Patient Safety Culture Measurement and Improvement Mark Fleming Saint Mary’s University Mark.fleming@smu.ca

Objectives Understand the nature and importance of culture and relationship with patient safety Evaluate current culture Measure, track, monitor culture Develop a strategic plan for safety culture measurement and improvement Implement culture improvement strategies Identify barriers to improvement

We can't solve problems by using the same kind of thinking we used when we created them Albert Einstein

Importance of culture “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.” (p. 14; IOM, 1999) “The biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm.” (p. 79; Crossing the Quality Chasm, 2001)

Culture and patient safety Safety Culture Norms and Behaviour Patient Safety Enabler/ Barrier Patient Safety Interventions

Patient safety culture A culture of safety can be defined as an integrated pattern of individual and organizational behaviour, based upon shared beliefs and values, that continuously seeks to minimize patient harm that may result from the processes of care delivery (Kizer, 1999).

Patient safety culture elements Leadership commitment to safety Organizational resources for patient safety Priority of safety versus production Effectiveness and openness of communication Openness about problems and errors Organizational learning Frequency of unsafe acts (Singer et al. 2003)

Measurement and Improvement Organizational level Major system wide change process requiring significant resources Step change in patient safety outcomes Unit level Focused intervention Incremental improvement

1. Investigate Build expertise in safety culture Form small assessment and improvement team Select appropriate instrument Agency for Health Care Research and Quality Hospital survey on patient safety (79 items) (Sorra & Nieva, 2004) Safety Attitudes Questionnaire SAQ (60 items) (Sexton & Thomas 2003) York University Modified Stanford (32 items) (Ginsburg et al, 2009)

York University Modified Stanford Based on PSCI and Capital Health questionnaire Organizational leadership for safety Unit leadership for safety Perceived state of safety Shame and repercussions Learning Good psychometrics (alpha’s .66-.86) Currently used by Accreditation Canada Large Canadian data set

2. Initiate Obtain Informed senior leadership support Involve health care staff Planning and implementation of assessment Keep staff informed about progress

3. Implement Collect data Interpret results Feedback results to staff

Unit level assessment and improvement Conduct safety culture survey (e.g. MSI ) Group exercise Representative group of frontline caregivers 30 – 60 minutes to complete Helps to make sense out of culture survey results and create actions for improvement Normalizes patient safety culture conversations The “Culture Check-up” was developed by Sexton and colleagues in 2006. The purpose of this tool is to provide structure and direction for patient safety culture discussions and action planning sessions. The culture check-up is meant to be completed as a group exercise with a representative sample of frontline caregivers. The exercise is broken down into three tasks: Using the results from the SAQ (or another validated patient safety culture survey) the group selects one item which less than 60% of respondents agreed upon. There is also an option to chose upon a list of diagnostic items provided. For the item chosen, the group members discuss what that item means to them, if the item score is reflective of their experiences, and what 100% agreement for this item would look like. The final task is for the group to identify one actionable idea to improve the results related to this item. The culture check-up can be a useful tool when trying to make sense out of culture survey results and make decisions on the next actions to take to improve the culture of the organization. The tool can be used immediately after the organization received culture survey results or periodically through the year as a way of keeping in a finger on the pulse of the culture. The more often the culture check-up tool is completed, the more it will help in normalizing conversations about patient safety culture.

4. Improve Involve cross section of staff in development of improvement plan Implement an improvement plan Monitor the implementation of plan Evaluate effectiveness of plan Assess change in culture

Patient Safety Culture Improvement Tool (PSCIT) Perceptions are based in reality i.e. perceptions of leadership commitment reflect their interactions with leaders Organisations and units with different cultures have different practices Safety culture improvement involves system change e.g. perceptions of leader commitment is improved through training and evaluating safety leadership practices

Patient safety culture elements Leadership Senior Manager Clinical Manager Physician Risk analysis Workload management Sharing and learning Resource management

Example element

How to use the audit Self assessment of systems supporting the safety culture Completed by unit or department to assist in identifying opportunities to improve Completed by senior management team to form basis for improvement workshop

Improving patient safety culture Leadership Judged by actions not words Solution focused approach Assess current culture Work at team level to develop local action plan Implement changes Reassess culture Health care specific challenges Unclear management control Limited acceptance of need to change

Taking Action Culture is shared by group members Groups consist of individuals Culture change requires individuals to change their values, beliefs and behaviour Cultural change can begin at the: Organizational level Unit level Individual level So what are you going to do to change the culture? Fundamentally patient safety culture is about people and it changes by the actions of people. With your greater understanding of culture what are you going to do differently? Consider the current culture within your organization and your department or unit. What aspects of the culture could be improved? Identify one action that would improve the culture within your organization. Identify one action that would improve the culture within your department or unit. List one thing that you are going to do to promote a positive safety culture.

Summary Creating a culture of patient safety is crucial The culture determines what behaviours are acceptable and unacceptable Patient safety culture consists of a number of dimensions It is important to understand the current culture before trying to change it Cultural change can be conducted at the organisational or unit level

References Kizer, K. W. 1999. Large system change and a culture of safety. In: Enhancing Patient Safety and Reducing Errors in Health Care. Chicago, IL: National Patient Safety Foundation Ginsburg L, Gilin D, Tregunno D, Norton P G, Flemons W. and Fleming M (2009) Advancing measurement of patient safety culture Health Services Research Vol 44 no 1 pp205-223 Sexton JB, Paine LA, Manfuso J, Holzmueller CG, Martinez EA, Moore D, Hunt DG, & Pronovost PJ.(2007) A check-up for safety culture in "my patient care area". Joint Commission journal on quality and patient safety. Nov;33(11):699-703, 645 Fleming, M. and Wentzell, N. (2008) Patient Safety culture improvement tool: development and guidelines for use. Healthcare Quarterly Volume 11 Special issue pp10-15 Jackson, J. Sarac, C. and Flin R. (2010) Hospital safety climate surveys: measurement issues Current Opinion in Critical Care , 16:632–638