1. CUSP/Stop CAUTI Collaborative Carol Hafley, MHA, BSN, RN Assistant Director Missouri Center for Patient Safety Jefferson City, MO chafley@mocps.org 573-636-1014 x227 Supplement – Preparing for the HSOP Survey 5/17/2011 Content Call 6 – Supplement 5/17/11 Document 2

2. The “Secret Ingredient” Comprehensive Unit-Based Patient Safety Program 1.Form a unit CUSP team with executive sponsorship 2.Measure unit culture 3.Educate staff on Science of Safety 4.Identify defects using the Staff Safety Assessment; prioritize defects 5.Learn from one defect per quarter 6.Implement team/communication tools 2

3. Why Measure Unit Culture? Determine how bedside staff are feeling related to communication and recognizing defects – Diagnose and assess the current status of patient safety culture. – Identify strengths and areas for patient safety culture improvement. – Examine trends in patient safety culture change over time. – Measure/evaluate the cultural impact of patient safety initiatives and interventions. CUSP is the intervention that will help you improve culture results – Results will be discussed during coaching call 5 – unit culture action plan development 3

4. AHRQ’s Hospital Survey on Patient Safety (HSOPS) 42 items assess 12 dimensions of patient safety culture 1. Communication openness 2. Feedback & communication about error 3. Frequency of event reporting 4. Handoffs & transitions 5. Management support for patient safety 6. Nonpunitive response to error 7. Organizational learning--continuous improvement 4

5. AHRQ’s Hospital Survey on Patient Safety (HSOPS) 8. Overall perceptions of patient safety 9. Staffing 10. Supv/mgr expectations & actions promoting patient safety 11. Teamwork across units 12. Teamwork within units Patient safety “grade” (Excellent to Poor) 5

6. HSOPS Process The HSOPS webinars scheduled this week and next will walk through this process and the timeline – survey will be open beginning the middle of June and go through mid-July. Each Team Leader must identify how many staff members on the unit will be surveyed – all staff should take the survey! – Physicians – including residents, physician assistants – Licensed Staff – RNs, RTs, LPNs, therapists, pharmacists, dietician etc. – Non-licensed Staff – CNAs, technicians (i.e. EKG tech), Unit Clerks, Housekeepers, etc. Goal is reaching a 60% response rate You will receive weekly response rate updates from MHA. 6

7. HSOPS Process: If the unit has recently completed a safety survey If units have already taken a patient safety culture survey and the following is true: – A) survey occurred within the last 6 months – B) unit received at least a 60% response rate – C) there have been no major staff, leadership, or structural changes in the unit, such as Staff turnover/layoffs Changes in medical staff or medical staff model (i.e. open vs. closed unit) Change in manager... then you do not need to take it again – you will need to discuss with Carol how to get your results imported. 7

8. HSOPS Process: Getting a 60% Response Rate Value it! Explain to staff why filling out the survey is so important – showcase specific examples from the unit that help validate that culture improvement is important for all staff Spend time in your next Team Meeting planning how you will reach 60% : – Engage your physician champion to encourage physicians to take the survey – Make the survey accessible to all staff – Email the URL vs. Putting URL on one computer accessible to all staff – both are options Make it a challenge – if the unit reaches 60%, get some sort of incentive (i.e recognition, small gift, pizza or ice cream party, etc.) 8

9. Upcoming Dates Attend ONE HSOPS Training Webinar (May 16, 19, 23, or 26). No need to register, just join the meeting. June 1, 2011 – Data Collection for CAUTI rates and prevalence begins!! June 10, 2011 – Kick Off Meeting in Columbia, Courtyard by Marriot, 8 AM to 3 PM. Invitation was emailed on May 11. Please RSVP and register so we can get a head count! 9