1. Connecting the Dots: Improving Unit Safety Culture to Stop HAI Katherine J. Jones, PT, PhD University of Nebraska Medical Center

2. Supported By 2 AHRQ Partnerships in Implementing Patient Safety Grants (1 U18 HS015822, 1R18HS021429) The content is solely the responsibility of the author and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. National Rural Health Association Nebraska Department of Health and Human Services AHRQ Office of Communications and Knowledge Transfer Hospitals in Nebraska, Iowa, Louisiana, Washington, Oregon, Alaska

3. Learning Objectives 3 Define safety culture Describe how to measure safety culture Explain the relationship between prevention and healthcare-associated infections and safety culture

4. What is Safety Culture 4 Definition Role of Organizational Culture Categories of Culture 3 Levels of Culture 4 Components of Culture

5. Definition of Safety Culture 5 Enduring, shared, LEARNED 1 beliefs and behaviors that reflect an organization’s willingness to learn from errors 2 Four beliefs present in a safe, informed culture 3 – Our processes are designed to prevent failure – We are committed to detect and learn from error – We have a just culture that disciplines based on risk taking – People who work in teams make fewer errors

6. The Role of Organizational Culture Safety Culture 4 A cross cutting contextual factor Moderates effectiveness of patient safety interventions Associated with adverse events and patient satisfaction Organizational Culture 1 Allows us to make sense of environment Reflects common language… is heard and observed Leaders create/teach culture – Share information – Reward, provide feedback – Hold people accountable 6

7. Negative Correlation: HSOPS and Patient Safety Events 5 Higher HSOPS scores are associated with fewer adverse events, which validates patient safety culture assessment as a meaningful indication of the safety of patients.

8. Positive Correlation: HSOPS and Patient Satisfaction 6 “….behaviors and attitudes [of hospital employees] can directly affect the pain, discomfort, health, and recovery of patients.”

9. Categories of Culture 1 Macroculture Organizational Culture Subculture Microculture 9

10. Three Levels of Organizational Culture 1 “…values reflect desired behavior but are not reflected in observed behavior.” (Schein, 2010, pp. 24, 27) Behaviors Beliefs & Values Underlying Assumptions Desired Behavior: Round to assess catheter appropriateness Observed Behavior: Do not participate in rounds Value: Teamwork Value: Autonomy Assumption: Safety is a system property Assumption: Safety is a result of individual competency 10

11. Four Components of Safety Culture 7 11 HRO LEARNING FLEXIBLE JUST REPORTING 1.Reporting Culture 2.Just Culture 3.Flexible (Teamwork) Culture 4.Learning Culture Effective reporting and just cultures create atmosphere of trust Sensemaking 8 of patient safety events and high reliability result from an explicit plan to engineer behaviors from each component of safety culture

12. Continuous Quality Improvement HROs Engage in Continuous Improvement Action Plan Measure Beliefs and Behaviors Implement Practices We can not change what we do not measure! 12

13. How Do you Measure Safety Culture? 1 13 Qualitative – Focus Groups – Structured Interviews – Observation Quantitative Survey Tools…use best tool for your setting – Goals of assessment

14. Goals of Culture Assessment 1,9,10 14 Identify areas of culture in need of improvement – Identify impairments in organizational learning Increase awareness of patient safety concepts Evaluate effectiveness of patient safety interventions over time Conduct internal and external benchmarking, Meet regulatory requirements Identify gaps between beliefs and observed behaviors within subcultures and microcultures

15. When Should you Measure Safety Culture? 11 15 Baseline prior to patient safety intervention 12 – 24 month intervals to monitor change over time

16. Hospital Survey on Patient Safety Culture 12 16 Survey tool kit available http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm http://www.ahrq.gov/qual/patientsafetyculture/hospsurvindex.htm Comparative Database for Benchmarking http://www.ahrq.gov/qual/hospsurvey12/ http://www.ahrq.gov/qual/hospsurvey12/ –1,128 hospitals; 567,703 respondents in 2012 database 42 items categorized in 12 composites/dimensions –9 dimensions measure culture at dept/unit level –3 dimensions measure culture at hospital level 2 additional outcome measures at dept/unit level (Patient Safety Grade, Number of Events Reported) Comments

17. How Do you Interpret HSOPS Results? 17 1.Reason’s Components of Safety Culture 7 2.Identify unit-wide areas in need of improvement 3.Conduct external benchmarking 9 o State Averages o National Database ICU 4.Conduct internal benchmarking 9 o Nurse vs. Non-nurse (professional subcultures) 5.Understand Reverse-worded Items 6.Identify beliefs & behaviors in composites 1

18. Crosswalk Reason’s Components 7 Reason’s Components 4 Reporting Culture – a safe organization is dependent on the willingness of front-line workers to report their errors and near-misses Just Culture – management will support and reward reporting; discipline occurs based on risk- taking HSOPS Dimension or Outcome Measure Frequency of Events Reported (U) Number of Events Reported (O) Nonpunitive Response to Error (U) O=Outcome Measure, U=Unit, H=Hospital 18

19. Crosswalk Reason’s Components 7 Reason’s Components 4 Flexible Culture - authority patterns relax when safety information is exchanged because those with authority respect the knowledge of front-line workers Learning Culture - organization will analyze reported information and then implement appropriate change HSOPS Dimension or Outcome Measure Teamwork w/in Units (U) Staffing (U) Communication Openness (U) Teamwork ax Units (H) Hospital Handoffs (H) Hospital Mgt. Support (H) Manager Actions (U) Feedback & Communication (U) Organizational Learning (U) Overall Perceptions (U) Patient Safety Grade (O, U) 19

20. Unit-Wide Areas in Need of Improvement 20 Below State or National average Less than 75% positive Large “gap” between beliefs and behaviors within the composites

21. External Benchmarking 21

22. Internal Benchmarking 22

23. Reverse-Worded Items 23 Score reported is “percent positive” – Percentage of responses rated 4 or 5 (Agree/Strongly agree or Most of the Time/Always) for positively-worded items, or 1 or 2 (Disagree/Strongly Disagree or Rarely/Never) for reverse- worded items Positive is positive for patient safety, higher score better – We work in “crisis mode” trying to do too much, too quickly. (A14R) 8 of 12 composites have at least 1 reverse-worded item 2 Composites all items reverse-worded – Handoffs & Transitions – Nonpunitive Response to Error

24. Reporting Culture Frequency of Events Reported Three items elicit perceptions of reporting BEHAVIOR. 24

25. Action Planning: Interventions Support Reporting Successful reporting systems 13 Nonpunitive Confidential Independent Expert analysis Timely Systems-oriented Responsive Formal Reporting of adverse events with standardized taxonomies (e.g. National Coordinating Council for Medication Error Reporting and Prevention A – I Error Severity Taxonomy) Near misses are frequently reported, valued, and learned from using anonymous log Non-harmful errors that reach the patient are frequently reported, valued, and learned from Informal Reporting – Safety Briefings 14 Informal Reporting – Leadership WalkRounds, 15 Leveraging Frontline Expertise 16

26. Just Culture Non-punitive Response to Error 26 Three items elicit perceptions of response to error. Last item “R3. Staff worry that mistakes they make are kept in their personnel file.”…always least positive.

27. Action Planning: Interventions to Support Just Culture 27 Understand human error, 7 human factors – Active errors (sharp end) – Latent errors Just Culture and behavior 17-19 – Conduct: human error, negligence, reckless, intentional rule violation – Disciplinary decision-making: outcome-based, rule-based, risk-based Unsafe Acts Algorithm 7 Disruptive Behavior Policy/Standards 20

28. Unsafe Acts Algorithm 7 CulpableGray AreaBlameless Adapted from James Reason. (1997). Managing the Risks of Organizational Accidents. Known medical condition? NO YES NO YES NO YES NO YES NO Were the actions as intended? Evidence of illness or substance use? Knowingly violated safe procedures? Pass substitution test? (Could someone else have done the same thing)? History of unsafe acts? Were the consequences as intended? Were procedures available, workable, intelligible, correct and routinely used? Deficiencies in training, selection, or inexperienced? Substance abuse without mitigation Sabotage, malevolent damage Substance use with mitigation Possible reckless violation System induced violation Possible negligent behavior System induced error Blameless error, corrective training, counseling indicated Blameless error NO 28

29. Flexible Culture Teamwork within Units Four items elicit perceptions of teamwork within units. TeamSTEPPS Tools to bridge gap between belief and behavior: Briefs, Huddles, Debriefs; Situational Awareness, Mutual Support, Seeking & Offering Task Assistance 29

30. Flexible Culture Communication Openness Three items elicit perceptions of communication openness. TeamSTEPPS Tools to Bridge the Gap between belief and behavior : Advocacy and Assertion, Two Challenge Rule, CUS 30

31. Flexible Culture Handoffs & Transitions 31 Four items elicit perceptions of handoffs & transitions. TeamSTEPPS Tools to Structure Communication: SBAR, Check Back, Call Out, I PASS the BATON

32. Action Planning: Interventions to Support Flexible (Teamwork) Culture Team Strategies & Tools to Enhance Performance & Patient Safety 21 http://teamstepps.ahrq.gov Adopting team behaviors positively impacts all components of safety culture because teamwork supports learning. 22 32

33. Mutual Support Tool: CUS…Graded Assertiveness 33 I’m CONCERNED that Mr. Johnson has a urinary catheter. It was put in in the ICU without an order. No response… I’m UNCOMFORTABLE leaving it in because he does not currently have any evidence-based indications for a catheter. No response… This is a SAFTEY issue. Mr. Johnson is at risk for a CAUTI if we do not remove the catheter.

34. Communication Tool: SBAR…Brief, Clear, Timely, Complete Communication 34 At shift change: S: Mr. Johnson still has a urinary catheter. B: It was put in in the ED without an order. I have a call in to Dr. Smith, the hospitalist, to remove it. A: Mr. Johnson does not currently have any indications for a catheter. R: Call Dr. Smith again, if he does not return the call within an hour.

35. Learning Culture Supervisor Manager Expectations 35 Four Items elicit perceptions of leadership behavior. Interventions: TeamSTEPPS Leadership Tools (Briefs, Huddles, Debriefs; Feedback; Resource Management; Conflict Resolution); Frontline engagement 15, 16

36. Learning Culture Feedback & Communication about Error 36 Four items elicit perceptions of feedback about error. Interventions: TeamSTEPPS Briefs, Huddles, Debriefs; Frontline engagement; 15, 16 Communication Notebook; Bulletin Board; Unit Newsletter; Formal In- services & Unit meetings

37. Learning Culture Organizational Learning—Continuous Improvement 37 Learning Tools : Briefs, Huddles, Debriefs; Leadership WalkRounds, 15 Leveraging Frontline Expertise; 16 Individual and Aggregate RCA; Failure Mode and Effects Analysis

38. Action Planning: Reporting, Just, and Flexible Practices Support Learning 38 Ultimately, the willingness of workers to report depends on their belief that the organization will analyze reported information and then implement appropriate change—organizational practices support a learning culture. 7 Practices/Tools Individual RCA 23 Aggregate RCA 24 FMEA 25 Safety Briefings 14 Leadership WalkRounds, 15 Leveraging Frontline Expertise 16 Close the loop with reporting…feedback

39. What is the Relationship between Patient Safety Interventions and Safety Culture? Leadership Safety Culture Patient Safety Inter- vention Safety culture, patient safety interventions and leadership influence each other. 39

40. Role of Leaders in Transformational Change 1 40 Create a compelling positive vision Concretely define the goal as a performance problem…not “changing culture” Ensure new behaviors are formally taught Ensure new behaviors are reinforced – Provide opportunities for practice, coaching, feedback – Be a positive role model Create structures consistent with new way of thinking/working/behaving…policy/procedure, job descriptions, performance appraisals

41. Summary What is safety culture? – Beliefs, behaviors reflect organizational ability to learn – Associated with adverse events, patient satisfaction How do you interpret results? – Reason’s Components (12 composites – 4 components) – Gaps between beliefs/behaviors within composites – Variation by subculture (profession), microculture (unit) – Leadership must drive culture

42. Summary Action Planning – Identify areas in need of improvement within 4 components…reporting, just culture, teamwork, learning What is the relationship between STOP HAI and Safety Culture? Leadership Safety Culture STOP HAI

43. Leaders Engineer Culture 43 “…it is the unique function of leadership to perceive the functional and dysfunctional elements and to manage cultural evolution and change.” Schein, E.H. Organizational Leadership and Culture 4 th ed. San Francisco: John Wiley & Sons; 2010.

44. Thank you! Questions? 44

45. References 45 1.Schein, E.H. Organizational Leadership and Culture 4 th ed. San Francisco: John Wiley & Sons; 2010. 2.Wiegmann. A synthesis of safety culture and safety climate research; 2002. http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/02-03.pdf http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/02-03.pdf 3.Institute of Medicine. Patient safety: Achieving a new standard of care. Washington, DC: The National Academies Press; 2004. 4.Weaver SJ, Lubomski LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strategy: A systematic review. Ann Int Med. 2013;158:369-374. 5.Mardon RE, Khanna K, Sorra J, Dyer N, Famolaro T. Exploring relationships between hospital patient safety culture and adverse events. J Patient Saf 2010;6: 226-232. 6.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 2012;8: 131-139. 7.Reason, J. (1997). Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited.

46. References 46 8.Battles et al. (2006). Sensemaking of patient safety risks and hazards. HSR, 41(4 Pt 2), 1555- 1575. 9.Nieva VF, Sorra J. Safety culture assessment: A tool for improving patient safety in healthcare organizations. Qual Saf Health Care 2003; 12(Suppl II): ii17-ii23. 10.Jones, Skinner, Xu, Sun, Mueller. (2008). The AHRQ Hospital Survey on Patient Safety Culture: a tool to plan and evaluate patient safety programs. Advances in Patient Safety: New Directions and Alternative Approaches http://www.ncbi.nlm.nih.gov/books/NBK43699/http://www.ncbi.nlm.nih.gov/books/NBK43699/ 11.National Quality Forum (NQF). Safe practices for better healthcare--2010 update: A consensus report. Washington, DC: NQF; 2010. Available at: http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_ –_2010_Update.aspx http://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_ –_2010_Update.aspx 12.AHRQ. Hospital Survey on Patient Safety Culture. Available at: http://www.ahrq.gov/professionals/quality-patient- safety/patientsafetyculture/hospital/resources/index.html http://www.ahrq.gov/professionals/quality-patient- safety/patientsafetyculture/hospital/resources/index.html 13.Leape, L.L. (2002) Reporting adverse events. The New England Journal of Medicine, 347, 1633-1638 Institute for Healthcare Improvement.

47. References 47 14.Conduct Safety Briefings. Available at: http://www.ihi.org/knowledge/Pages/Changes/ConductSafetyBriefings.aspx http://www.ihi.org/knowledge/Pages/Changes/ConductSafetyBriefings.aspx 15.Institute for Healthcare Improvement. Patient Safety Leadership WalkRounds. Available at: http://www.ihi.org/knowledge/pages/tools/patientsafetyleadershipwalkrounds.aspx http://www.ihi.org/knowledge/pages/tools/patientsafetyleadershipwalkrounds.aspx 16.Singer SJ, Rivard PE, Hayes JE, Shokeen P, Gaba D, Rosen A. Improving patient care through leadership engagement with frontline staff: A Department of Veterans Affairs case study. The Joint Commission Journal on Quality and Patient Safety. 2013;39:349-360. 17.Marx D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives. New York, NY: Columbia University; 2001. Available at: http://psnet.ahrq.gov/resource.aspx?resourceID=1582 http://psnet.ahrq.gov/resource.aspx?resourceID=1582 18.Frankel AS, Leonard MW, Denham CR. Fair and just culture, team behavior, and leadership engagement: the tools to achieve high reliability. HSR. 2006;41(4),PartII:1690-1709. 19.Wachter RM, Pronovost PJ. Balancing "no blame" with accountability in patient safety. N Engl J Med. 2009;361:1401-1406. 20.AHRQ. Patient Safety Primers. Disruptive and Unprofessional Behavior. Available at: http://psnet.ahrq.gov/primer.aspx?primerID=15 http://psnet.ahrq.gov/primer.aspx?primerID=15

48. References 48 21.Agency for Healthcare Research and Quality. TeamSTEPPS: Strategies and tools to enhance performance and patient safety. Available at: http://teamstepps.ahrq.gov/.http://teamstepps.ahrq.gov/ 22. Jones KJ, Skinner AM, High R, Reiter-Palmon R. A theory-driven longitudinal evaluation of the impact of team training on safety culture in 24 hospitals. BMJ Qual Saf. 2013;22:394-404. 23.US Department of Veterans Affairs. National Center for Patient Safety. Root Cause Analysis Tools. Available at: http://www.patientsafety.gov/CogAids/RCA/index.html#page=page-1 http://www.patientsafety.gov/CogAids/RCA/index.html#page=page-1 24.Neily et al. Using aggregate root cause analysis to improve patient safety. Jt Comm J Qual Saf 29(8):434-439, 2003. 25.US Department of Veterans Affairs. National Center for Patient Safety. Using Healthcare Failure Modes and Effects Analysis. Available at: http://www.patientsafety.gov/SafetyTopics/HFMEA/HFMEA_JQI.html http://www.patientsafety.gov/SafetyTopics/HFMEA/HFMEA_JQI.html

49. Funding Prepared by the Health Research & Educational Trust of the American Hospital Association with contract funding provided by the Agency for Healthcare Research and Quality through the contract, “National Implementation of Comprehensive Unit- based Safety Program (CUSP) to Reduce Catheter-Associated Urinary Tract Infection (CAUTI), project number HHSA290201000025I/HHSA29032001T, Task Order #1.”