1. For further information about this feedback report, contact: Name DR RICHARD ZAMMIT Title DIRECTOR HEALTH CARE SERVICES STANDARDS Address PALAZZO CASTELLANIA MERCHANTS STREET VALLETTA, MALTA Phone 00356 22992655 Email richard.zammit@gov.mt Hospital Survey on Patient Safety Culture MATER DEI HOSPITAL 2008 PLEASE DO NOT CITE – UNPUBLISHED MATERIAL

2. Survey Background The Hospital Survey on Patient Safety Culture is sponsored in the USA by the Quality Interagency Coordination Task Force (QuIC), a group established in accordance with a 1998 Presidential directive to ensure that all Federal agencies involved in purchasing, providing, studying, or regulating health care services are working together and toward a common goal of improving quality care. This research is funded in the USA by the Agency for Healthcare Research and Quality (AHRQ). The development of this safety culture assessment tool included a review of the scientific literature pertaining to safety, error and accidents, as well as error reporting. In addition, hospital employees and managers were interviewed to identify key patient safety and error reporting issues. Other published and unpublished safety culture assessment tools also were examined. Page

3. Survey Measures Four overall patient safety outcomes: 1.Overall perceptions of safety 2.Frequency of events reported 3.Number of events reported 4.Overall patient safety grade The research survey also is intended to measure: The Hospital Survey on Patient Safety Culture is designed to measure: Ten dimensions of culture pertaining to patient safety: 1.Supervisor/manager expectations & 6. Nonpunitive response to error actions promoting patient safety 7. Staffing 2.Organizational learning – continuous 8. Hospital management support improvement for patient safety 3.Teamwork within units 9. Teamwork across hospital units 4.Communication openness 10. Hospital handoffs & transitions 5. Feedback & communications about error Page

4. Survey Methodology In MAY – JUNE 2008, the Hospital Survey on Patient Safety Culture interview was conducted to a sample of 400staff at MATER DEI HOSPITAL. Overall, 369 responses to the survey were recorded, a 92% response rate. The face to face interview method was chosen to maximize response rates. In this feedback report, the percentages of employee responses to specific survey items are grouped according to the safety culture dimensions being assessed. Some percentages shown in the graphs may not add to exactly 100 percent, due to rounding. Due thanks to Dr Christine Baluci who carried out these interviews during her Public Health training programme with the Department for Health Care Services Standards and Ms Carmen Azzopardi for data inputting. Page

5. Demographic Data about Respondents 1. Primary hospital work area, department or clinical area where respondents spend most of their work time: 10.6 % No specific unit 0.8 % Mental health 13.8 % Medicine (non-surgical)2.2 % Rehabilitation 22.8 % Surgery2.7 % Pharmacy 7.0 % Obstetrics3.0 % Laboratory 11.4 % Pediatrics5.4 %Radiology 4.9 % Emergency department5.1 % Anesthesiology 6.5 % Intensive care unit 3.8 % Other NIL % (Blank/Missing) Page

6. 1.cont: Position in hospital of staff interviewed: 47% nurses 12% other 10% technicians 4% administration 7% patient care asst/hospital aide 13% attending staff physician 5% therapist 2% pharmacists Demographic Data about Respondents

7. Demographic Data (continued) 3. Time worked --in the hospital1% Less than 20 hours9% 20 to 39 hours90% 40 hours or more (hours/week) --in the hospital5% Less than 1 year23% 1 to 5 years21% 6 to 10 years (years) 19% 11 to 15 years15% 16 to 20 years17% 21 years or more --in their current hospital work area20% Less than 1 year25% 1 to 5 years24% 6 to 10 years (years) 15% 11 to 15 years 10% 16 to 20 years6% 21 years or more --in their current7% Less than 1 year 25% 1 to 5 years 23% 6 to 10 years specialty (years) 18% 11 to 15 years 15% 16 to 20 years12% 21 years or more 4. Percentage of respondents with direct interaction or contact with patients: 91% Page

8. Main Findings: Strengths Teamwork within units – The extent to which staff support one another, treat each other with respect, and work together as a team was a patient safety composite with the highest average percent positive response (75%), indicating this is an area of strength. The survey item with the highest average percent positive response (83%) was: ‘People support one another in this unit’. Patient safety grade – The majority of respondents within Mater Dei Hospital (68 percent) gave their work area or unit a grade either ‘A – Excellent’ (16 percent) or “B – Very Good” (52 percent) on patient safety. Page

9. Main Findings: Areas for Improvement Non punitive response to errors – The extent to which staff feel that their mistakes and event reports are not held against them and that mistakes are not kept in their personnel file was the patient safety composite with the lowest average percent positive response (39 percent), indicating this is an area with a potential for improvement. The survey item with the lowest average percent response (34 percent) was: ‘ Staff worry that mistakes they make are kept in their personnel file ’. Number of events reported – On average, the majority of respondents (70 percent) reported no events over the past 12 months. It is likely that this percentage represents under reporting of events and is identified as an area for improvement because patient safety problems may not be recognised or identified and therefore may not be addressed.. Page

10. 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) Page

11. 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. Page

12. Number of Events Reported Respondents were asked to indicate the number of events they had reported in the past 12 months. 1. In the past 12 months, how many event reports have you filled out and submitted? (Survey item G1) 100% 80% 60% 40% 20% 1 to 23 to 56 to 10Zero or No response 11 to 20 21 or more % of Respondents Page

13. Overall Patient Safety Grade Respondents were asked to give their work unit an overall grade on patient safety. 2. Please give your work area/unit in this hospital an overall grade on patient safety. (Survey item E1) 100% 60% 40% 20% 80% % of Respondents A Excellent B Very Good C Acceptable D Poor E Failing Page

14. Supervisor/Manager Expectations & Actions Promoting 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. My supervisor/manager says a good word when he/she sees a job done according to established patient safety procedures. (B1) 2. My supervisor/manager seriously considers staff suggestions for improving patient safety. (B2) R 3.Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking shortcuts. (B3) R 4.My supervisor/manager overlooks patient safety problems that happen over and over. (B4) Page

15. Organizational Learning—Continuous Improvement NOTE: The item letter and number in parentheses indicate the item’s survey location. Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree 1.We are actively doing things to improve patient safety. (A6) 2.Mistakes have led to positive changes here. (A9) 3.After we make changes to improve patient safety, we evaluate their effectiveness. (A13) Page

16. 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) Page

17. 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 Page

18. 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 Page

19. 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 Page

20. Staffing Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree R Indicates reversed-worded items. NOTE: The item letter and number in parentheses indicate the item’s survey location. 1.We have enough staff to handle the workload. (A2) R 2.Staff in this unit work longer hours than is best for patient care. (A5) R 3.We use more agency/temporary staff than is best for patient care. (A7) R 4.We work in “crisis mode” trying to do too much, too quickly. (A14) Page

21. 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) Page

22. 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 units do not coordinate well with each other. (F2) R 4.It is often unpleasant to work with staff from other hospital units. (F6) Page

23. 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) Page

24. Respondents comments Page ‘ I thought I would feel better at Mater Dei Hospital but it is the opposite. The public is expecting more good service from Mater Dei Hospital when the same problems that were at St Lukes Hospital have migrated with us. The main problem is overcrowding.’

25. Patient Safety Culture CompositesAverage % of Database Hospitals MDHMDH percentile 1.Teamwork Within Units79%75%25 th – 50 th 2.Supervisor/Manager Expectations & Actions Promoting Patient Safety75%72%25 th – 50 th 3.Management Support for Patient Safety70%37%< 10 th 4.Organisational Learning – Continuous Improvement70%62%10 th – 25 th 5.Overall Perception of Patient Safety64%53%10 th – 25 th 6Feedback & Communication About Error62%46%< 10 th 7 Communication Openness 62%65%50 th – 75 th 8.Frequency of Events Reported60%29%< 10 th 9.Teamwork Across Units57%49%25 th – 50 th 10.Staffing55%35%< 10 th 11. Handovers & Transitions 45%44%50 th – 75 th 12.Non Punitive Response to Error44%39%25 th – 50 th Comparative Results

26. Institutionalised reporting system Communication Openness Handovers & Transitions REPORTING and LEARNING SYSTEM

27. The way forward EU roadmap: High Level Group on Patient Safety recommendations – a. Establish effective reporting and learning systems….. b. Establish a transparent, open and honest patient safety culture by clarifying the legal situation on health professionals’ liability issues and creating an environment where it is easy to report and there is an opportunity to learn from mistakes without fear of punishment.

28. Leadership in management ‘Leaders as teachers help people restructure their views of reality to see beyond the superficial conditions and events into the underlying causes of problems and therefore to see new possibilities for shaping the future.’ Building learning organisations Peter Senge

29. Center of excellence The really critical innovation occurs at the interface with the customers ! The staff are our main assets at ‘the state of the art’ Mater Dei Hospital. Managerial responsibility to provide the appropriate framework to turn knowledge from mistakes’ reporting into value.