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Improving Clinical Outcomes and Unit Culture through the Development of Safety Attitudes Questionnaire Action Plan Margaret Cornell Vigorito, MS, RN, PHR, SHRM-CP, CPHQ April 19, 2016 This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSQIN_C1_032316_0468
Objectives Describe how conducting a staff debrief and discussion on unit safety culture results helps to inform the development of a Safety Attitudes Questionnaire Action Plan (SAQAP) Describe the impact that a documented unit SAQAP has on future Safety Attitude Questionnaire Survey results Understand the impact of a unit SAQAP on CLABSI and VAP rates 3
Background: The RI ICU Collaborative November 2005 December 2012 Partnership between three state quality organizations: The RI Quality Institute Hospital Association of RI Healthcentric Advisors (formally Quality Partners of RI) 100% of RI adult ICUs enrolled 23 ICUs from 11 hospitals 4
ICU Collaborative Goal To improve patient safety and clinical outcomes for adult ICU patients through the development of a unit-based safety program and implementation of evidenced-based practices. 5
Program Components Fall 2005 Winter 2006 Winter 2006 Spring 2008 Spring 2010 Comprehensive Unit-Based Safety Program (CUSP) Catheter-Line Associated Blood Stream Infection Bundle (CLABSI) Ventilator Associated Pneumonia Bundle (VAP) Sepsis Palliative Care 6
CUSP Why? Strong Correlation Between Team Perception of Safety Climate Clinical Outcome Performance 7
Polling Question Has your unit or facility ever implemented a CUSP program? 8
CUSP What? 6 Step Process to Improve Unit Culture and Safety Climate 1 Safety Culture Assessment 2 Science of Safety Training 3 4 Staff Identify Safety Hazards Senior Executive Partnership 5 a. Learn from Safety Defects b. Tools to Improve 6 Safety Culture Reassessment 9
Safety Culture Defines: team attitudes norms behaviors Sets tone for how work gets done around here Impacts overall team performance 10
Safety Culture There is no I" in Team In sport you always think the strongest guy should be going for it and getting the best results. The thing is, cycling also has a very important team aspect, which I don't think that a lot of people fully grasp. - Chris Froome 11
Safety Culture the Road to Improvement 12
Safety Culture oops! 13
Safety Culture Assessment Safety Attitudes Questionnaire (SAQ) Frontline caregivers assessment of patient safety across 6 domains Valid and reliable Developed at University of Texas by Bryan Sexton, PhD Baseline assessment administered to 23 RI ICUs in 2005 and then annually 14
Polling Question Polling Question Does your unit or facility administer a safety culture survey at least annually? 15
SAQ Action Plan (SAQAP) Documented plan of action identifying: cultural improvement opportunities interventions based on SAQ results 16
Hypothesis ICUs who develop a Safety Attitudes Questionnaire Action Plan (SAQAP) in response to their units 2007 SAQ results will demonstrate significantly greater improvement in the 2008 SAQ survey and infection outcomes compared to those that did not have an SAQAP 17
Aims To analyze the impact of the SAQAP on the 2008 SAQ survey results compared to 2007 survey results across six safety domains To determine the impact of the SAQAP on 2008 CLA-BSI and VAP rates compared to 2007 CLA-BSI and VAP rates 18
Methods Safety Attitudes Questionnaire (SAQ) Administered by Pascal Metrics HealthBench 5 point Likert scale (disagree strongly to agree strongly) Administered 2007 and 2008 to all 23 ICUs Assessment in 6 domains: 1. Teamwork 2. Safety Climate 3. Perceptions Of Management 4. Work Conditions 5. Job Satisfaction 6. Stress Recognition 19
Methods BSI and VAP Collected and submitted (web based tool) by each hospital NNIS definitions 2007 and 2008 annual mean rates reported per 1000 line days and 1000 ventilator days 20
Methods Intervention SAQAP development strongly recommended SAQ improvement toolkit Educational learning session/site visits Survey to track SAQAP development and completion 21
Unit Safety Attitudes Questionnaire Improvement Action Plan Template Issue Intervention/Action Lead Target Completion Completion Date Comments/Status 22
Methods: Statistical Analysis Statistical significance between groups calculated using student s t-test Significance value of p<0.10 given small number of units P-value compares change from 2007 to 2008 with each group 23
Results High response rates in SAQ: 82% in 2007 85% in 2008 Respondents from multiple disciplines Majority were nurses, female, white, and employed 2-5 years No significant difference in respondents between 2007 and 2008 24
Results Units with Action Plans 39% (9/23) units developed SAQAP Median response rate=83% (range=80-94%) Higher safety culture scores on 5/6 SAQ domains, compared to units without SAQAP 10.2% decrease in BSI rates 15.2% decrease in VAP rates 25
61% (14/23) units had no plan Results Units without Action Plans Median response rate=83%(range=67-100%) Higher safety culture scores on 1/6 SAQ domains, compared to units with SAQAP 2.2% decrease in BSI rates 4.8% increase in VAP rates 26
SAQ Domains 2007 Mean % Teamwork Climate Units with SAQAP (N=9) 2008 mean % Rel % Units without SAQAP (N=14) 2007 mean % 2008 mean % Rel % P-value 53 62.8 18.4 39 36.5-6.4 0.07 Safety Climate 58 62.4 7.5 41 42.4 3.4 NS Job Satisfaction 54 68.0 25.9 41 44.1 7.3 0.07 Stress Recognition Working Conditions Perceptions of Management 33.3 34.8 4.5 43.5 40.6-6.6 NS 49.2 46.4-5.6 30.4 28.6-5.9 NS 40.5 48.7 20.2 25.7 25.9 0.7 NS 27
Results % change in SAQ Scores 2007 to 2008 30 25 20 15 10 5 0-5 -10 Units with Plans Units without Plans 28
Units with SAQAP (N=9) Units without SAQAP (N=14) Infection measures 2007 mean % 2008 mean % Rel % 2007 mean % 2008 mean % Rel % P- value CLABSI 1.85 1.66-10.2 1.75 1.71-2.2 NS VAP 3.1 2.63-15.2 3.56 3.73 +4.8 NS 29
Results-% change in BSI and VAP 2007 to 2008 9 4-1 -6-11 Units with SAQAP Units without SAQAP -16 CLA-BSI VAP 30
Strengths 100% state adult ICU participation High response rates in SAQ 31
Limitations Extent of intervention implementation not evaluated Self-selection Generalizability of results to non-icu and other states unknown Small state and sample size 32
Implications First study demonstrating relationship of SAQAP to improving culture and clinical outcomes Many QI cohorts fail to identify and understand the nature of the variability that exists within their overall improvement efforts The planners appear to do bet 33
Conclusions SAQAP help teams improve their unit culture in multiple domains SAQAP help teams reduce BSI and VAP rates SAQAP are an effective way of improving unit culture of safety and patient outcomes 34
Sustainability 80% (18/23) of units with documented AND implemented SAQAP in response to 2008 results Higher safety culture scores in 4/6 domains (range of 16-21 percentage points) from 2008 to 2009 For the first time, state performance levels out of the danger zone (.60%) in 4/6 domains Further sustainability was demonstrated with the results of the 2010 SAQ SAQAP development became a standard practice 35
References DePalo V., et al.: The Rhode Island ICU Collaborative: A model for reducing Central Line-Associated Bloodstream Infection and Ventilator-Associated Pneumonia Statewide, Quality and Safety in Health Care 19; 231-233, August, 2005. Sexton J.B., et al.: A Culture Check-Up for Safety in My Patient Care Area. The Joint Commission Journal on Quality and Patient Safety 33: 699-703, November, 2007. Sexton J.B., et al.: The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Services Research 6;44, April 3, 2006. Vigorito M.C., et al.: Improving Safety Culture Results in Rhode Island ICUs: Lessons Learned from the Development of Action-Oriented Plans. The Joint Commission Journal on Quality and Patient Safety 37: 509-514, November, 2011. 36
Resources Action Planning Tool for the AHRQ Surveys on Patient Safety Culture http://www.ahrq.gov/sites/default/files/publications/files/planningtool_0.pdf Agency for Healthcare Research and Quality Patient Safety Network https://psnet.ahrq.gov/primers/primer/5/safety-culture Armstrong Institute for Patient Safety and Quality http://www.hopkinsmedicine.org/armstrong_institute/training_services/cusp_offerings/cusp_guidanc e.html Team Check Up Tool http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/toolkit/teamcheckup.html TeamSTEPPS Pocket Guide http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculumtools/teamstepps/instructor/essentials/pocketguide.pdf 37
Continuing on the Road to Improvement 38
Be part of a Winning Team! 39
Questions 40