1. Title Block HSOPS: So You’ve Done the Survey – Now What? Dolores Hagan, RN, BSN K-HEN Education/Data Manager

2. Objectives Upon completion of this session, the participant will be able to: Interpret HSOPS survey results Identify areas for targeted interventions Determine appropriate interventions based on survey results

3. “The biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures but as opportunities to improve the system and prevent harm”¹ ¹Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001

4. Why Survey? Diagnose safety culture to identify areas for improvement and raise awareness about patient safety Evaluate patient safety interventions or programs and track changes over time Conduct internal and external benchmarking Fulfill directives or regulatory requirements

5. Survey Success Key senior leadership support Determine who will be surveyed Monitor and encourage respondent participation Review result reports Implement action planning and change initiation

6. The Tool Agency for Healthcare Research an Quality (AHRQ) Hospital Survey Of Patient Safety (HSOPS) Survey Goals –Improve patient safety –Encourage error reporting and analysis to promote learning and prevention –Staff empowerment Survey Purpose –Examines patient safety culture from a staff perspective –Identify areas of strengths and opportunities for improvement

7. What It Measures Seven unit-level aspects of safety culture –Supervisor/Management expectations and actions promoting safety –Organizational Learning – Continuous Improvement –Teamwork within units –Communication openness –Feedback and communication about errors –Nonpunitive response to error –Staffing

8. What It Measures Three hospital-level aspects of safety culture –Hospital management support for patient safety –Teamwork across units –Hospital handoffs and transitions Four outcome variables –Overall perceptions of safety –Frequency of event reporting –Patient safety grade –Number of events reported

9. Results Report Demographics Composite scores Item Level scores Patient Safety Grade Frequency of event reporting National database comparison –By unit –By staff type

10. Results Analysis Begin by looking at Composite scores –Identify strengths – any section scored > 75 –Identify opportunities – any section scored < 50 Drill down to the Item Level Review national database comparison for breakdown by unit and staff type

11. Sharing Survey Results Results sharing –Who will present the results –To whom they will presented to (sequencing) –When and how results are presented Plan your approach –Prepare for defensiveness and negativism –Provide specialized training to department leaders on patient safety culture

12. Results Sharing Staff who participated need to hear the results Feedback and action planning may be combined for greater impact Clinical staff, department leaders and supervisors must be involved in feedback discussions

13. Seizing Opportunity Common areas of opportunity –Reporting ‘near misses’ –Staff feel free to question decisions of those with more authority or ask questions when something doesn’t seem right –Person feels ‘blamed’, fears retaliation –Staffing Not enough Work in crisis mode too often –Feedback about errors reported –Teamwork across units –Handoff communication

14. Technical Assistance Resources available through K-HEN –One on one analysis of HSOPS results –TeamSTEPPS training –Comprehensive Unit Based Safety Program (CUSP) –Learning from Defects analysis

15. Improvement Tools TeamSTEPPS(http://teamstepps.ahrq.gov/)http://teamstepps.ahrq.gov/ Failure Mode Effects Analysis (FMEA) Learning from Defects Analysis (http://www.k- hen.com/Portals/16/Documents/KHENKick off/Learning_from_Defects_Tool.pdf)http://www.k- hen.com/Portals/16/Documents/KHENKick off/Learning_from_Defects_Tool.pdf Huddles (http://www.k-hen.com/Pivot.aspx - Falls November 2012 Coaching Call)http://www.k-hen.com/Pivot.aspx

16. References/Resources http://qualitysafety.bmj.com/content/12/su ppl_2/ii17.fullhttp://qualitysafety.bmj.com/content/12/su ppl_2/ii17.full Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press, 2001 http://www.patientsafety.gov/SafetyTopics /HFMEA/FMEA2.pdfhttp://www.patientsafety.gov/SafetyTopics /HFMEA/FMEA2.pdf