1. Understanding Reassessment Results from the AHRQ Hospital Survey on Patient Safety Culture
A WebEx for QIOs from the Rural HIQIOSC Nov. 1, 2007
Katherine Jones, PT, PhD
Anne Skinner, RHIA
Liyan Xu, MS
Junfeng Sun, PhD
Acknowledge Anne and support from AHRQ
Supported by AHRQ Grant 1 U18 HS015822

2. Implementing a Program of Patient Safety in Small Rural Hospitals
One of 17 AHRQ PIPs grants funded 7/05 – 6/07
Purpose: To implement the patient safety practices of voluntary medication error reporting and organizational learning in 35 small rural hospitals.
Aim 1: Develop the organizational infrastructure for reporting and analyzing medication errors that is needed to identify system sources of error.
My experience with the AHRQ Hospital Survey on Patient Safety Culture is a result of our Partnerships in Implementing Patient Safety Grant funded by AHRQ from July 2005 – June The purpose of our project was to implement the patient safety practices of voluntary medication error reporting and organizational learning in 35 Critical Access Hospitals. We used MEDMARX, the internet based national medication error reporting program, to develop the organizational infrastructure for reporting and analyzing medication errors that is needed to identify system sources of error. Knowing that our major intervention was to improve reporting will help understand my examples of our reassessment results.

3. Objectives Obtain a working definition of safety culture
Explain Reason’s concept: a safe, informed culture is engineered by implementing practices
Describe the HSOPSC as a diagnostic tool that measures an organization’s safety culture for supporting quality improvement
Explain HSOPSC reassessment results in context of how leaders use information and implement change
Explain how to use items within a dimension to engineer interactions between practices that produce a safe, informed culture

4. Patient Safety Practice: Organizational Learning
“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.”
Crossing the Quality Chasm: A New Health System for the 21st Century, p. 79
I want to begin this discussion by emphasizing that the IOM identified the biggest challenge we face in improving health care 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. In other words, the biggest challenge is implementing the patient safety practice of organizational learning…there is no more important foundation for quality improvement than understanding what it means to be a learning organization.

5. Definition of Safety Culture
Enduring, shared beliefs and practices that reflect an organization’s willingness to learn from errors*
Three beliefs present in a safe, informed culture**
Healthcare processes can be designed to prevent failure
There is an organizational commitment to detect, learn from error
There is a just culture that disciplines based on risk
A safe, informed culture strives to be a high reliability organization
Understanding reassessment results from the AHRQ survey requires that you first understand the construct that the survey is measuring.
The survey is measuring the construct of safety culture which can be defined as the enduring, shared beliefs and practices (think behaviors) that reflect an organization’s willingness to learn from errors. The IOM identified three beliefs present in a safe, informed culture:
Healthcare processes can be designed to prevent failure
There is an organizational commitment to detect, learn from error
There is a just culture that disciplines based on risk
A safe, informed culture should be a high reliability organization, which is an organization that is
HRO:
preoccupied with failure
sensitive to how each team member affects a process
allows those who are most knowledgeable about a process to make decisions, and
resistz the temptation to blame individuals for errors within complex processes
*Wiegmann. A synthesis of safety culture and safety climate research; 2002.
**Institute of Medicine. Patient safety: Achieving a new standard of care.
Washington, DC: The National Academies Press; 2004.

6. Components of Safety Culture
Psychologist James Reason categorized safety culture into four components, which reflect his assertion that an informed culture is a safe culture. These four components identify the beliefs and practices present in an organization that is informed about risks and hazards and takes action to become safe. These four subcomponents are a reporting culture, a just culture, a flexible culture, and a learning culture. The practices needed to support the subcomponents must be deliberately implemented or engineered to interact with each other to achieve a safe, informed culture.
Fundamentally, a safe organization is dependent on the willingness of front-line workers to report their errors and near-misses—organizational practices support a reporting culture. This willingness of workers to report depends on their belief that management will support and reward reporting and that discipline occurs based on risk-taking—organizational practices support a just culture. The willingness of workers to report also depends on their belief that authority patterns relax when safety information is exchanged because those with authority respect the knowledge of front-line workers—organizational practices support a flexible culture. 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. The interaction of these four components produces an informed, safe organization that is highly reliable. We recognized that the organizational beliefs and practices associated with these components of culture are assessed by the ARHQ HSOPSC.
Reason, J. Managing the Risks of Organizational Accidents.
Hampshire, England: Ashgate Publishing Limited; 1997.

7. A Reporting culture is engineered by implementing practices . . .
“Any safety information system depends crucially on the willing participation of the workforce, the people in direct contact with the hazards. To achieve this, it is necessary to engineer a reporting culture—an organization in which people are prepared to report their errors and near-misses.” (Reason, p. 195)
Practices/Tools
Characteristics of successful reporting systems (Leape, 2002)
Nonpunitive
Confidential
Independent
Expert analysis
Timely
Systems-oriented
Responsive
Chart Audit
Secret Shopper
Safety Briefings
Leadership WalkRounds
Reporting, obtaining information about the processes and outcomes of care, is the foundation of a safe, informed culture. Psychologist James Reason states, “Any safety information system depends crucially on the willing participation of the workforce, the people in direct contact with the hazards. To achieve this, it is necessary to engineer a reporting culture—an organization in which people are prepared to report their errors and near-misses.” The practices that support a reporting culture include formal reporting systems that are
Nonpunitive
Confidential
Independent
Expert analysis
Timely
Systems-oriented
Responsive
Other forms of reporting are Chart Audit, Secret Shopper, Safety Briefings, Leadership WalkRounds

8. A Just culture is engineered by implementing practices . . .
The willingness of workers to report depends on their belief that management will support and reward reporting and that discipline occurs based on risk-taking…there is a clear line between acceptable and unacceptable behavior —organizational practices support a just culture.
Practices/Tools
Understanding human error (Reason 2003, 2006)
Active errors (sharp end)
Latent errors
Just Culture and behavior (Marx, 2001)
Conduct: human error, negligence, reckless, intentional rule violation
Disciplinary decision-making: outcome-based, rule-base, risk-based
Unsafe Acts Algorithm
The willingness of workers to report depends on their belief that management will support and reward reporting and that discipline occurs based on risk-taking…there is a clear line between acceptable and unacceptable behavior —organizational practices support a just culture.
Discipline does not take place in response to human error but in response to knowingly increasing the risk to patients or peers. These practices include….

9. A Flexible culture is engineered by implementing practices . . .
Practices/Tools
Team Skills
Leadership
Huddles, Briefs, Debriefs
Structured Communication
SBAR, CUS
Mutual Support
Situation Monitoring
Handoffs & Transitions
The willingness of workers to report depends on their belief that authority patterns relax when safety information is exchanged because managers respect the knowledge of front-line workers—organizational practices support a flexible culture.
The willingness of workers to report depends on their belief that authority patterns relax when safety information is exchanged because managers respect the knowledge of front-line workers—organizational practices support a flexible culture.
Relaxing authority patterns to ensure effective communication is included in team skills

10. Reporting, Just, and Flexible practices support organizational 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.
Practices/Tools
Individual RCA
Aggregate RCA
FMEA
Safety Briefings
Leadership WalkRounds
A learning culture takes action based on information about its systems. A learning culture is driven to improve through constant feedback about the successes and failures of its processes. The foundation of a learning culture is information systems…reporting. 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. Root cause analysis, individual and aggregate, FMEA, Safety Briefings, and Leadership WalkRounds are the tools that organizations use to learn from their experience.

11. Reason’s Components HSOPSC Dimensions or Outcome Measures
Reporting Culture - a safe organization is dependent on the willingness of front-line workers to report their errors and near-misses
Frequency of Events Reported
Number of Events Reported
Just Culture - management will support and reward reporting; discipline occurs based on risk-taking
Nonpunitive Response to Error
Let’s see how Reason’s components of culture are measured by the AHRQ survey….

12. Reason’s Components HSOPSC Dimensions or Outcome Measures
Flexible Culture - authority patterns relax when safety information is exchanged because those with authority respect the knowledge of front-line workers
Teamwork w/in Depts
Communication Openness
Teamwork ax Depts
Hospital Handoffs
Learning Culture - organization will analyze reported information and then implement appropriate change
Manager Actions
Hospital Mgt Support
Feedback & Communication about error
Organizational Learning

13. What does HSOPSC measure?
HSOPSC measures an organization’s willingness to learn from errors
HSOPSC identifies impairments and evaluates progress in how an organization collects, analyzes, and learns from information about its processes
Does an organization’s ability to learn from experience support quality improvement efforts?
Use items within the dimensions to identify patient safety practices necessary to address impairments
Based on our understanding of the definition of safety culture, the AHRQ HSOPSC is measuring an organization’s willingness to learn from errors. Like any diagnostic instrument, the survey allows you to identify impairments and evaluate progress. Specifically, the survey identifies impairments and evaluates progress in how an organization collects, analyzes, and learns from information about its processes. The survey answers the question: Does an organization’s ability to learn from experience support quality improvement efforts? Items within each dimension can be linked to specific patient safety practices necessary to address impairments in learning as an organization.

14. ENGINEERING A CULTURE OF SAFETY
Measurement
To Identify Impairments
Interventions
To Improve Practices
I want to make it very clear that the AHRQ survey is a diagnostic tool. As a physical therapist, I use diagnostic tools to assess whether a patient’s balance is impaired. Based on the impairments I find, I teach the patient specific, targeted exercises to address each impairment. Similarly, based on the impairments in organizational learning identified by the survey, senior leaders need to implement specific practices or behaviors to support the four components of a safe, informed culture.
Another similarity between maintaining balance as an individual and safety culture in organizations, is that reporting is the foundation of both. We can not maintain balance without sensory information from our joints, eyes, and inner ears. We can’t maintain and improve our organizations without information about the success and failures of our processes
XXXXX
Sensory information reported from the periphery
Sensory information integrated in the brain (just culture framework)
Coordinated, flexible motor output
Falls lead to learning from mistakes
Practice leads to improvement
ENGINEERING A CULTURE OF SAFETY
Inventory of Tools

15. Physician Quality Reporting Initiative Hospital Quality Initiative
So what are all of the demands small rural hospitals are supposed to be reacting to? I am a strong advocate of using the AHRQ survey, because I believe that it can guide organizations to implement practices that are crucial to the success of every quality improvement project.
Physician Quality Reporting Initiative
Hospital Quality Initiative
Nursing Home Quality Initiative
DOQ-IT

16. Recap and Questions…
Safety culture is the shared beliefs and practices that support an organization’s willingness to learn from errors
Safety culture is composed of four components, which are measured by the AHRQ HSOPSC
The practices that support the four components of culture interact with each other to produce a safe, informed culture
QUESTIONS??

17. What determines willingness to learn from errors?
Patterns of information flow reflect the climate set by leaders
Personal use of information to achieve power
Information is processed through standard channels to maintain positions and protect departmental turf
Teams do whatever it takes to get the right information to the right people at the right time to achieve the mission
Leaders’ use of information differs by discipline (work area), job title (management vs nonmanagement)
Patterns of information flow--the Quantity, Relevance, Timeliness, and Appropriateness of information available --reflect the climate set by the leader
Personal use of information to achieve power
Information is processed through standard channels to maintain positions and protect departmental turf
Teams do whatever it takes to get the right information to the right people at the right time to achieve the mission
Leaders’ use of information differs by discipline (work area), job title (management vs nonmanagement)
Westrum, R. A typology of organizational cultures. Quality and Safety in Healthcare 2004;13:22-27.

18. MODEL OF INFORMATION FLOW
Attitudes of leaders about information
Information about Processes
Organizational
Learning
Teamwork & Communication
Knowledge to Evaluate & Conduct Processes
Evidence-Based
Guidelines
This model of information flow in an organization illustrates that an organization’s ability to learn from experience is determined by the attitudes of leaders about the use of information, the flow of information, sources of information, and the ability to work as a team. Effective use of information results in organizational learning, improvement of knowledge to evaluate and conduct processes, and ultimately in achieving the organization’s mission.
Sources of Information include: Near Miss Reports, Actual Error Reports, Incident Reports, Audits, Work-outs, Routine data collection, Satisfaction Surveys, Culture Survey
Characteristics of an Advanced Safety Culture Informed at all levels—all seek and provide info
Trust by all—due to a just culture even bad information is shared, accepted, and acted upon
Adaptable to change—learn from successes and failures
It worries—success does not create complacency
Processes
of Care
Mission: Provide high quality,
safe care for community
Adapted from Westrum (2004) & Firth-Cozens, J. Cultures for improving patient safety through learning: the role of teamwork. Quality and Safety in Health Care 2001;10:26-31.

19. Types of Culture
Pathological—use of information to enhance personal power
Punitive environment
Bureaucratic— use of information to adhere to rules, positions, and protect turf
Uninformed…no reporting
Generative—use of information to concentrate on the mission; not persons or positions
Thinking about the three major patterns of information flow, there are three basic types of culture…
Westrum, R. A typology of organizational cultures. Quality and Safety in Healthcare 2004;13:22-27.

20. Typology of Organizational Cultures
Pathological
Bureaucratic
Generative
Low cooperation
Rule oriented
Performance oriented
Messengers shot
Messengers neglected
Messengers encouraged
Responsibilities shirked
Responsibilities are narrow
Responsibilities are shared
A pathologic culture is characterized by …
A bureaucratic culture is characterized by…
A generative culture is characterized by…
Westrum, R. A typology of organizational cultures. Quality and Safety in Healthcare 2004;13:22-27.

21. Typology of Organizational Cultures
Pathological
Bureaucratic
Generative
Sharing info across depts
discouraged
Sharing info across depts tolerated
Sharing info across depts encouraged
Failure
scapegoating
Justice
Inquiry
Change crushed
Change
problem
Change implemented
Westrum, R. A typology of organizational cultures. Quality and Safety in Healthcare 2004;13:2-27.

22. Comparison of percent-positive scores on 12 safety culture dimensions by work area, 2007
This graph demonstrates the differences in safety culture across 21 CAHs for which we have 2005 baseline and 2007 reassessment data. In general, surgery and laboratory have a more positive perception of safety culture than do those who work the floor/the acute/skilled area.
Work in surgery and the laboratory was described as “less chaotic and more controlled by professional standards.” In addition, discussion of errors in surgery and laboratory were described as events that were investigated by the group. In contrast, errors in nursing were described as “picking on individuals.” These perceptions are consistent with the fact that the odds of those working in surgery and laboratory agreeing that in this department we discuss ways to prevent error from happening again were three times the odds of respondents working in acute/skilled care responding similarly.

23. Comparison of percent-positive scores on 12 safety culture dimensions by position, 2007
This graph demonstrates the differences in safety culture across 21 CAHs for which we have 2005 baseline and 2007 reassessment data. In general, managers have a more positive perception of safety culture than do nurses or providers. This difference is most evident in nonpunitive response to error. Do managers have a more positive view of safety culture because they have more of less information about the safety of care than providers and nurses? What we know is that just 10% of events are reported in voluntary reporting systems.

24. Recap and Questions…
Safety culture is the willingness to learn from experience
Reporting is the foundation of learning
The major determinant of culture is how we obtain and use information
The leaders in an organization support or inhibit reporting--how information is obtained and used
So if culture is the willingness to learn and Reporting (obtaining information) is the foundation of learning, then the major determinant of culture is how we obtain and use information. What I want you to understand is that it is the leaders in an organization, department, or unit that control how information is obtained (reporting functions) and how it is used.

25. Factors Affecting Reassessment
Primary Factor: How did organization use baseline?
Pathologic response
Bureaucratic response
Generative response…to engineer interactions between reporting, just, flexible, learning practices
Did nothing…ignored the results
Secondary factors
Did they have a strategy to implement change
Did not use information to target interventions at level of dept/job title
Changes in response rate from baseline
Changes in leadership
Changes in staffing
So…we are finally in a position to make sense out of reassessment results…how did organizations use the information from their baseline survey? In a pathologic way? In a bureaucratic way? Or in a generative way? Or did they just ignore it?
Some secondary factors to take into account include
Did they have a strategy to implement change
Did not use information to target interventions at level of dept/job title
Changes in response rate from baseline
Changes in leadership
Changes in staffing

26. Learning disabilities are tragic in children, but they are fatal in organizations. –
Organizational theorist Peter Senge
as cited in Reason, p. 219

27. I’m going to provide some examples of interpreting reassessment results in the next series of slides. We have baseline and reassessment results for 21 CAHs; the baseline survey was conducted in Fall 2005 and the reassessment was done in Spring We obtained an overall response rate of 70% in both years and 93% of survey respondents were categorized by department. We adapted the survey to better fit the rural hospital environment by collapsing multiple departments such as med/surg, neuro, ortho, OB etc into acute/skilled. The 12 survey dimensions are across the x axis on the bottom of the graph; beginning with overall perceptions on the left and ending with hospital handoffs and transitions on the right. The top black line and the bottom orange line represent the range of the positive responses from the 21 CAHs for each survey dimension. These two lines are not a specific hospital but are the most and least positive response in a dimension for any given hospital in The dashed blue line represents survey results for a specific hospital in 2005 and the solid blue line is their 2007 results. This particular graph represents the range of responses in 2007 and the aggregate responses from all 21 CAHs in 2005 (dashed) and 2007 (solid). In general there were improvements in all dimensions. Remember that aggregating information always results in a loss of information. So…let’s look as some examples of various types of culture according to the use of information.

28. For this organization, there was a significant increase in reporting, an improvement in the perceptions of a just culture/nonpunitive response. However, what did they do with this information? There weren’t any changes in communication openness of feedback and this org is close to the bottom of the range on these dimensions. The big increase in reporting did not translate into a big increase in organizational learning? Why? They didn’t use the tools associated with learning to translate the information into action. Could bureaucratic patterns of using information explain this?

29. First, for this organization, all dimensions in 2005 were more positive than the reassessment in 2007.
No change in reporting. No change in just culture/nonpunitive response. No change in communication openness or feedback about error. And finally, what are perceptions of management support? Significant declines. Organizational learning? A decline. Is this a pathologic culture? Does management really want to know what is going on?

30. First, for this organization, nearly all dimensions in 2007 were more positive than the baseline in With one exception…staffing.
Reporting increased and is near the top of the range. Communication openness and Feedback improved significantly. And who was driving these changes?…front-line managers. It will be interesting to see if perceptions of just culture continue to improve…Is this a generative culture?

31. Survey Items Nonpunitive Response to Error
Comparison in Reassessment Results for Just Culture
Between Bureaucratic/Pathologic and Generative Cultures
Survey Items Nonpunitive Response to Error
CAH B
2005
2007
CAH G
Staff feel like their mistakes are held against them. (Disagree)
53%
25%
38%
68%
When an event is reported, it feels like the person is being written up, not the problem. (Disagree)
40%
36%
48%
Staff worry that mistakes they make are kept in their personnel file. (Disagree)
13%
24%
43%
This slide compares item results for a CAH with a bureaucratic approach to information and one with a more generative approach. Our intervention increased the amount of information being reported but CAH B used the old method of discussing reported events with the individual. They did not look for patterns or use aggregate root cause analysis to see patterns of error in the context of their processes. CAH G engages staff in aggregate analysis of falls and medication errors on a quarterly basis, which resulted in improvements in nonpunitive response to error.

32. This slide illustrates what happens when survey results are ignored
This slide illustrates what happens when survey results are ignored. Participating in the baseline survey educated respondents about the beliefs and practices associated with a safety culture and raised expectations that leaders would act and change would occur. When change did not occur, respondents in this hospital held their organization to a higher standard at reassessment than they had at baseline. So you see a decline in every dimension except reporting, especially in perceptions of whether the organization is a learning organization.

33. Finally, this slide demonstrates the significant impact of improving staffing and perceptions of s just culture…You see improvements in nearly every survey dimension but not in management support.

34. Strategy for Leading Change
Engage: How do we make our hospital safer for patients and staff?
Educate: What do we need to do?
Execute: How do we ensure we do it?
Evaluate: How will we know we made a difference?
Endure: How will we sustain the change?
Expand: How will we share our success with others?
Using information effectively means that there is a strategy to implement change in which explicit attention is paid to the steps of change. Peter Pronovost and colleagues at Johns Hopkins use this 6 step strategy.
Pronovost et al. (2006). Creating high reliability in health care organizations. HSR, 41(4), Part II,

35. Strategy for Leading Change
Eight Steps of Change
A simple fable helps learning organizations to overcome resistance to change
The change strategy inherent in the fable about penguins learning to cope with their melting iceberg are similar to Pronovost’s…
Kotter J, Rathgeber H. (2006). Our iceberg is melting: Changing and
succeeding under any conditions. New York: St. Martin's Press.

36. Recap and Questions…
How leaders used information from the baseline is a major determinant of reassessment results
Significant improvement in a dimension requires attention to educating, executing, and evaluating the results of changes that were implemented
QUESTIONS??

37. The interaction of practices that support reporting, just, flexible, and learning cultures produces an informed, safe organization that is highly reliable.
In the last portion of our discussion, I want to demonstrate how results on specific survey items reveal the interaction between the components of culture and identify specific practices that are needed to address an impairment or weakness in organizational learning. e.

38. Survey Items Reflecting Components of a Safe, Informed Culture Overall
EXAMPLE OF RESPONSES FROM FOUR COMPONENTS OF CULTURE
Survey Items Reflecting Components of a Safe, Informed Culture
Overall
Acute/
Skilled
Surgery
REPORTING: When a mistake is made, but is caught and corrected before affecting the pt, how often is this reported? (Frequently)
65%
73%
78%
JUST: When an event is reported, it feels like the person is being written up, not the problem. (Disagree)
50%
20%
FLEXIBLE: Staff feel free to question the decisions or actions of those with more authority. (Agree)
42%
13%
56%
LEARNING: Mistakes have led to positive changes here. (Agree)
67%
40%
This slide provides a snapshot of item responses from each of the four components of a safe, informed culture for an organization. The aggregate overall results, the results for the acute/skilled care area and the results for surgery.
What I want you to see is that fairly strong reporting doesn’t result in a safe, informed culture if events are seen in isolation. If staff feels like the person is being written up, and are afraid to speak up to those with more authority, it is likely they don’t use Safety Briefings or aggregate root cause analysis…practices that allow learning informally in the context of daily work and formally in the context of the system. The emphasis of both practices is the clear connection for front-line staff that mistakes lead to learning.

39. What practices are needed?
EXAMPLE OF RESPONSES FROM FLEXIBLE CULTURE ITEMS
Survey Items From Teamwork Within Departments
Overall
Acute/
Skilled
Surgery
People support one another in this department. (Agree)
92%
80%
78%
When a lot of work needs to be done quickly, we work together as a team to get the work done. (Agree)
89%
73%
88%
In this department, people treat each other with respect. (Agree)
84%
60%
75%
When one area in this department gets really busy, others help out. (Agree)
68%
13%
44%
This slide provides item responses from the Teamwork Within Depts Dimension. The disconnect between the belief that people support one another and the behavior of helping each other out indicates a need for teamwork skills—huddles, briefs, debriefs. Whenever you see this disconnect between belief and behavior, ask yourself which tools/practices are needed?
What practices are needed?

40. What practices are needed?
EXAMPLE OF RESPONSES FROM LEARNING CULTURE ITEMS
Survey Items Reflecting Learning Culture (Organizational Learning)
Overall
Acute/
Skilled
Surgery
We are actively doing things to improve patient safety. (Agree)
91%
100%
89%
Mistakes have led to positive changes here. (Agree)
67%
40%
78%
After we make changes to improve pt safety, we evaluate their effectiveness. (Agree)
74%
87%
71%
When events are seen in isolation and staff is not given an opportunity to participate in learning through RCA, Briefings or WalkRounds, then they are less likely to see a clear relationship between mistakes and positive changes.
What practices are needed?

41. ? Component of Culture Practices
What practices did organizations engineer to achieve an informed culture?
Component of Culture
Practices
REPORTING: When a mistake is made that could harm the pt but does not, how often is this reported? ?
JUST: When an event is reported, it feels like the person is being written up, not the problem.
FLEXIBLE: We are given feedback about changes put into place based on event reports.
LEARNING: Mistakes have led to positive changes here.

42. Recap and Questions…
Specific item results reveal the impairments or weaknesses in learning
Practices to address learning impairments may need to be specific to departments, shifts, job titles, which is why it is important to be able to accurately categorize employees
QUESTIONS????

43. Component of Culture Practices
What practices did organizations engineer to achieve an informed culture?
Component of Culture
Practices
REPORTING: When a mistake is made, but is caught and corrected before affecting the pt, how often is this reported?
MEDMARX voluntary medication error reporting program
JUST: When an event is reported, it feels like the person is being written up, not the problem.
Anonymous reports of near misses, Close Encounters of the Safety Kind
FLEXIBLE: Staff feel free to question the decisions or actions of those with more authority.
Use of structured communication tools as necessary to overcome authority patterns
LEARNING: Mistakes have led to positive changes here.
Documented changes in med use system on process map
The next four slides provide examples of the interaction between practices across the four components of culture….

44. Component of Culture Practices
What practices did organizations engineer to achieve an informed culture?
Component of Culture
Practices
REPORTING: When a mistake is made, but is caught and corrected before affecting the pt, how often is this reported?
Safety Briefing
JUST: When an event is reported, it feels like the person is being written up, not the problem.
Exchange of information about near misses in the context of daily work
FLEXIBLE: In this department, we discuss ways to prevent errors from happening again.
Exchange of information about defenses to intercept errors in the context of daily work
LEARNING: Mistakes have led to positive changes here.
Immediate feedback about how mistakes lead to positive change
Reporting…systematic collection of information about errors, informal exchange of information in Safety Briefings, Leadership WalkRounds
Just…

45. Component of Culture Practices
What practices did organizations engineer to achieve an informed culture?
Component of Culture
Practices
REPORTING: When a mistake is made, but is caught and corrected before affecting the pt, how often is this reported?
Leadership
WalkRounds
JUST: When an event is reported, it feels like the person is being written up, not the problem.
Informal exchange of information about errors and near misses in the context of daily work
FLEXIBLE: Staff feel free to question the decisions or actions of those with more authority.
Use of structured communication tools as necessary to overcome authority patterns
LEARNING: Mistakes have led to positive changes here.
Immediate feedback about how mistakes lead to positive change
Reporting…systematic collection of information about errors, informal exchange of information in Safety Briefings, Leadership WalkRounds
Just…

46. Component of Culture Practices
What practices did organizations engineer to achieve an informed culture?
Component of Culture
Practices
REPORTING: When a mistake is made that could harm the pt, but does not, how often is this reported?
Medmarx voluntary medication error reporting program, reports of pt. and visitor falls
JUST: When an event is reported, it feels like the person is being written up, not the problem.
Quarterly aggregated root cause analyses of med errors and falls keeps focus on systems, not individuals
FLEXIBLE: Staff feel free to question the decisions or actions of those with more authority.
Action plans created to address system problems identified in aggregate root cause analysis
LEARNING: Mistakes have led to positive changes here.
Action plans and results posted and communicated to staff

47. Lessons Learned
HSOPSC is a strategic management tool that can guide implementation and evaluation of practices that support an informed, safe culture in nation’s smallest hospitals
Survey dimensions reflect Reason’s components of culture and can be linked to practices
Heightens awareness of culture variation within organizations
Detects changes in culture over time
Reassessment with HSOPSC reveals
How leaders use information
Whether organizations engineered practices to support the four components of culture in response to baseline survey
Driver of culture: how we collect, analyze, disseminate, use information, which is dependent upon leadership style and professional training

48. Lessons Learned
Execution of practices that support a safe, informed culture in resource-deficient CAHs requires
Assessment of safety culture using effective data collection methods
An infrastructure that supports systematic reporting
Adherence to principles of just culture
Team training to support a flexible culture
Learning from error in the context of daily work (Safety Briefings and Leadership Walkrounds)
Systematically learning from events using individual RCA and aggregate RCA to learn from multiple non-harmful errors

49. Lessons Learned
Because it is the leadership skills of front-line managers and the nature of professional training that determine how we use information to learn from experience, we must assess safety culture at multiple levels: units, depts, positions, hospital, and multiple hospitals
Using and doing lead to thinking and believing
Language of systematic error reporting supports just culture
Becoming a learning organization requires practices that support all components of a safe, informed culture
Driver of culture: how we collect, analyze, disseminate, use information, which is dependent upon leadership style and professional training

50. Lessons Learned from Dundy County, Nebraska
“Once the AHRQ survey identified areas for improvement, through the grant, we spent the next year working on those areas. The education and training on teamwork, communication, and RCA gave us tools we hadn’t heard of. We have seen our organization change from one that makes the same errors over and over to one that analyzes errors and attempts to learn from them.”
Lessons Learned from Dundy County, Nebraska
(pop. 2,109)
James Reason has a quote: Learning disabilities

51. Web site where tools are posted
Contact Information
Katherine Jones, PhD, PT
Anne Skinner
Web site where tools are posted