1. Patient Safety Culture in West Virginia’s Rural Hospitals In the beginning…. West Virginia Medical Institute

2. Background The IOM Report. To Err is Human, focused attention on patient safety and medical errors However, rural West Virginia hospitals did not have systems or infrastructure in place to improve processes as suggested by IOM WVMI saw opportunity to assist and implemented the WV Patient Safety Improvement Program, initially with corporate funds We received an AHRQ grant 9/2004 to expand the scope of the original project

3. Objectives Improve patient safety and the culture of patient safety in rural West Virginia hospitals by: 1. Offering a free, confidential event reporting system protected from legal discovery 2. Developing a collaborative network to share information and best practices

4. Barriers to Implementation Lack of IT Infrastructure in rural areas of West Virginia Peer Review Statutes- Hospital legal staff feared data could be discoverable Computer Literacy of hospital staff Lack of trained IT staff

5. Today 23 hospitals are participating in the AHRQ project to date, 13 of these are CAH Baseline evaluation question: What is the patient safety culture in West Virginia’s critical access hospitals?

6. Critical Access Hospitals There are 1013 CAHs across the nation Small rural hospitals differ from larger urban facilities in many different ways that can impact on their ability to implement and sustain patient safety initiatives. Do they differ with respect to the patient safety culture in their facilities?

7. Hospital Survey on Patient Safety Culture: Methodology Distributed to staff designated by hospital administration at time of system training.* Completed surveys turned in at end of training session. Data scanned into an Excel database and analyzed used SAS. Data collection is ongoing as hospitals are still being recruited.

8. Hospital Survey: Results Through April 2005, 860 surveys have been completed representing staff at 16 hospitals 10 of the 16 (62.5%) are CAHs

9. Demographic Data about Respondents 1. Primary hospital work area, department or clinical area where respondents spend most of their work time: 14.9 % Many different hospital units / No specific unit 0.3% Psychiatry / mental health 11.1% Medicine (non-surgical)3.8% Rehabilitation 1.9% Surgery2.2% Pharmacy 0.6% Obstetrics4.8% Laboratory 0.3% Pediatrics4.4% Radiology 9.5% Emergency department0.3% Anesthesiology 0.3% Intensive care unit (any type)45.4% Other 2. Staff position in the hospital: 21.2 % Registered nurse2.6% Dietician 0.3% Physician assistant / Nurse practitioner8.3% Unit assistant / Clerk / Secretary 6.0% LVN / LPN0.6% Respiratory therapist 6.1%Patient care assistant / Hospital aide / Care partner1.3% Physical, occupational, or speech therapist 0.3% Attending / Staff physician6.1% Technician (e.g., EKG, Lab, Radiology) 0.0% Resident physician / Physician in training24.4% Administration / Management 6.1% Pharmacist20.5%Other

10. AHRQ Staff Survey Summary Results

11. Demographic Data (continued) 3. Time worked --in the hospital8.4% Less than 1 year33.6% 1 to 5 years24.9% 6 to 10 years (years) 8.7% 11 to 15 years9.9% 16 to 20 years14.4% 21 years or more --in their current hospital work area10.2% Less than 1 year40.7% 1 to 5 years23.1% 6 to 10 years (years) 9% 11 to 15 years 7.2% 16 to 20 years9.9% 21 years or more --in their current4.5% Less than 1 year 24.5% 1 to 5 years 17.6% 6 to 10 years specialty (years) 16.1% 11 to 15 years 11.3% 16 to 20 years 26% 21 years or more 4. Percentage of respondents with direct interaction or contact with patients: 73.2%

12. Overall Perceptions of Safety R Indicates reversed-worded items. NOTE: The item letter and number in parentheses indicate the item’s survey location. Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree 1.Patient safety is never sacrificed to get more work done. (A15) 2.Our procedures and systems are good at preventing errors from happening. (A18) R 3.It is just by chance that more serious mistakes don’t happen around here. (A10) R 4.We have patient safety problems in this unit. (A17)

13. Frequency of Events Reported 1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported? (D1) 2. When a mistake is made, but has no potential to harm the patient, how often is this reported? (D2) 3. When a mistake is made that could harm the patient, but does not, how often is this reported? (D3) % Never/ % Sometimes % Most of the Rarely time/Always Survey Items NOTE: The item letter and number in parentheses indicate the item’s survey location.

14. Teamwork Within Units NOTE: The item letter and number in parentheses indicate the item’s survey location. Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree 1.People support one another in this unit. (A1) 2.When a lot of work needs to be done quickly, we work together as a team to get the work done. (A3) 3.In this unit, people treat each other with respect. (A4) 4.When one area in this unit gets really busy, others help out. (A11)

15. Communication Openness 1. Staff will freely speak up if they see something that may negatively affect patient care. (C2) 2. Staff feel free to question the decisions or actions of those with more authority. (C4) R 3. Staff are afraid to ask questions when something does not seem right. (C6) R Indicates reversed-worded items. NOTE: The item letter and number in parentheses indicate the item’s survey location. % Never/ % Sometimes % Most of the Rarely time/Always Survey Items

16. Feedback and Communication About Error 1.We are given feedback about changes put into place based on event reports. (C1) 2. We are informed about errors that happen in this unit. (C3) 3.In this unit, we discuss ways to prevent errors from happening again. (C5) NOTE: The item letter and number in parentheses indicate the item’s survey location. % Never/ % Sometimes % Most of the Rarely time/Always Survey Items

17. Nonpunitive Response to Error R 1.Staff feel like their mistakes are held against them. (A8) R 2. When an event is reported, it feels like the person is being written up, not the problem. (A12) R 3.Staff worry that mistakes they make are kept in their personnel file. (A16) R Indicates reversed-worded items. NOTE: The item letter and number in parentheses indicate the item’s survey location. Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree

18. Hospital Management Support for Patient Safety R Indicates reversed-worded items. NOTE: The item letter and number in parentheses indicate the item’s survey location. Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree 1.Hospital management provides a work climate that promotes patient safety. (F1) 2.The actions of hospital management show that patient safety is a top priority. (F8) R 3. Hospital management seems interested in patient safety only after an adverse event happens. (F9)

19. Teamwork Across Hospital Units R Indicates reversed-worded items. NOTE: The item letter and number in parentheses indicate the item’s survey location. Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree 1.There is good cooperation among hospital units that need to work together. (F4) 2.Hospital units work well together to provide the best care for patients. (F10) R 3.Hospital unites do not coordinate well with each other. (F2) R 4.It is often unpleasant to work with staff from other hospital units. (F6)

20. Hospital Handoffs & Transitions R Indicates reversed-worded items. NOTE: The item letter and number in parentheses indicate the item’s survey location. Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree R 1.Things “fall between the cracks” when transferring patients from one unit to another. (F3) R 2.Important patient care information is often lost during shift changes. (F5) R 3.Problems often occur in the exchange of information across hospital units. (F7) R 4.Shift changes are problematic for patients in this hospital. (F11)

21. How Does CAH Pt. Safety Culture Differ from Larger Hospitals in WV? At the level of composite scores the differences are minimal, with the exceptions of: Communication Openness, Teamwork Across Hospital Units, and Hospital Handoffs and Transitions.

22. Culture differences continued Differences appear in specific questions 74% v 57% strongly agree/agree that patient safety is NEVER sacrificed to get more work done. 64% v 44% strongly agree/agree that they have enough staff to handle the workload. 29% v 44% strongly agree/agree that they work in “crisis mode” trying to do too much, too quickly 58% v 42 SA/A there is good cooperation among hospital units that need to work together

23. Discussion: So What? Reminder: Convenience sample, reflecting the opinions of those chosen or choosing to participate in training. The patient safety culture in WV rural hospitals of all sizes still have areas needing improvement, e.g., attention to near misses, non-punitive response. Some of the ways in which CAH culture may differ, e.g., better teamwork, better transitions could theoretically support the ease with which patient safety interventions could be implemented.

24. Time will tell

25. Contact Information Gail Bellamy, Principal Investigator, gbellamy@wvmi.org gbellamy@wvmi.org Patricia Ruddick, Project Manager, pruddick@wvmi.org pruddick@wvmi.org David Lomely, Analyst, dlomely@wvmi.org