporting…feedback

39. What is the Relationship between Patient Safety Interventions and Safety Culture? Safety culture, patient safety interventions and leadership influence each other.

40. Role of Leaders in Transformational Change 1 • Create a compelling positive vision • Concretely define the goal as a performance problem…not “changing culture” • Ensure new behaviors are formally taught • Ensure new behaviors are reinforced • Provide opportunities for practice, coaching, feedback • Be a positive role model • Create structures consistent with new way of thinking/working/behaving…policy/procedure, job descriptions, performance appraisals

41. Summary • What is safety culture? • Beliefs, behaviors reflect organizational ability to learn • Associated with adverse events, patient satisfaction • How do you interpret results? • Reason’s Components (12 composites – 4 components) • Gaps between beliefs/behaviors within composites • Variation by subculture (profession), microculture (unit) • Leadership must drive culture

42. Summary • Action Planning • Identify areas in need of improvement within 4 components…reporting, just culture, teamwork, learning • What is the relationship between STOP HAI and Safety Culture?

43. “…it is the unique function of leadership to perceive the functional and dysfunctional elements and to manage cultural evolution and change.” Schein, E.H. Organizational Leadership and Culture 4th ed. San Francisco: John Wiley & Sons; 2010. Leaders Engineer Culture

44. Thank you! Questions?

45. References • Schein, E.H. Organizational Leadership and Culture 4th ed. San Francisco: John Wiley & Sons; 2010. • Wiegmann. A synthesis of safety culture and safety climate research; 2002. http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/02-03.pdf • Institute of Medicine. Patient safety: Achieving a new standard of care. Washington, DC: The National Academies Press; 2004. • Weaver SJ, Lubomski LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strategy: A systematic review. Ann Int Med. 2013;158:369-374. • Mardon RE, Khanna K, Sorra J, Dyer N, Famolaro T. Exploring relationships between hospital patient safety culture and adverse events. J Patient Saf 2010;6: 226-232. • Sorra J, Khanna K, Dyer N, Mardon R, Famolaro T. Exploring relationships between patient safety culture and patients’ assessments of hospital care. J Patient Saf 2012;8: 131-139. • Reason, J. (1997). Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited.

46. References • Battles et al. (2006). Sensemaking of patient safety risks and hazards. HSR, 41(4 Pt 2), 1555-1575. • Nieva VF, Sorra J. Safety culture assessment: A tool for improving patient safety in healthcare organizations. Qual Saf Health Care 2003; 12(Suppl II): ii17-ii23. • Jones,Skinner, Xu, Sun, Mueller. (2008). The AHRQ Hospital Survey on Patient Safety Culture: a tool to plan and evaluate patient safety programs. Advances in Patient Safety: New Directions and Alternative Approaches http://www.ncbi.nlm.nih.gov/books/NBK43699/ • National Quality Forum (NQF). Safe practices for better healthcare--2010 update: A consensus report. Washington, DC: NQF; 2010. Available at: http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_–_2010_Update.aspx • AHRQ. Hospital Survey on Patient Safety Culture. Available at: http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/index.html • Leape, L.L. (2002) Reporting adverse events. The New England Journal of Medicine, 347, 1633-1638 Institute for Healthcare Improvement.

47. References • Conduct Safety Briefings. Available at: http://www.ihi.org/knowledge/Pages/Changes/ConductSafetyBriefings.aspx • Institute for Healthcare Improvement. Patient Safety Leadership WalkRounds. Available at: http://www.ihi.org/knowledge/pages/tools/patientsafetyleadershipwalkrounds.aspx • Singer SJ, Rivard PE, Hayes JE, Shokeen P, Gaba D, Rosen A. Improving patient care through leadership engagement with frontline staff: A Department of Veterans Affairs case study. The Joint Commission Journal on Quality and Patient Safety. 2013;39:349-360. • Marx D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives. New York, NY: Columbia University; 2001. Available at: http://psnet.ahrq.gov/resource.aspx?resourceID=1582 • Frankel AS, Leonard MW, Denham CR. Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability. HSR. 2006;41(4),PartII:1690-1709. • Wachter RM, Pronovost PJ. Balancing "no blame" with accountability in patient safety. N Engl J Med. 2009;361:1401-1406. • AHRQ. Patient Safety Primers. Disruptive and Unprofessional Behavior. Available at: http://psnet.ahrq.gov/primer.aspx?primerID=15

48. References • Agency for Healthcare Research and Quality. TeamSTEPPS: Strategies and tools to enhance performance and patient safety. Available at: http://teamstepps.ahrq.gov/. • Jones KJ, Skinner AM, High R, Reiter-Palmon R. A theory-driven longitudinal evaluation of the impact of team training on safety culture in 24 hospitals. BMJ Qual Saf. 2013;22:394-404. • US Department of Veterans Affairs. National Center for Patient Safety. Root Cause Analysis Tools. Available at: http://www.patientsafety.gov/CogAids/RCA/index.html#page=page-1 • Neily et al. Using aggregate root cause analysis to improve patient safety. Jt Comm J Qual Saf 29(8):434-439, 2003. • US Department of Veterans Affairs. National Center for Patient Safety. Using Healthcare Failure Modes and Effects Analysis. Available at: http://www.patientsafety.gov/SafetyTopics/HFMEA/HFMEA_JQI.html

49. Funding Prepared by the Health Research & Educational Trust of the American Hospital Association with contract funding provided by the Agency for Healthcare Research and Quality through the contract,“National Implementation of Comprehensive Unit-based Safety Program (CUSP) to Reduce Catheter-Associated Urinary Tract Infection (CAUTI), project number HHSA290201000025I/HHSA29032001T, Task Order #1.”