1. 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

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

4. 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  

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

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

7. 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

8. 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

9. Brief overview of Safety Culture

10. 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”

11. 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

12. 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

13. Why Does Safety Culture Matter?

14. 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.

15. 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

16. Measuring Safety Culture

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

18. 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

19. 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

20. 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.

21. 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)

22. 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?

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

24. Overview of the Survey Administration Process

25. Cohort 2 HSOPS Survey Period
Opens: Dec 4th, :00 pm ET Closes: Feb 13th, :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 for more information.

26. 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, , meetings)
Upload Unit Data
Enter unit background info
Start!
Upload participant addresses or previously collected data

27. 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

28. Effective HSOPS Surveys…
Are confidential and anonymous
Responses not linked with 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

29. HSOPS Key Team Members

30. 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

31. 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 addresses
Sorra & Nieva, 2004

32. = 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

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

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

35. 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

36. 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 for more information.

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

38. 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

39. 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

40. 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
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

41. 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
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

42. 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 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 Jun;22(3):
MacDavitt K, Chou SS, Stone PW. Organizational climate and health care outcomes. Jt Comm J Qual Patient Saf 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 Dec;6(4):
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 Jul 31. [Epub ahead of print]
Schein E. Organizational culture and leadership, 4th edition. San Francisco, CA: Jossey- Bass

43. 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 Oct- Dec;34(4):
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 Jul 10. [Epub ahead of print].
Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No ). AHRQ Publication No 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 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 Nov;37(11):
Weaver SJ. A configural approach to patient safety climate: The relationship between climate profile characteristics and patient safety. Doctoral dissertation. University of Central Florida
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.

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

45. 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

46. Next Onboarding Call: Project Kickoff
December 17, :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

47. 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

48. 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

49. 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)

50. CUSP 4 MVP – VAP Website
Visit:

51. 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