2. Evolution of patient safety culture in Belgian hospitals 4 th International Improvement Science and Research Symposium 8 April 2014, Paris Annemie Vlayen, PhD Hasselt University, Faculty of Medicine & Life Sciences, Patient Safety Research Group, Belgium annemie.vlayen@uhasselt.be

3. The authors declare that there are no conflicts of interest Evolution of patient safety culture in Belgian hospitals after implementing a national patient safety plan Annemie Vlayen 1, Johan Hellings 1,2, Ward Schrooten 1, Leandro Garcia Barrado 3, Margareta Haelterman 4 and Hilde Peleman 4 1 Hasselt University, Faculty of Medicine & Life Sciences, Patient Safety Research Group, Belgium 2 AZ Delta, Roeselare-Menen, Belgium 3 Hasselt University, Interuniversity Institute for Biostatistics and Statistical Bioinformatics, Belgium 4 FPS Health, Food Chain Safety and Environment, Acute, chronic and Elderly Care Policy Unit, Brussels, Belgium

4. Facts & Figures Brussels-Capital Bilingual 14% of hospitals Flandria Dutch (Flemish) speaking 53% of hospitals German speaking French speaking Currently 189 Belgian hospitals 104 acute 64 psychiatric 21 long-term care Wallonia 33% of hospitals

5. Belgian Federal Program on Quality and Safety STRUCTUREPROCESSOUTCOME Pillar 1 Pillar 2 Pillar 3 Government funding € 7.810.000/ year www.patient-safety.be

6. http://www.uhasseltq.be

7. Research questions 1.To what extent did the Belgian hospitals’ safety culture evolve after participating in the federal program on quality and patient safety (after a period of three years)? 2.To what extent could variations in safety culture be explained by predictor variables? Language (regional context) Hospital characteristics (type of hospital, statute, hospital size) Respondent characteristics (work area, staff position, work experience, numbers of hours worked per week) Measurement occasion (first or second measurement) time effect?

8.  Participants: Belgian acute, psychiatric and long-term care hospitals participating in the Federal Program Quality and Safety  Instrument: Hospital Survey on Patient Safety Culture (AHRQ) Validated versions in Dutch (Flemish) French German  Follow-up study design Safety culture survey design 2008 2012 Baseline measurement Follow-up measurement Benchmarking 2017 Third measurement Benchmarking Vlayen A, Hellings J, Claes N, Peleman H, Schrooten W: A nationwide hospital survey on patient safety culture in Belgian hospitals: setting priorities at the launch of a 5-year patient safety plan. BMJ Qual Saf 2012, 21:760-767. 180 out of 205 hospitals (88%) 179 out of 197 hospitals (91%) ?

9. Safety Culture 12 dimensions (42 items) D1 Supervisor/manager expectations and actions promoting safety D2 Organizational learning– continuous improvement D3 Teamwork within units D4 Communication openness D5 Feedback and error communication D6 Non-punitive response to error D7 Staffing D8 Management support for patient safety D9 Teamwork across units D10 Handoffs and transitions O1 Overall perceptions of patient safety O2 Frequency of events reported Hospital Survey on Patient Safety culture Unit level Hospital level Outcome dimensions Vlayen A, Hellings J, Claes N, Peleman H, Schrooten W: A nationwide hospital survey on patient safety culture in Belgian hospitals: setting priorities at the launch of a 5-year patient safety plan. BMJ Qual Saf 2012, 21:760-767.

10. ... Benchmark database Long-term care Comparative research: Methodology Data collection Hospital wide measurement Survey form Measurement protocol Anonymously to all individuals with (in)direct patient interaction Paper-based OR Electronically 13 week time table Workshops + technical support Electronic data entry Comparative report Exclusion criteria Entire section incomplete <1/2 items answered All items scored identically Statistical analysis Respondent level Hospital level Unit group level Professional group level Odds ratios Dendogram

11. Comparative research: Participants BENCHMARKING 1 (2008) 143 hospitals BENCHMARKING 2 (2012) 141 hospitals 90 acute 42 psychiatric 11 LTC 83 acute 48 psychiatric 10 LTC Language Dutch (Flemish) French Bilingual 98 44 1 96 40 5 Survey method Paper based Electronic Mixed method Missing 117 19 7 0 90 32 16 3 Response rates Physicians Employees 53,7% 35,6% 56,7% 50,4% 31,8% 53,6% Number of respondents Nurses Physicians 55 225 31 894 4 883 56 505 34 326 5 256 111 trending hospitals 69 acute 34 psychiatric 8 long-term care (LTC)

12. Evolution of safety culture Safety culture dimensions D1: Supervisor/manager expectations and actions promoting safety D2: Organizational learning–continuous improvement D3: Teamwork within units D4: Communication openness D5: Feedback and error communication D6: Non-punitive response to error D7: Staffing D8: Management support for patient safety D9: Teamwork across units D10: Handoffs and transitions O1: Overall perceptions of patient safety O2: Frequency of events reported Measurement 1 2 +8.5%

13. Safety culture dimensions D1: Supervisor/manager expectations and actions promoting safety D2: Organizational learning–continuous improvement D3: Teamwork within units D4: Communication openness D5: Feedback and error communication D6: Non-punitive response to error D7: Staffing D8: Management support for patient safety D9: Teamwork across units D10: Handoffs and transitions O1: Overall perceptions of patient safety O2: Frequency of events reported Evolution of safety culture

14. Improvement > 5% Decrease > 5% Evolution of safety culture

15. Variability between hospital units 1 = Many different hospital units/ no specific unit 2 = Internal medicine 3 = Surgical care units 4 = Operating theatre 5 = Gynaecology / obstetrics 6 = Pediatrics 7 = Intensive care units 8 = Emergency 9 = Rehabilitation 10 = Geriatrics 11= Psychiatrics 12 = Medical-technical services (diagnostics) 13 = Pharmacy Vlayen A, Schrooten W, Wami W, Aerts M, Claes N, Barrado Garicia L and Hellings J. Variability of patient safety culture in Belgian acute hospitals, Journal of Patient safety. 2013 Sep 27. [Epub]

16. Variability between professional groups Vlayen A, Schrooten W, Wami W, Aerts M, Claes N, Barrado Garicia L and Hellings J. Variability of patient safety culture in Belgian acute hospitals, Journal of Patient safety. 2013 Sep 27. [Epub] 1 = Nurse 2 = Head nurse 3 = Nursing aid 4 = Physician 5 = Physician head of department 6 = Physician assistant/ in training 7 = Pharmacist 8 = Assistant pharmacy 9 = Middle management 10 = Technician 11 = Therapist

17. Lessons learned 1.( Slight) positive evolution of safety culture in Belgian hospitals  Key Problem areas in Belgian hospitals  Handoffs and transitions  Staffing  Reporting of events + punitive response to error  Improvement for ‘Management support for patient safety’ 2.Large comparative safety culture databases allow identifying patterns and trends Tailor-made approach for improving safety culture Significant predictorsLess significant predictors Hospital type + statute Regional context (‘language’) Work area Profession Measurement occasion (time effect) Hospital size (number of beds) Work experience

18.  Need for implementation research to enriching evidence of the effectiveness of safety culture strategies  Need for mixed-methods design for evaluating safety culture: quantitative + qualitative approach  Need for integrating and linking of Quality and Safety data Safety culture Internal hospital organization of Quality and Safety → Governance Leadership styles Individual safety performance of professionals (behavior) Outcomes of care Future approach

19. Belgian Federal program on Quality and Patient Safety (2013-2017) themes: Safety culture improvement Communication (Clinical) Leadership Patient and family empowerment High-risk medication Identity-vigilance Safe surgery Transmural care More information on: www.patient-safety.bewww.patient-safety.be

20. References  Belgian safety culture measurement tools, validation reports and benchmark results available from: www.patient-safety.bewww.patient-safety.be  Vlayen A, Hellings J, Schrooten W, Garcia Barrado L, Haelterman M, Peleman H: EVOLUTION OF PATIENT SAFETY CULTURE IN BELGIAN HOSPITALS AFTER IMPLEMENTING A NATIONAL PATIENT SAFETY PLAN. BMJ Qual Saf 2014;23:346-347 doi:10.1136/bmjqs-2014-002893.2  Vlayen A, Hellings J, Claes N, Peleman H, Schrooten W: A nation- widehospital survey on patient safety culture in Belgian hospitals: setting priorities at the launch of a 5-year patient safety plan. BMJ Qual Saf 2012, 21:760-767.  Vlayen A, Schrooten W, Wami W, Aerts M, Claes N, Barrado Garicia L and Hellings J. Variability of patient safety culture in Belgian acute hospitals, Journal of Patient safety. 2013 Sep 27. [Epub ahead of print]

21. Contact information Dr. Annemie Vlayen, PhD Hasselt University, Faculty of Medicine & Life Sciences, Patient Safety Research Group, Belgium annemie.vlayen@uhasselt.be