CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Onboarding: Building & Measuring Safety Culture ARMSTRONG INSTITUTE FOR PATIENT SAFETY AND QUALITY Johns Hopkins University

CUSP 4 MVP - VAP Comprehensive Unit-based Safety Program for Mechanically Ventilated Patients and Ventilator-Associated Pneumonia

Polling Question Who is on the call? IP – infection preventionist RN – registered nurse RT – respiratory therapist PT – physical therapist OT – occupational therapist MD - physician Healthcare executive Educator National project team Other  

Building & Measuring Safety Culture Nasir Ismail, MS CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

Polling Question Has your organization conducted a safety culture survey in the past 12 months? Yes No Do not know

Polling Question If yes, what survey instrument was used? Safety Attitude Questionnaire (SAQ) Hospital Survey on Patient Safety (HSOPS) Other survey or measurement tool Do not know

Learning Objectives Define safety culture Describe why safety culture is important for improvement efforts Identify best practices for measuring safety culture Define role and responsibilities of survey coordinator Identify characteristics of successful surveys Increase HSOPS response rate Describe debriefing and its benefits

Brief overview of Safety Culture

Culture provides the context for team success What is Safety Culture? 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? Culture provides the context for team success 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”

Core Aspects of Safety Culture CULTURE OF SAFETY Communication patterns and language Feedback, reward and corrective action practices Formal and informal leader actions and expectations Teamwork processes (backup 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. Schein, 2007

AI Model for Improving Care COMMON PROBLEMS LOCAL PROBLEMS Translating Evidence Into Practice (TRiP) Reducing Surgical Site Infections Comprehensive Unit-based Safety Program (CUSP) Summarize the evidence in a checklist Identify local barriers to implementation Measure performance Ensure all patients get the evidence Mechanical bowel preparation with oral antibiotics Pre-op warming CHG bathing Standard skin prep Separation of dirty and clean instruments Prework: Measure clinician and staff perceptions of safety culture (HSOPS survey) Prework: Measure clinician and staff perceptions of safety culture (HSOPS survey) Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools Engage Educate Execute Evaluate TECHNICAL WORK ADAPTIVE WORK

Why Does Safety Culture Matter?

Safety Culture Is Related to Outcomes Patient outcomes Clinician outcomes Patient care experience Incident reporting Burnout and turnover Infection rates, sepsis Postoperative hemorrhage Respiratory failure, accidental puncture or laceration Treatment errors Huang et al., 2010; Mardon et al., 2010; MacDavitt et al., 2007; Singer et al., 2009; Sorra et al., 2012; Weaver, 2011.

Why Safety Culture Matters 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 Haynes et al., 2011; Morello et al., 2012; Van Nord et al., 2010; Weaver et al., in press

Measuring Safety Culture

Measuring Safety Culture Measure safety culture “Pre-CUSP,” or pre- interventions Provides a baseline status Identifies assets and barriers that impact improvement efforts Reassess 12-18 months into improvement efforts Use reliable and valid survey instrument Hospital Survey on Patient Safety (HSOPS) Implement CUSP to improve safety culture results

What Is HSOPS? Hospital Survey On Patient Safety Culture (HSOPS) Measures safety culture within the clinical units of hospital Part of a suite of survey tools (SOPS) for hospitals, medical offices, and nursing homes Sponsored by Agency for Healthcare Research & Quality (AHRQ) HSOPS App: online survey tool Developed by the Armstrong Institute in partnership with CeCity Allows participants to complete the HSOPSsurvey online Provides detailed reports for survey coordinators to debrief clinical areas

HSOPS Dimensions Supervisor / manager expectations and actions promoting patient safety Nonpunitive response to error Staffing Organizational learning- continuous improvement Hospital management support for patient safety Teamwork within unit Teamwork across hospital units Communication openness Feedback and communication about error Hospital handoffs and transitions

HSOPS Sample Questions 10 COMPOSITE SCORES (DIMENSIONS) SAMPLE QUESTION Supervisor/manager expectations & actions promoting patient safety B1. My supervisor/manager seriously considers staff suggestions for improving patient safety. Organizational learning-continuous improvement A9. Mistakes have led to positive changes here. Teamwork within unit A1. People support one another in this unit. Communication openness C4. Staff feel free to question the decisions or actions of those with more authority. Feedback & communication about error C1. We are given feedback about changes put into place based on event reports.

HSOPS Sample Questions 10 COMPOSITE SCORES (DIMENSIONS) SAMPLE QUESTION 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. Cooperation is good among hospital units that need to work together. Hospital handoffs & transitions F5. Important patient care information is often lost during shift changes. (negatively worded)

HSOPS Sample Questions 4 OUTCOME VARIABLES SAMPLE QUESTION 1. Overall perceptions of safety A15. Patient safety is never sacrificed to get more work done. 2. Frequency of event reporting D1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported? 3. Patient safety grade (within hospital unit) 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?

HSOPS Scoring Scoring guidelines created by AHRQ Scores represent the percentage of positive responses Percentage of responses as 4 or 5

Overview of the Survey Administration Process

Cohort 2 HSOPS Survey Period Opens: Dec 4th, 2014 12:00 pm ET Closes: Feb 13th, 2015 5:00 pm ET TIP: In order to access the HSOPS and data portal, you must submit a completed Data Usage Agreement (DUA) and a Registration Form. Contact cusp4mvp@jhmi.edu for more information.

Timeline of Key HSOPS Tasks PHASE TASK PREP (~3 WKS) WK1 WK2 WK3 WK4 WK5 WK6 WK7 WK8 WK 9 Planning Stage Logistical tasks Who will administer? Who will be surveyed? Publicize! Motivate participation Create a debriefing plan Alert Participants Provide pre-notification (post, email, meetings) Upload Unit Data Enter unit background info Start! Upload participant email addresses or previously collected data

Timeline of Key HSOPS Tasks PHASE TASK PREP (~3 WKS) WK1 WK2 WK3 WK4 WK5 WK6 WK7 WK8 WK 9 Track Monitor response rates Target > 60% Remind 1st reminder Remind Again Final reminder End The Survey Close the survey Collect Data Download results report Execute Debrief & plan improvements

Effective HSOPS Surveys… Are confidential and anonymous Responses not linked with email address or identifying information Results reported as unit-level aggregate Leaders must use as a tool for learning and improvement Have a clear purpose that motivates staff to complete State reason asking staff to complete the survey Share what will happen with results Show what will be done based on their input Have formal and informal leadership support Stress the importance of staff input Make resources (time and logistics) available for staff to participate

HSOPS Key Team Members

HSOPS Survey Coordinator Key Responsibilities Coordinate survey administration with hospital and clinical area leadership Participate in HSOPS training webinars and related conference calls Use the online survey database Support survey participants throughout the process Enter data about the participating clinical areas Monitor the survey response rate Distribute survey materials and information Communicate with other project HSOPS Coordinators

Pre-Notification Materials Purpose of the survey and how responses will be used Survey participants all staff nursing staff all clinical staff a random sample of staff Expected time needed to complete the survey Assurances of confidentiality or anonymity Expected timeframe for reply Method to return completed survey Optional incentives (always a nice touch) Contact information for questions Make sure your list is up to date, check for: Staff on administrative or extended sick leave, Staff who appear in more than one staffing category or hospital area/unit, Staff who have moved to another hospital area/unit, Staff who no longer work at the hospital, and Other changes that may affect the accuracy of your list email addresses Sorra & Nieva, 2004

= Response Rate Matters Safety culture reflects the shared perceptions among staff members Minimum response rate of 60% is necessary for a representative sample Results valid and reliable only if reflect majority of staff members = Actual participants Response Rate Invited participants

Increase Your HSOPS Response Rate Set a goal Make a plan Display fliers & posters Provide incentives Raffle Competition between units or provider groups

HSOPS Options OPTION 1 OPTION 2 Administer new HSOPS survey Use HSOPS data collected within last 12 months Online HSOPS App Email staff Central workstation Upload spreadsheet to online HSOPS App

If you collect other safety culture data, the HSOPS… Provides opportunity to receive unit-based results and feedback Allows comparison with other participants in your cohort

Inviting Staff To Complete The HSOPS Survey Alternate Workstation ID Method Some clinical areas prefer to submit surveys via a central computer located within the unit Request a work area id Set up a computer workstation in the clinical area Instruct staff to use the provided link and ID Contact cusp4mvp@jhmi.edu for more information.

Debriefing and Its Benefits CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

What Is Debriefing? Debrief survey results with all your team members Debriefing is a semi-structured conversation among frontline clinicians that a facilitator leads Encourages open communication, transparency, and interactive discussion across all levels of the work area between disciplines Engages clinicians and staff in generating and implementing their ideas about how to create an effective safety culture in their work area

Debriefing: Making HSOPS Data Meaningful Work units that debrief safety culture perform better Data are data Turn data into information with debriefing Debriefing accelerates improvement Units that did not debrief survey results only achieved 2.2% reduction in infection rates Units that used semi-structured debriefing of culture survey achieved 10.2% reduction in infection rates YES NO

Additional Tips for Effective Surveys Communicate to all staff the importance of their input Monitor response rates and send reminders throughout the survey administration process Use several channels of communication Email Announcements during staff meetings Bulletin boards or break rooms Create a debriefing plan and share results Reach out for assistance from national project team and your orgnization

Action Items for New HSOPS Surveys Identify survey coordinator(s) for participating work areas Send list of survey coordinators to your coordinating entity Determine targeted survey participants and sample size Select method to conduct survey Online HSOPS app Email Alternate workstation Prepare informational materials to publicize the survey (posters, flyers, newsletter entries, meeting agenda items) Send pre-notification letter, post pre-notification information, or hold pre-notification meeting Develop debriefing plan to share results with staff

References Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Dziekan G, Herbosa T, Kibatala PL, Lapitan MC, Merry AF, Reznick RK, Taylor B, Vats A, Gawande AA; Safe Surgery Saves Lives Study Group. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf. 2011 Jan;20(1):102-7. Huang DT, Clermont G, Kong L, Weissfeld LA, Sexton JB, Rowan KM, Angus DC. Intensive care unit safety culture and outcomes: a US multicenter study. Int J Qual Health Care. 2010 Jun;22(3):151-61. MacDavitt K, Chou SS, Stone PW. Organizational climate and health care outcomes. Jt Comm J Qual Patient Saf. 2007 Nov;33(11 Suppl):45-56. Mardon RE, Khanna K, Sorra J, Dyer N, Famolaro T. Exploring relationships between hospital patient safety culture and adverse events. J Patient Saf. 2010 Dec;6(4):226-32. Morello RT, Lowthian JA, Barker AL, McGinnes R, Dunt D, Brand C. Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Qual Saf. 2012 Jul 31. [Epub ahead of print] Schein E. Organizational culture and leadership, 4th edition. San Francisco, CA: Jossey- Bass. 2010.

References Singer SJ, Falwell A, Gaba DM, Meterko M, Rosen A, Hartmann CW, Baker L. Identifying organizational cultures that promote patient safety. Health Care Manage Rev. 2009 Oct- Dec;34(4):300-11. 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 Jul 10. [Epub ahead of print]. Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004. van Noord I, de Bruijne MC, Twisk JW. The relationship between patient safety culture and the implementation of organizational patient safety defences at emergency departments.. Int J Qual Health Care. 2010 Jun;22(3):162-9. Vigorito MC, McNicoll L, Adams L, Sexton B. Improving safety culture results in Rhode Island ICUs: lessons learned from the development of action-oriented plans. Jt Comm J Qual Patient Saf. 2011 Nov;37(11):509-14. Weaver SJ. A configural approach to patient safety climate: The relationship between climate profile characteristics and patient safety. Doctoral dissertation. University of Central Florida. 2011. Weaver, S. J., Dy, S., Lubomski, L., & Wilson, R. Promoting a culture of safety. In R.M. Watcher, P.G. Shekelle, P. Pronovost (Eds.). Making healthcare safer: A critical analysis of the evidence of patient safety practices (AHRQ report # TBD). Rockville, MD. In press.

CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients Next Steps CUSP 4 MVP – VAP Improving Care for Mechanically Ventilated Patients

Next Steps: Homework By February 11, 2015 OR Administer HSOPS to your unit staff Develop plan to achieve response rate goal Report response rate during coaching call Survey closes February 13th OR Upload your pre-existing HSOPS data from the last 12 months into the project data portal

Next Onboarding Call: Project Kickoff December 17, 2014 1:00 – 3:00 PM EST Introduce teams to the CUSP 4 MVP-VAP project Examine five steps of CUSP and implementation strategy Science of Safety Staff Safety Assessment Share Cohort 1 executive engagement successes Reiterate the vital importance of both technical and adaptive interventions

Mark Your Calendar: Upcoming Content Sessions Tune in to the content webinars for evidence supporting each intervention Content webinars are 90 minutes and occur on the third Wednesday of each month at 11:00 am EST DATE TOPIC Jan 21, 2015 Science of Safety & Identifying Defects Pain, Agitation, and Delirium (PAD) and Sedation Management Feb 18, 2015 Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT) Utility of the Exposure Receipt Assessment Mar 18, 2015 Delirium Assessment Training Benefits of Subglottic Endotracheal Tubes

Mark Your Calendar: Upcoming Data Sessions Tune in to the data webinars for evidence supporting each intervention Data webinars are 60 minutes and occur on the first Wednesday of each month at 11:00 am EST DATE TOPIC Jan 7, 2015 Strategies for Collecting and Entering Daily Care Process Measures Feb 4, 2015 Completing the Exposure Receipt Assessment Preliminary Structural Assessment Data Reports Mar 4, 2015 Intro to Objective Outcome Measures Mar 11, 2015 Understanding Your HSOPS Data & Reports Debrief Your Safety Culture Results The debriefing call will give you strategies to work with staff on your unit regardless of which safety culture survey you used

Mark Your Calendar: Upcoming IP Sessions Tune in to these Infection Prevention webinars for training on the importance and details of ventilator-associated events IP webinars are 60 minutes and occur on the fourth Wednesday in January, February and March at 11:00 am EST DATE TOPIC Jan 28, 2015 VAE Surveillance Training: An Overview Feb 25, 2015 VAE Surveillance Training: Infection-related Ventilator-associated Complication (IVAC) Mar 25, 2015 VAE Surveillance Training: VAP (PVAP)

CUSP 4 MVP – VAP Website Visit: https://armstrongresearch.hopkinsmedicine.org/cusp4mvp.aspx

What Can I Find on the CUSP 4 MVP – VAP Website? HSOPS Resources HSOPS Manual Quick Reference Guide Debriefing Plan template Educational Materials Toolkits Literature Reviews Fast Fact Sheets CUSP Tools and Guides Archive of webinars led by subject matter experts