Fostering A Culture of Safety: AHRQ’s Patient Safety Culture Survey

1. Fostering A Culture of Safety:AHRQ’s Patient Safety Culture Survey Debbie Smith, RN,CPHQ Redmond Regional Medical Center Presentation to Tennessee Hospital Association March 2009

3. Redmond Regional Medical Center • 230 bed, rural, Northwest Georgia • No obstetrics or behavioral health • Cardiovascular primary service line • Interventional Cardiology • Open Heart • 1,200 employees • HCA TriStar Division facility

4. Culture of Safety “History” • Designated “Patient Safety Officer” in 2001 • Hired Director of Regulatory Services 2006 • Previous experience with AHRQ pilot survey 2001 • Designated as Redmond’s Patient Safety Officer 2007

5. Culture of Safety “History” • Conducted “un-submitted” AHRQ survey in 2001 • HCA Corporate builds into annual Code of Conduct • Restructured to TriStar Division December 2006 • AHRQ Survey January 2007 • AHRQ Survey December 2008

6. Patient Safety Structure

7. Patient Safety Structure

8. Culture of Safety: TriStar Division • Structures Patient Safety in Risk Prevention through “premium credit” incentives • AHRQ Survey • Leapfrog Survey • CREW training available to all staff members 2007 and 2008 • Encourages facilities prior to surveys and supports with efforts for improvement after surveys • Quality and Regulatory Group meetings

9. Patient Safety Program Basis

10. Key to Successful Culture LEADERSHIP! “As a nurse, I believe in providing the safest environment possible when it comes to our patients. Our culture at Redmond is to provide quality outcomes and our patients deserve our attention to every minute detail…..” Brenda M. Waltz, CEO “Qualitypatient care is the true reason for the hospital’s existence. Patient safety is indeed the hospital’s culture as it has been evidenced by the attitude of no blame and disclosure of significant adverse events prior to them being the healthcare industry standard.” Deborah Branton, V.P. Risk, Ethics, Compliance

11. Approach to Patient Safety?

12. Approach to Patient Safety?

13. Patient Safety Activities • Multidisciplinary Patient Safety Team of front-line staff members (monthly) • Med Administration Processes • Falls Prevention • Restraint Use • National Patient Safety Goals • Ad-hoc Items as Requested by Admin

14. Patient Safety Activities • Annual Patient Safety Newsletter with paychecks 1st pay-period in January and to physicians • Periodic articles in Employee Newsletter • Celebration of National Patient Safety Awareness Week

15. Patient Safety Activities • Administrative Walk-Arounds • Corporate MRSA initiative • Culture of Safety questions to staff • Patient Safety Tracers in clinical areas • Clinical Teams • Lean Healthcare “Kaizen” events

16. The AHRQ Survey • One tool of many used by facility • Provides a high-level assessment of organization’s culture • Allows you to drill-down to area-specific perceptions • Includes comment section, aids understanding of data

17. AHRQ Survey Logistics • Available to every employee via intranet link • Communicated encouragement for participation for 2 weeks via email to staff • Communicated to staff and physicians 1:1 by Vice President of Risk, Ethics and Compliance

18. Survey Response

19. AHRQ Survey Participant Response

20. AHRQ Survey Job Class Response

21. AHRQ Survey Patient Care Response

22. Challenges to Participation • TIMING • Fielded end of December /staff variability around holiday schedules • Staff not engaged due to holidays

23. Challenges to Participation • Opportunities among Departments • Very little Med/Surg participation • Very little Physician participation • Pharmacy • Dietary • Respiratory • Physical Therapy

24. TIMELINESS Results available early January 2009

25. Culture of Safety Results

26. Culture of Safety Results

27. Drill Down Analysis • 12 Categories • 42 Questions • Responses Positive, Neutral and Negative

28. Drill Down Analysis • Review results according to category, NOT in the order they were presented in the survey • 43% of questions are “reverse” – worded negative instead of positive • May counterbalance the results of the positively worded questions • Form conclusions and recommendations only after assessing the “counterbalance”

29. Review the Balance 4 categories balanced (+ = -)

30. Drill Down Analysis • Determine the feasibility of the negative responses in comparison to the positive • Would not prioritize this for immediate improvement actions

31. Analysis: Make it Manageable • Assess the “Areas of Strength” • 18/42 questions @ Redmond • Eliminate categories that have all =/> 50% questions as areas of strength (positive balance) • 5/12 categories @ Redmond • Eliminate categories that are neutral balance • Focus on categories with “no” area of strength (negative balance) • 3/12 categories @ Redmond • 2nd priority would be categories with <50% questions as areas of strength (negative balance)

32. Form Recommendations • Recommend to Leadership which categories/ issues to focus action on • Category: Handoff communication • Unit-to-Unit Transfers • Shift Change Report • Exchange of Info Across Units • Shift Changes are Problematic ***Already had identified this through National Patient Safety Goal observations in 2008

33. Develop Action Plans • Prior to survey 2008 • Lean Healthcare Kaizen event in ED • SBAR process for rapid response • SBAR+D process for contacting physician with critical change information • SBAR+D process for intra-unit transfers

34. Develop Action Plans • After survey First quarter 2009 • SBAR+D telephonic report for shift-to-shift report • Charge Nurse to Nurses Aid Hand-off report • Failure Mode Effects Analysis • SBAR+D telephonic report + nurse to nurse hand-off for ED to nursing transfers

35. Revelations • Staff do not always have the level of understanding of the culture that Leadership sets forth • Lack of continual, ongoing communication of day-to-day decisions and activities • Lack of understanding of definition of “culture” • Lack of communication of ongoing long-term activities and the impact of improvement actions taken

36. Revelations • Staff do not always understand the meaning of the questions in the survey • Example: STAFFING • We use more agency/temporary staff than is best for patient care • 8% negative response • Virtually no agency use during 2008!

37. Action Plan Next Steps Focus on Building Team trust between ED and other clinical departments

38. Prepping for Re-Survey “Insanity is doing the same thing over and over again and expecting different results” Albert Einstein

39. Prepping for Re-Survey • TriStar Division required each facility to work on actions and re-field the survey in late summer 2009 • Redmond is taking the revelations and is developing strategies to increase participation, understanding of questions and what actually is occurring within the facility that address the survey’s negative results

40. Gauging Success • Do we have a successful patient safety program? • TJC survey November 2008 with 1 Patient Safety RFIs • Winner of 4 GHA PHA Patient Safety Awards in past 3 years and received Circle of Excellence award • Are we perfect? • No, AHRQ identified opportunities • Staff still in need of continual communication of Patient Safety awareness and culture

41. Questions? QUESTIONS?