1. © The Johns Hopkins University and The Johns Hopkins Health System Corporation, 2011 Conducting a Culture Check Up Jill Marsteller, PhD, MPP Mike Rosen, PhD, Sallie Weaver, PhD August 9, 2012

2. Agenda Brief review of benefits of strong safety culture Interventions to improve safety culture How to conduct a culture check-up 2

3. Safety Culture and Adverse Events at the Hospital Level HSOPS  PSI Composite –Handoffs and transitions of care: r = -.50 –Teamwork across units: r = -.42 –Frequency of events reported: r = -.33 –Teamwork within units: r = -.32 –Staffing: r = -.29 –Overall perceptions of patient safety: r = -.26 –Management support for patient safety: r = -.25 –Organizational learning: r = -.24 –Supervisor / manager expectations and actions: r = -.23 –Nonpunitive response to error: r = -.22 Armstrong Institute for Patient Safety and Quality 3 Mardon et al., 2010

4. Safety culture is related to  Patient outcomes  Patient care experience  Infection rates, sepsis  Postop. hemorrhage, respiratory failure, accidental puncture/laceration  Treatment errors  Clinician outcomes  Incident reporting, burnout, turnover Mardon et al., 2010; Weaver, 2011; MacDavitt et al., 2007; Singer et al., 2009; Sexton et al., 2011 Armstrong Institute for Patient Safety and Quality 4

5. Safety Culture and Length of Stay in the ICU …there was a 15% increase in length of stay for an ICU. For every 10% decrease in percent positive response to safety climate items… Armstrong Institute for Patient Safety and Quality 5 Huang et al., 2010

6. Safety Culture and Mortality in the ICU Armstrong Institute for Patient Safety and Quality 6 Huang et al., 2010 …the odds ratio for mortality was 1.24 for the hospital. For every 10% decrease in perceptions of management items…

7. Safety Culture and Improvement Armstrong Institute for Patient Safety and Quality 7 Quality & Safety Intervention Patient Outcomes Safety Culture Safety culture moderates the effectiveness of safety and quality improvement efforts –Safety climate scores correlated with the degree of reduction in mortality and morbidity achieved in the implementation of a surgical checklist (r =.71, p <.05) Haynes et al., 2011

8. Interventions to Improve Safety Culture A systematic review of 21 studies found some evidence to support positive effects of –leadership walk rounds (p=0.02) –multi-faceted unit-based programs (p < 0.05) (Morello et al. 2012) CUSP specifically mentioned Armstrong Institute for Patient Safety and Quality 8

9. Conducting a Culture Checkup With unit: Share the dimension and item-level data (good and bad) –Bulletin boards –Meet with executives –Staff meetings With CUSP team: Examine item-level data for –Items with lowest scores –Items with large differences from overall CSTS; overall for your unit type; or other units within your hospital –Items with discrepancies among professions Armstrong Institute for Patient Safety and Quality 9

10. Conducting a Culture Checkup Treat the item as a defect Convene groups of 5-7 to discuss the item –Represent different professions (depending on item) –Try for more than one group –30-60 minutes –Provide lunch! Armstrong Institute for Patient Safety and Quality 10

11. Conducting a Culture Checkup Instruct group members to: –avoid personalizing discussion –concentrate on being open –avoid offering justifications or becoming defensive Group leaders must model it! Spend ½ time on clarifying reasons for low scores; ½ time on generating ideas to improve issues Be concrete—generate action items Take notes on a board for the group to see Armstrong Institute for Patient Safety and Quality 11

12. Conducting a Culture Checkup Divide the group board into problems and solutions, try to match one to one Leader uses Culture Item Discussion Form Close group by picking best suggestions to improve the area of the weak HSOPS item Armstrong Institute for Patient Safety and Quality 12

13. Statement to be discussed:Unit Safety Assessment Score (percent agreement): Role Specific score variation: e.g. MD vs RN, RN vs Techs, Clinical vs. Admin 1.What does this statement mean to you? (Why do you think our unit scored this way? Are specific groups rating this item lower, and if so, why?) 2. How accurately does the unit score reflect your experience on this unit? Share examples without using names. 3. How would it look (i.e., what behaviors/processes would we see ) on this unit if 100% of caregivers responded agree strongly with this item? (What’s the vision for how we’d like it to be? What are some negative things we could avoid by improving in this area?) 4. Identify at least one actionable idea to improve unit results in this area: Culture Item Discussion Form: Armstrong Institute for Patient Safety and Quality 13

14. After the groups Compare across groups for consistent themes Prioritize suggestions for improvement Generate action items and assign people, timeframe for reporting, measures of success Get leadership to publicly highlight the issue and improvement plan Plan follow-up polling opportunities to see if people’s perceptions of the area improve over time Armstrong Institute for Patient Safety and Quality 14

15. References 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. 2012 Jul 31. [Epub ahead of print]Morello RTLowthian JABarker ALMcGinnes RDunt DBrand C BMJ Qual Saf. Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program. J Patient Saf 2005;1:33–40. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf 2011 Jan;20(1):102-107. Huang DT, Clermont G, Kong L, Weissfeld LA, Sexton JB, Rowan KM, et al. Intensive care unit safety culture and outcomes: a US multicenter study. Int J Qual Health Care 2010 Jun;22(3):151-161. Mardon, R. E., Khanna, K., Sorra, J., Dyer, N., & Famolaro, T. (2010). Exploring relationships between hospital patient safety culture and adverse events. Journal of Patient Safety, 6(4), 226-232. Armstrong Institute for Patient Safety and Quality 15