Composite Results and Comparative Statistics Report

Patient Safety Culture Survey of Staff in Acute Hospitals Report April 2015 Page 1

Table of Contents Executive Summary 3 1.0 Purpose and Use of this Report 8 2.0 Introduction 8 3.0 Survey Administration 10 4.0 Respondents Characteristics 12 5.0 Composite Results 14 5.1 Main Findings 15 5.2 Dimensions 17 5.3 Clinical Governance Development 27 5.4 Open Disclosure 29 6.0 Comparative Statistics 31 6.1 Description and Interpretation 31 6.2 Comparative Tables 33 7.0 Action Planning for Improvement 37 8.0 References 38 9.0 List of Figures 39 10.0 List of Tables 39 11.0 List of Appendices 40 Appendix A: Adapted AHRQ Survey Tool 41 Appendix B: Respondent Characteristics 54 Appendix C: Clinical Governance Development Index Score 56 Page 2

Executive Summary Quality and safety has been a major focus in healthcare over the last ten years and internationally significant efforts have been made to incorporate this as an integral part of all health systems. How health staff feel about patient safety at their hospital is an important part of assessing and changing the culture within the organisation (Nieva, V.F., Sorra, J. 2003). Without understanding the culture within an organisation, across all staff groups, and at every level of the organisation, it is difficult to improve systems and ensure that robust quality and patient safety processes are implemented effectively. Much attention has been given to focusing on improving healthcare services and service user (patient) outcomes, whilst this is commendable and should always be a priority; still more work needs to be done with healthcare providers, namely, the staff who are employed to deliver this care of the safest and highest quality. Optimum patient care should encompass compassion and caring (Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013), but compassion and caring also apply to the way we treat team members (ward and wider inter disciplinary teams) in the workplace. Hence, healthcare staff must engage with service users, other team members and also the healthcare organisation in which they work (Macleod and Clarke, 2009). Being expected to do more with less, has left some staff feeling demoralised, having no voice in their organisations and feeling increasingly stressed, in some cases burnt out. It is precisely during these very difficult times that leaders and managers within the healthcare organisations, need to motivate inspire and engage their staff to be the best they can be. However, this will only happen within a culture of trust and transparency, staff must feel they are valued, respected, that their voices are heard and that their opinions count. These are the principles of staff engagement ( NHS Employers, 2011). In 2012, the Quality and Patient Safety Directorate now the Quality Improvement Division (QID) in collaboration with the Regional Managers for Quality and Patient Safety, piloted the National Patient Safety Culture Survey for Staff in Acute Hospitals in five hospitals. The survey tool used was an adapted version of the Agency for Health Care Research (United States (US)) Hospital Survey on Patient Safety Culture (AHRQ 2004). Following this pilot, the tool was further refined and the survey was rolled out as a national project in 2013. In order to facilitate hospitals as much as possible, it was necessary to divide the national project up into five phases which commenced in June 2013 and continued through to March 2014. Each participating hospital received its own survey report. This assessment of a hospital s patient safety culture should assist the hospital in meeting the National Standards for Safer Better Healthcare (HIQA 2012) and enable the hospital to incorporate its survey findings into any quality improvement plans being developed to meet the requirements of the National Standards for Safer Better Healthcare. Page 3

In order to meet further information requirements, data from 41 participating hospitals and 4,700 respondents were merged into one composite database and analysed. This Composite Results and Comparative Statistics Report presents this analysis in the form of overall results and comparative measures, so as to enable each hospital to compare its results with those of other hospitals. The Quality Improvement Division is committed to providing the integral support within the overall system to enable hospitals tom address comparative culture outcomes. Page 4

MAIN FINDINGS: Areas of Strength The three areas of strength i.e. the three multi-question dimensions with the highest percent positive responses were: Teamwork Within Units/Departments (Staff support each other, treat each other with respect and work together as a team) 79% Organisational Learning Continuous Improvement (There is a learning culture in which mistakes lead to positive changes and changes are evaluated for effectiveness) 70% Supervisor/Manager Expectations & Actions Promoting Patient Safety (Supervisor/Manager 67% consider staff suggestions for improving patient safety, praise staff for following patient safety procedures, and do not overlook patient safety problems) The same three areas of strengths across 653 hospitals in the US were identified in the AHRQ s User Comparative Database Report for 2014. Areas with Potential for Improvement The three areas with the most potential for improvement i.e. the three multi-question dimensions with the lowest percent positive responses were: Non Punitive Response to Error (Staff feel that their mistakes and event reports are not held against them) 47% Handoffs and Transitions (Important patient care information is transferred across hospital units/departments and during shift changes) 42% Staffing (There are enough staff to handle the workload and work hours are appropriate to provide the best care for patients) 40% The AHRQ s User Comparative Database Report for 2014 identifies the same three areas with the most potential for improvement. Page 5

Clinical Governance is defined as a framework through which healthcare teams are accountable for the quality, safety and satisfaction of patients in the care they deliver. (Gauld et al. 2011). The Clinical Governance Development Index Score was determined from an additional series of questions, included with the AHRQ Survey, and the average across the hospitals was: Clinical Governance Development Index Score (measures the extent to which a healthcare organisation is working to develop clinical governance) 47% This is on a par with baseline results from the 2011 New Zealand study that developed the index. Page 6

Dimensions 1-12 The average % positive responses for the multi-question dimensions range from 40% to 79%. AHRQ results range from 44% to 81%. Average % Positive Response by Dimension 1.Teamwork within Wards/Departments 79% 3.Organisational Learning - Continuous Improvement 70% 2.Supervisor/M anager Expectations & Actions 67% 7.Communication Openness 60% 8.Frequency of Incidents Reported 60% 9.Teamwork Across Wards/Departments 57% 6.Feedback & Communication about Error 56% 5.Overall Perceptions of Patient Safety 53% 4.Management Support for Patient Safety 52% 12.Non Punitive Response to Error 47% 11.Handoffs & Transitions 42% 10.Staffing 40% Dimension 13 - Overall Grade on Patient Safety 65% of respondents graded patient safety on their wards/departments positively (as Excellent or Very Good ) and 7% graded it negatively (as Poor or Failing ). The AHRQ equivalents were 76% and 5% respectively. Dimension 14 - Number of Events Reported 67% of respondents had completed and submitted an incident report within the past year. The equivalent for US hospitals is 44% (AHRQ). Page 7

1.0 Purpose and Use of this Report This Report provides: Composite survey results for all participating hospitals; Comparative statistics to enable each hospital to compare its results with those of other hospitals; Assistance for hospitals in internal assessment and in their learning of the patient safety improvement process; Assistance for hospitals in identifying their areas of strengths and areas for improvement in patient safety culture. 2.0 Introduction Quality and safety has been a major focus in healthcare over the last ten years and internationally significant efforts have been made to incorporate this as an integral part of all health systems. How health care staff feel about patient safety at their hospital is an important part of assessing and changing the culture within the organisation (Nieva, V.F., Sorra, J. 2003). Without understanding the culture within an organisation, across all staff groups, and at every level of the organisation, it is difficult to improve systems and ensure that robust quality and patient safety processes are implemented effectively. A significant review of the available international patient safety culture survey tools were explored and surveys applicable to many health service areas were considered. The multitude of available survey tools in itself indicates the lack of synergy within healthcare safety culture improvement, as no one tool has transpired to be the very best. It was agreed by the pilot project group that the survey that best met the needs within Irish healthcare was the Agency for Healthcare Research and Patient Safety Culture Surveys (2004). This was supported by Halligan and Zecevic (2011), who reviewed 12 different survey tools, of which the following four were the most commonly cited: the Agency for Healthcare Research and Quality (AHRQ) s Hospital Survey on Patient Safety Culture (2003) ; Safety Attitudes Questionnaire (2003) ; Patient Safety Climate in Healthcare Organisations Survey (2007) ; Modified Stanford Patient Safety Culture Survey Instrument (2009). The Agency for Healthcare Research and Quality (AHRQ) s Hospital Survey on Patient Safety Culture was adapted to the Irish healthcare setting, through minor changes in terminology, and with the addition of specific questions on Clinical Governance Development and Open Disclosure. The inclusion of Clinical Governance questions were drawn from the New Zealand Clinical Governance Development Index (CGDI, 2011) and the Clinical Governance Development Programme (HSE, 2012). The Open Disclosure questions were obtained from the Open Disclosure project, established in 2010. Page 8

In 2012, the Quality and Patient Safety Directorate now the Quality Improvement Division (QID) in collaboration with the Regional Managers for Quality and Patient Safety, piloted the National Patient Safety Culture Survey for Staff in Acute Hospitals in five hospitals. Following this pilot, the tool was further refined and the survey was rolled out as a national project in 2013. In order to facilitate hospitals as much as possible, it was necessary to divide the national project up into five phases which commenced in June 2013 and continued through to March 2014. The purpose of undertaking such a survey is to assess and understand the culture of all staff within organisations; to raise awareness of the many areas of quality and patient safety that need to be considered within an organisation; to give organisations information of their staff perceptions of patient safety issues, which in turn enables the organisation to focus on areas that need to be considered for improvement. Undertaking an exercise of assessing the culture within the organisation also gives staff an opportunity to openly express their views, thus influencing the specific areas for which the hospital may subsequently decide to develop quality improvement plans. The survey will also enable an organisation to assess how existing processes and systems pertaining to patient safety have been implemented, and evaluate their effectiveness from a staff viewpoint. By conducting the survey there is generally more communication within the organisation around the topics contained in the survey and this in turn results in greater awareness amongst staff for all aspects of quality and patient safety. The QID was also keen to assist hospitals in meeting the National Standards for Safer Better Healthcare (HIQA 2012), and by assessing the culture within their organisations, this would enable hospitals to incorporate the findings of the survey into any quality improvement plans being developed to meet the requirements of the National Standards for Safer Better Healthcare. Page 9

3.0 Survey Administration The national roll-out of the National Patient Safety Culture Survey for Staff in Acute Hospitals commenced in June 2013. As with the pilot in 2012, the survey was open to all hospital staff with both electronic and paper based survey tools available for use. In order to facilitate hospitals as much as possible, it was necessary to divide the national project up into five phases which continued right through to the end of March 2014, Table 1. Two hospitals are excluded from the table - one agreed to participate but no responses were received from it and the other one refused to facilitate the survey and did not participate at all. A total of 43 hospitals participated in the survey. Table 1: Survey Period and Numbers of Participating Hospitals in each Phase Number of Phase Survey Period Participating Hospitals Pilot Beginning of June 2012 to End of July 2012 5 Phase 1 End of June 2013 to End of August 2013 18 Phase 2 Beginning of September 2013 to End of October 2013 9 Phase 3 End September 2013 to End of November 2013 5 Phase 4 End of October 2013 to Beginning of December 2013 3 Phase 5 Beginning of February 2014 to End of March 2014 3 Data from 41 participating hospitals and 4,700 respondents were merged into one composite database and analysed. In line with an AHRQ criterion, two hospitals with fewer than 10 respondents were excluded. Table 2 presents the average and range across these 41 hospitals and 4,700 respondents. Table 2: Average and Range of Responses Across Hospitals Average Minimum Maximum Number of Respondents per Hospital 115 12 523 Hospital Response Rate (%) 13 1 39 The majority of hospitals, 29, provided their staff with the option of completing the questionnaire using either the paper or the electronic version of the survey tool, Table 3. The average response rates for the Paper Only and Either hospitals were on a par and significantly higher than the equivalent rate for Web Only hospitals. Page 10

Table 3: Numbers and Percentages of Hospitals and Respondents by Survey Tool Hospitals Respondents Average Hospital Response Rate Survey Tool N % N % % Paper Only 9 22 937 20 14 Web Only 3 7 223 5 3 Either 29 71 3,540 75 14 Total 41 100 4,700 100 13 Page 11

4.0 Respondent Characteristics The main characteristics of the 4,700 database respondents were: 51% were nurses/midwives; 80% had direct interaction with patients; 30% had been working in their current wards/departments for 1-5 years and another 30% for 6-10 years; and 77% worked 20-39 hours per week. Tables 4 to 7 provide detailed breakdowns for the respondent characteristic questions that were applicable to all hospitals. Table 4: Numbers and Percentages of Respondents and Staff Census Headcount by Staff Position Respondents Staff Census Headcount** Staff Position * N % N % Medical/Dental 300 7 6,373 13 Nursing/Midwifery 2,326 51 20,934 42 Health & Social Care Professionals 764 17 5,774 12 General Support Staff 376 8 5,679 11 Management/Administration 641 14 7,376 15 Other Patient & Client Care 134 3 3,634 7 TOTAL 4,541 100 49,770 100 Missing Values 159 Overall Total 4,700 * This question was itemised as Q16 for Single and Group Hospitals and as Q14 for Pilot Hospitals. ** Source: HR Management Information as appropriate to the survey months. Table 5: Numbers and Percentages of Respondents by Direct Interaction with Patients Respondents Direct Interaction with Patients * N % Yes 3,648 80 No 909 20 TOTAL 4,557 100 Missing Values 143 Overall Total 4,700 * This question was itemised as Q17 for Single and Group Hospitals and as Q15 for Pilot Hospitals. Page 12

Table 6: Numbers and Percentages of Respondents by Years Worked in Current Ward/Department Respondents Years Worked in Current Ward/Department * N % Less than 1 year 442 10 1-5 years 1,376 30 6-10 years 1,372 30 11-15 years 882 19 16-20 years 253 6 21 years or more 239 5 TOTAL 4,564 100 Missing Values 136 Overall Total 4,700 * This question was itemised as Q15 for Single and Group Hospitals and as Q13 for Pilot Hospitals. Table 7: Numbers and Percentages of Respondents by Hours Worked per Week Respondents Hours Worked per Week * N % Less than 20 hours 217 5 20-39 hours 3,555 77 40-59 hours 694 15 60-79 hours 108 2 80 hours or more 15 0 TOTAL 4,589 100 Missing Values 111 Overall Total 4,700 * This question was itemised as Q14 for Single and Group Hospitals and as Q12 for Pilot Hospitals. The other respondent characteristics questions varied, depending on whether the hospital was part of a hospital group or not or was a pilot hospital, and their breakdowns are provided in Appendix B. Page 13

5.0 Composite Results This section provides results from analysis of the composite database for twelve Patient Safety Culture dimensions with multiple questions: 1. Teamwork within Wards/Departments (4 questions) 2. Supervisor/manager Expectations & Actions Promoting Patient Safety (4 questions) 3. Organisational Learning Continuous Improvement (3 questions) 4. Hospital Management Support for Patient Safety (3 questions) 5. Overall Perceptions of Patient Safety (4 questions) 6. Feedback and Communications about Error (3 questions) 7. Communication Openness (3 questions) 8. Frequency of Incidents Reported (3 questions) 9. Teamwork Across Hospital Wards/Departments (4 questions) 10. Staffing (4 questions) 11. Hospital Handoffs and Transitions (4 questions) 12. Non Punitive Response to Error (3 questions); for two further Patient Safety Culture dimensions with a single question. 13. Overall Grade for Patient Safety (1 question) 14. Number of Events Reported (1question); for Clinical Governance Development; and for Open Disclosure. Composite results are reported as averages of the 41 individual hospitals results so that equal weight is given to each hospital s results. This methodology is necessary for the purposes of this survey as the patient safety culture pertains collectively to a hospital, not to individual respondents. Page 14

5.1 Main Findings Areas of Strength (Dimensions 1-12) : The three areas of strength i.e. the dimensions with the highest percent positive responses were: Teamwork Within Units/Departments (Staff support each other, treat each other with respect and work together as a team) 79% Organisational Learning Continuous Improvement (There is a learning culture in which mistakes lead to positive changes and changes are evaluated for effectiveness) 70% Supervisor/Manager Expectations & Actions Promoting Patient Safety (Supervisor/Manager 67% consider staff suggestions for improving patient safety, praise staff for following patient safety procedures, and do not overlook patient safety problems) The same three areas of strengths across 653 hospitals in the US were identified in the AHRQ s User Comparative Database Report for 2014. Areas with Potential for Improvement (Dimensions 1-12): The three areas with the most potential for improvement i.e. the three dimensions with the lowest percent positive responses were: Non Punitive Response to Error (Staff feel that their mistakes and event reports are not held against them) 47% Handoffs and Transitions (Important patient care information is transferred across hospital units/departments and during shift changes) 42% Staffing (There are enough staff to handle the workload and work hours are appropriate to provide the best care for patients) 40% The AHRQ s User Comparative Database Report for 2014 identifies the same three areas with the most potential for improvement. Note: % Calculations exclude missing values. Page 15

Clinical Governance is defined as a framework through which healthcare teams are accountable for the quality, safety and satisfaction of patients in the care they deliver. (Gauld et al. 2011). Clinical Governance Development Index Score: This was determined from an additional series of questions, included with the AHRQ Survey, and its average across hospitals was: Clinical Governance Development Index Score (measures the extent to which a healthcare organisation is working to develop clinical governance) 47% This is on a par with baseline results from the 2011 New Zealand study that developed the index. Note: % Calculations exclude missing values. Page 16

5.2 Dimensions Figure 1 illustrates the results for the first twelve multi-question dimensions (in descending order) with AHRQ comparisons and is followed by the percent positive responses to the other two single-question dimensions. Figure 1: Average % Positive Response by Dimension w ith AHRQ comparisons PSCS AHRQ 1.Teamwork within W ards/ Departments 79% 81% 3.Organisational Learning - Continuous Impro vement 70% 73% 2.Supervisor/ M anager Expectations & Actions 7.Communicat ion Openness 8.Frequency of Incidents Reported 9.Teamwork Across W ards/ Departments 67% 60% 62% 60% 66% 57% 61% 76% 6.Feedback & Communication about Erro r 5.Overall Perceptions of Patient Safety 4.M anagement Support for Patient Safety 12.Non Punitive Response to Error 11.Handoffs & Transit io ns 56% 53% 52% 47% 44% 42% 47% 67% 66% 72% 10.Staffing 40% 55% Dimension 13 - Overall Grade on Patient Safety 65% of respondents consider patient safety on their wards/departments as excellent (19%) or very good (46%) (Figure 14). The AHRQ reported a combined 76% with 33% as excellent and 43% as very good. Dimension 14 - Number of Events Reported 67% of respondents had completed and submitted an incident report within the past year (Figure 15). The AHRQ equivalent was 44%. Note: % Calculations exclude missing values. Page 17

The following series of figures, Figures 2 to 13, provides % Positive, % Neutral and % Negative responses for each dimension and for each question within a dimension. The % Positive category is determined by Agree, Strongly Agree, Most of the Time and Always responses to positively worded questions and by Disagree, Strongly Disagree, Never and Rarely responses to reverse worded questions (as indicated by the letter R ). The converse of this determines the % Negative category while Neither and Sometimes responses fall into the % Neutral category. Equal weight is given to each question within a dimension so the % responses for the dimension as a whole are calculated as the average of the questions responses. Dimension 1 Description Teamwork within Wards/Departments Staff support each other, treat each other with respect, and work together as a team Figure 2: % Responses to Teamwork within Wards/Departments Dimension and Questions % Positive % Neutral % Negative DIMENSION 79 9 13 1. People support one another in this ward/department (4a) 87 6 8 2. When a lot of work needs to be done quickly, we work together as a team to get the work 83 8 9 3. In this ward/department people treat each other with respect (4d) 81 8 11 4. When one area in this ward/department gets really busy, others help out (4k) 63 13 24 Note: % Calculations exclude missing values and may not sum to 100% due to rounding. Page 18

Dimension 2 Description Supervisor/Manager Expectations and Actions Promoting Patient Safety Supervisor/Manager consider staff suggestions for improving patient safety, praise staff for following patient safety procedures, and do not overlook patient safety problems. Figure 3: % Responses to Supervisor/Manager Expectations and Actions Promoting Patient Safety Dimension and Questions % Positive % Neutral % Negative DIM ENSION 67 16 17 1. M y line manager says a good word when he/she sees a job done according to established patient safety procedures (5a) 60 18 22 2. M y line manager seriously considers staff suggestions for improving patient safety (5b) 69 14 16 R3. Whenever pressure builds up, my line manager wants us to work faster, even if it means taking shortcuts (5c) 64 19 17 R 4. M y line manager overlooks patient safety problems that happen over and over (5d) 74 14 12 1 Dimension 3 Description Organisational Learning - Continuous Improvement Mistakes have led to positive changes and changes are evaluated for effectiveness Figure 4: % Responses to Organisational Learning - Continuous Improvement Dimension and Questions % Positive % Neutral % Negative DIMENSION 70 17 13 1. We are actively doing things to improve patient safety (4f) 84 10 6 2. Mistakes have led to positive changes here (4i) 66 21 13 3. After we make changes to improve patient safety we evaluate their effectiveness (4m) 60 21 19 Note: % Calculations exclude missing values and may not sum to 100% due to rounding. Page 19

Dimension 4 Description Management Support for Patient Safety Hospital management provides a work climate that promotes patient safety and shows that patient safety is a top priority Figure 5: % Responses to Management Support for Patient Safety Dimension and Questions % Positive % Neutral % Negative DIMENSION 52 17 30 1. Hospital management provides a work environment that promotes patient safety (9a) 65 14 21 2. The actions of hospital management show that patient safety is a top priority (9h) 53 21 26 R 3. Hospital management seems interested in patient safety only after an incident happens (9i) 39 16 45 2 Dimension 5 Description Overall Perceptions of Patient Safety Procedures and systems are good at preventing errors and there is a lack of patient safety problems Figure 6: % Responses to Overall Perceptions of Patient Safety Dimension and Questions % Positive % Neutral % Negative DIMENSION 53 17 30 1. Patient safety is never sacrificed to get more work done (4o) 54 16 30 2. Our procedures and systems are good at preventing errors from happening (4r) 68 18 14 R 3. It is just by chance that more serious mistakes don't happen around here (4j) 49 15 35 R 4. We have patient safety problems in this ward/department (4q) 42 18 40 Note: % Calculations exclude missing values and may not sum to 100% due to rounding. Page 20

Dimension 6 Description Feedback and Communication about Error Staff are informed about errors that happen, given feedback about changes implemented, and discuss ways to prevent errors Figure 7: % Responses to Feedback and Communication about Error Dimension and Questions % Positive % Neutral % Negative DIMENSION 56 24 19 1. We are given feedback about changes put into place based on incident reports (6a) 39 29 32 2. We are informed about errors that happen in this ward/department (6c) 64 23 13 3. In this ward/department, we discuss ways to prevent errors from happening again (6e) 66 21 13 3 Dimension 7 Description Communication Openness Staff freely speak up if they see something that may negatively affect a patient and feel free to question those with more authority Figure 8: % Responses to Communication Openness Dimension and Questions % Positive % Neutral % Negative DIMENSION 60 26 14 1. Staff will freely speak up if they see something that may negatively affect patient care (6b) 73 20 7 2. Staff feel free to question the decisions or actions of those with more authority (6d) 46 29 25 R 3. Staff are afraid to ask questions when something does not seem right (6f) 62 28 10 Note: % Calculations exclude missing values and may not sum to 100% due to rounding. Page 21

Dimension 8 Description Frequency of Incidents Reported Mistakes of the following types are reported: (1) mistakes caught and corrected before affecting the patient, (2) mistakes with no potential to harm the patient, and (3) mistakes that could harm the patient but do not Figure 9: % Responses to Frequency of Incidents Reported Dimension and Questions % Positive % Neutral % Negative DIMENSION 60 21 19 1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported? (7a) 53 24 23 2. When a mistake is made, but has no potential to harm the patient, how often is this reported? (7b) 53 23 24 3. When a mistake is made that could harm the patient, but does not, how often is this reported? (7c) 74 17 9 Dimension 9 Description Teamwork Across Wards/Departments Hospital wards/departments cooperate and coordinate with one another to provide the best care for patients Figure 10: % Responses to Teamwork Across Wards/Departments Dimension and Questions % Positive % Neutral % Negative DIMENSION 57 21 22 1. There is good cooperation among hospital wards/departments that need to work together (9d) 59 22 18 2. Hospital wards/departments work well together to provide the best care for patients (9j) 69 20 11 R3. Hospital wards/departments do not coordinate well with each other (9b) 38 21 41 R4. It is often unpleasant to work with staff from other hospital wards/departments (9f) 61 21 18 Note: % Calculations exclude missing values and may not sum to 100% due to rounding. Page 22

Dimension 10 Staffing Description There are enough staff to handle the workload and work hours are appropriate to provide the best care for patients Figure 11: % Responses to Staffing Dimension and Questions % Positive % Neutral % Negative DIMENSION 40 18 42 1. We have enough staff to handle the workload (4b) 26 9 65 R 2. Staff in this ward/department work longer hours than is best for patient care (4e) 40 24 36 R 3. We use more agency/temporary staff than is best for patient care (4g) 60 23 17 R 4. We work in 'crisis mode' trying to do too much, too quickly (4n) 32 16 51 Dimension 11 Handoffs and Transitions Description Important patient care information is transferred across hospital wards/departments and during shift changes Figure 12: % Responses to Handoffs and Transitions Dimension and Questions % Positive % Neutral % Negative DIMENSION 42 27 32 R 1. Things 'fall between the cracks' when transferring patients from one ward/department to another (9c) 36 25 40 R 2. Important patient care information is often lost during shift changes (9e) 51 26 23 R 3. Problems often occur in the exchange of information across hospital wards/departments (9g) 35 22 42 R 4. Shift changes are problematic for patients in this hospital (9k) 45 34 21 Note: % Calculations exclude missing values and may not sum to 100% due to rounding. Page 23

Dimension 12 Non Punitive Response to Error Description Staff feel that their mistakes and incident reports are not held against them and that mistakes are not kept in their personnel file Figure 13: % Responses to Non Punitive Response to Error Dimension and Questions % Positive % Neutral % Negative DIMENSION 47 21 32 R 1. Staff feel like their mistakes are held against them (4h) 49 22 30 R 2. When an incident is reported, it feels like the person is being reported, not the problem (4l) 52 16 32 R 3. Staff worry that mistakes they make are kept in their personnel file (4p) 42 24 34 Note: % Calculations exclude missing values and may not sum to 100% due to rounding. Page 24

Dimension 13 - Overall Grade of Patient Safety (Question 8) Nearly two-thirds of respondents, 65%, provided a positive response (those responses that were considered excellent or very good ) to the question on patient safety for their ward/department (Figure 14). 100 Figure 14: % Responses to Overall Grade on Patient Safety 80 % 60 40 20 0 46 28 19 6 1 Excellent Very good Acceptable Poor Failing Grade Note: % Calculations exclude missing values and may not sum to 100% due to rounding. Page 25

Dimension 14 - Number of Events Reported (Question 10) Just over two-thirds of respondents, 67%, had completed and submitted at least one incident report within the past year (Figure 15). 4 100 Figure 15: % Responses to Number of Events Reported 80 % 60 40 33 29 20 18 10 10 0 None 1-2 3-5 6-10 11+ Number of Reports Note: % Calculations exclude missing values and may not sum to 100% due to rounding. Page 26

5.3 Clinical Governance Development One adaptation of the AHRQ survey tool for the Irish context was to include questions to determine staff perceptions in relation to Clinical Governance Development. Clinical Governance is: a framework through which healthcare teams are accountable for the quality, safety and satisfaction of patients in the care they deliver. In determining clinical governance development questions to be included in the survey, questions were drawn from the New Zealand Clinical Governance Development Index (CGDI, 2011). This incorporated clinical governance structures; how quality and safety are incorporated into clinical governance; responsibility and accountability; and the involvement of patients and families. Two additional questions were also included pertaining to whether staff had received education or training in relation to clinical governance, and also whether patients and families are involved in improving quality and safety. Table 8: % Reponses to Clinical Governance Development Questions Don't Yes No Know Question 11 (Q17 for Pilot Hospitals) % % % 11a. Have you had any clinical governance education or training? 40 46 14 11b. To your knowledge, has your hospital established a clinical governance structure that ensures a partnership between clinicians and management? 49 9 42 Great Some No Don't Extent Extent Extent Know Question 12 (Q18 for Pilot Hospitals) % % % % 12a. To what extent do you believe that quality and safety is the goal of every clinical initiative in your hospital? 40 50 3 7 12b. To what extent do you believe that quality and safety is the goal of every management/administrative initiative in your hospital? 12c. To what extent are clinicians in your hospital involved as full active participants in all governance decision making processes? 12d. To what extent are clinicians in your hospital involved in a partnership with management with shared decision making, responsibility and accountability? 33 54 6 8 17 49 7 26 17 48 8 27 12e. To what extent has your hospital sought to identify clinical leaders? 20 36 8 35 12f. To what extent has your hospital sought to give responsibility to your team for clinical service decision making in your clinical area? 12g. To what extent do staff in this hospital involve patients and families in improving quality and patient safety? 17 43 14 27 15 46 15 23 Note: % Calculations exclude missing values and may not sum to 100% due to rounding. Page 27

Each hospital s CGDI score is based on the combined responses to seven questions, Q11b and Q12a-f, per individual respondent (see Appendix C for further information on how the score is calculated). It gives an indication of staff perception of the extent of the clinical governance development for the hospital. Of note is that the percentages of negative responses ( No Extent ) are lower than the percentages of positive responses ( Great Extent, Some Extent ) for Q 12a-f. The composite score for database hospitals was 47%. Page 28

5.4 Open Disclosure Within the survey additional questions were presented in relation to Open Disclosure in order to determine the perceptions of staff to Open Disclosure. Open disclosure is An open consistent approach to communicating with patients when things go wrong in healthcare. This includes expressing regret for what has happened, keeping the patient informed, providing feedback on investigations and the steps taken to prevent a recurrence of the adverse event. (Australian Commission on Safety and Quality in Health care, 2008) Four specific questions were included in the survey tool and the composite % positive responses are shown in Figure 16. Positive responses are defined as Most of the Time or Always for Question 7d and as Strongly Agree or Agree for Questions 9l to 9n. Figure 16: % Positive Responses to Open Disclosure Questions * 7d. When a mistake is made that caused harm to a patient how often is this reported? 94 9l. Hospital management and clinicians support and engage in open disclosure w ith patients/their support person follow ing an adverse event 51 9m. Follow ing an adverse event staff are supported by the organisation in relation to their needs 43 9n. Hospital management support and promote a culture of open disclosure/communication w ithin the organisation 48 0 20 40 60 80 100 * The five Pilot Hospitals are excluded as their open disclosure questions are not compatible with those re-configured for the national roll-out. % Note: % Calculations exclude missing values. Page 29

In considering the Open Disclosure responses it is important to take cognisance of the following patient safety dimensions that were presented earlier in the report: Management Support for Patient Safety Feedback and Communication about Error Communication Openness Non Punitive Responses to Error Overall Grade on Patient Safety Page 30

6.0 COMPARATIVE STATISTICS The tables in this section are provided so that each hospital can compare its results with the database average and it can position its results relative to the distribution of results for all database hospitals. These are only relative comparisons though, so even if a hospital s result is well positioned there may still be room for improvement in a particular area within the hospital. For that reason, these comparative statistics should be used to supplement hospitals own efforts toward identifying areas of strength and areas on which to focus improvement efforts. 6.1 Description and Interpretation Rather than establishing statistically significant results which may or may not be meaningful, the AHRQ recommends the use of a 5 percentage points difference as a rule of thumb when comparing an individual hospital s result (score) with the database s average (mean). Thus, if an individual hospital s score is 5 percentage points greater or less than the database average then that hospital can consider itself to be better or worse than the database average. If it is not, then the hospital should consider itself as being on a par with the average. Percentiles are used to indicate the distribution of scores across all database hospitals thereby enabling an individual hospital to position itself within that distribution. Hospital scores were ranked from lowest to highest and then they were divided into 100ths i.e. percentiles. Consequently, a specific percentile value shows the percentage of hospitals that scored at or below that specific value. For example, the 10 th percentile is the score where 10% of hospitals scored the same or lower, the 25 th percentile is the score where 25% of hospitals scored the same or lower etc. Page 31

Only the more commonly used percentiles are presented in this report. Definitions and interpretations of the reported comparative statistics are provided in Table 9a. Table 9a: Description and Interpretation of Comparative Statistics Statistic Interpretation Average Mean of hospitals scores Minimum Lowest hospital score 10 th percentile 10% of hospitals scored the same or lower (representing the lowest scoring hospitals) or. 90% of hospitals scored higher 25 th percentile 25% of hospitals scored the same or lower (representing the lower scoring hospitals) or. 75% of hospitals scored higher 50 th percentile (median) The median is the middle value in the distribution of scores so 50% of hospitals scored the same or lower and 50% scored higher 75 th percentile 25% of hospitals scored higher (representing the higher scoring hospitals) or 75% of hospitals scored the same or lower 90 th percentile 10% of hospitals scored higher (representing the highest scoring hospitals) or 90% of hospitals scored the same or lower Maximum Highest hospital score Table 9b is provided as a data source for examples of how to make valid hospital comparisons by interpreting the statistics correctly. It is recommended that an individual hospital would (i) compare its score with the database average by using the 5 percentage points rule of thumb; and (ii) position its score relative to the percentile scores provided. Example 1): i) A comparison of an individual hospital s average % positive response of 86% for the Teamwork within Wards/Departments dimension with the database average of 79% would mean that it is better than the database average as the former is more than 5 percentage points higher than the latter. (ii) Furthermore, and as highlighted in red in Table 9b, an examination of the percentile scores indicates that the individual hospital is among the highest scoring hospitals (the top 10% of hospitals) as its 86% result exceeds the 90 th percentile score of 85%. Example 2) a) A hospital with a 77% average could consider itself as being on a par with the database average of 79% as the 5 percentage points criterion is not satisfied. b) Interpretation of the distribution of scores across hospitals, and as highlighted in blue in Table 9b, locates the individual hospital in the lower half of the distribution (less than the 50 th percentile) but it s better than the lower scoring hospitals (greater than the 25 th percentile). Page 32

Table 9b: Interpretation of Comparative Statistics for Examples Average Minimum 10th %tile 25th %tile Percentiles 50th %tile 75th %tile 90th %tile Maximum 79% 67% 69% 75% 79% 82% 85% 92% 6.2 Comparative Tables Tables 10-15 provide comparative statistics for the percentage positive responses or scores for each dimension; each dimension question; the CDGI score; and each Open Disclosure question. Table 10: Comparative Statistics for % Positive Responses to Dimensions 1-12 Dimension Average Minimum 10th %tile 25th %tile Percentiles 50th %tile 75th %tile 90th %tile Maximun 1.Teamwork within Wards/Departments 79% 67% 69% 75% 79% 82% 85% 92% 2.Supervisor/Manager Expectations & Actions 67% 33% 58% 62% 67% 72% 77% 82% 3.Organisational Learning - Continuous Improvement 70% 57% 59% 64% 70% 76% 79% 92% 4.Management Support for Patient Safety 52% 28% 37% 42% 50% 61% 72% 77% 5.Overall Perceptions of Patient Safety 53% 38% 44% 46% 51% 61% 64% 79% 6.Feedback & Communication about Error 56% 37% 46% 51% 55% 61% 70% 79% 7.Communication Openness 60% 46% 51% 55% 60% 65% 70% 76% 8.Frequency of Incidents Reported 60% 47% 51% 56% 60% 64% 67% 86% 9.Teamwork Across Wards/Departments 57% 34% 43% 48% 56% 65% 73% 77% 10.Staffing 40% 24% 30% 32% 38% 46% 50% 60% 11.Handoffs & Transitions 42% 19% 25% 33% 41% 49% 61% 76% 12.Non Punitive Response to Error 47% 30% 38% 42% 46% 53% 60% 72% Page 33

Table 11: Comparative Statistics for % Positive Responses to Dimensions 1-12 Questions DIMENSION & QUESTION 1.Teamwork within Wards/Departments Minimum 10th %tile 25th %tile Percentiles 50th %tile 75th %tile 90th %tile Maximum 4a. People support one another in this ward/department 87% 73% 80% 83% 86% 92% 95% 100% 4c. When a lot of work needs to be done quickly, we work together as a team to get the work done 83% 64% 77% 80% 82% 88% 91% 94% 4d. In this ward/department, people treat each other with respect 81% 61% 71% 75% 82% 88% 93% 98% 4k. When one area in this ward/department gets really busy, others help out 63% 42% 54% 56% 63% 69% 74% 86% 2. Supervisor/Manager Expectations & Actions Promoting Patient Safety 5a. My line manager says a good word when he/she sees a job done according to established patient safety procedures 60% 43% 47% 53% 62% 68% 71% 75% 5b. My line manager seriously considers staff suggestions for improving patient safety 69% 36% 60% 64% 69% 76% 81% 85% 5c. Whenever pressure builds up, my line manager wants us to work faster, even if it means taking shortcuts (R) 64% 36% 53% 58% 66% 69% 78% 84% 5d. My line manager overlooks patient safety problems that happen over and over (R) 74% 15% 68% 70% 75% 79% 82% 92% 3.Organisational Learning - Continuous Improvement 4f. We are actively doing things to improve patient safety 84% 65% 76% 79% 84% 88% 93% 100% 4i. Mistakes have led to positive changes here 66% 52% 57% 62% 64% 72% 76% 87% 4m. After we make changes to improve patient safety, we evaluate their effectiveness 60% 16% 46% 50% 60% 67% 79% 100% 4.Management Support for Patient Safety 9a. Hospital management provides a work environment that promotes patient safety 65% 31% 47% 55% 64% 76% 86% 91% 9h. The actions of hospital management show that patient safety is a top priority 53% 25% 36% 43% 50% 63% 73% 93% 9i. Hospital management seems interested in patient safety only after an incident happens (R) 39% 14% 25% 30% 38% 50% 58% 63% 5.Overall Perceptions of Patient Safety 4o. Patient safety is never sacrificed to get more work done 54% 34% 39% 46% 52% 58% 69% 76% 4r. Our procedures and systems are good at preventing errors from happening 68% 48% 59% 60% 67% 73% 81% 92% 4j. It is just by chance that more serious mistakes don't happen around here (R) 49% 19% 36% 40% 46% 60% 63% 78% 4q. We have patient safety problems in this ward/department (R) 6.Feedback & Communication about Error Average 42% 18% 31% 34% 37% 48% 57% 75% 6a. We are given feedback about changes put into place based on incident reports 39% 17% 25% 33% 37% 45% 56% 67% 6c. We are informed about errors that happen in this ward/department 64% 39% 51% 56% 63% 69% 78% 93% 6e. In this ward/department, we discuss ways to prevent errors from happening again 66% 46% 56% 60% 66% 72% 81% 86% Page 34

DIMENSION & QUESTION 7.Communication Openness Minimum 10th %tile 25th %tile Percentiles 50th %tile 75th %tile 90th %tile Maximum 6b. Staff will freely speak up if they see something that may negatively affect patient care 73% 58% 60% 67% 72% 79% 83% 93% 6d. Staff feel free to question the decisions or actions of those with more authority 46% 31% 35% 41% 46% 53% 57% 67% 6f. Staff are afraid to ask questions when something does not seem right (R) 62% 33% 52% 56% 62% 67% 70% 78% 8.Frequency of Incidents Reported 7a. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported? 53% 34% 43% 46% 53% 58% 63% 83% 7b. When a mistake is made, but has no potential to harm the patient, how often is this reported? 53% 39% 43% 48% 53% 57% 65% 75% 7c. When a mistake is made that could harm the patient, but does not, how often is this reported? 74% 63% 66% 70% 72% 76% 83% 100% 9.Teamwork Across Wards/Departments 10.Staffing 9d. There is good cooperation among hospital wards/departments that need to work together 59% 34% 43% 48% 59% 69% 78% 93% 9j. Hospital wards/departments work well together to provide the best care for patients 69% 41% 55% 60% 68% 78% 83% 93% 9b. Hospital wards/departments do not coordinate well with each other (R) 38% 13% 20% 27% 39% 48% 57% 65% 9f. It is often unpleasant to work with staff from other hospital wards/departments (R) 61% 42% 44% 56% 60% 70% 76% 78% 4b. We have enough staff to handle the workload 26% 7% 14% 18% 23% 34% 42% 47% 4e. Staff in this ward/department work longer hours than is best for patient care (R) 40% 21% 28% 30% 39% 46% 52% 67% 4g. We use more agency/temporary staff than is best for patient care (R) 60% 36% 43% 52% 63% 68% 73% 89% 4n. We work in "crisis mode" trying to do too much, too quickly (R) 11.Handoffs & Transitions 32% 14% 19% 24% 30% 39% 50% 80% 9c. Things "fall between the cracks" when transferring patients from one ward/department to another (R) 36% 12% 17% 24% 36% 43% 57% 78% 9e. Important patient care information is often lost during shift changes (R) 51% 30% 35% 43% 47% 58% 69% 88% 9g. Problems often occur in the exchange of information across hospital wards/departments (R) 35% 6% 16% 26% 34% 44% 55% 69% 9k. Shift changes are problematic for patients in this hospital (R) 12.Non Punitive Response to Error Average 45% 13% 28% 34% 43% 52% 68% 77% 4h. Staff feel like their mistakes are held against them (R) 49% 30% 36% 43% 48% 53% 61% 80% 4l. When an incident is reported, it feels like the person is being reported, not the problem (R) 52% 10% 40% 45% 48% 59% 69% 100% 4p. Staff worry that mistakes they make are kept in their personnel file (R) 42% 26% 31% 37% 40% 44% 55% 64% Table 12: Comparative Statistics for % Positive Response to Dimension 13 - Overall Grade on Patient Safety Percentiles Minimum 10th 25th 50th 75th 90th Maximum Average %tile %tile %tile %tile %tile 65% 51% 52% 57% 64% 72% 77% 91% Table 13: Comparative Statistics for % Positive Response to Dimension 14 Number of Events Reported Percentiles Minimum 10th 25th 50th 75th 90th Maximum Average %tile %tile %tile %tile %tile 67% 47% 56% 59% 66% 74% 80% 92% Page 35

Table 14: Comparative Statistics for Clinical Governance Development Index Score Percentiles Minimum 10th 25th 50th 75th 90th Maximum Average %tile %tile %tile %tile %tile 47% 35% 40% 43% 46% 49% 55% 63% Table 15: Comparative Statistics for % Positive Responses to Open Disclosure Questions * Open Disclosure Question Average Minimum 10th %tile 25th %tile Percentiles 50th %tile 75th %tile 90th %tile Maximum 7d. When a mistake is made that caused harm to a patient how often is this reported? 94% 80% 88% 91% 94% 97% 100% 100% 9l. Hospital management and clinicians support and engage in open disclosure with patients/their support person following an adverse event 51% 20% 33% 42% 48% 62% 70% 83% 9m. Following an adverse event staff are supported by the organisation in relation to their needs 43% 25% 27% 34% 38% 56% 61% 75% 9n. Hospital management support and promote a culture of open disclosure/communication within the organisation 48% 23% 33% 39% 47% 55% 67% 70% * The five Pilot Hospitals are excluded from these average calculations as their open disclosure questions are not compatible with those re-configured for the national roll-out Page 36

7.0 Action Planning for Improvement In reviewing the responses to the survey the Quality and Patient Safety Division suggests that hospitals review all the data in this report and discuss and share the results with staff within their organisations. In reviewing the findings of this survey the results may assist hospitals in developing some of their quality improvement plans to meet the requirements of the National Standards for Safer Better Healthcare. Where processes, policies, guidelines and quality improvement initiatives are available, these should be reviewed, and where appropriate quality improvement plans developed to support the implementation of these. The delivery of survey results is not the end point in the survey process; it is just the beginning. Often, the perceived failure of surveys to create lasting change is actually due to faulty or non-existent action planning or survey follow-up. Seven steps of action planning are provided to give hospitals guidance on the next steps to take to turn their survey results into actual patient safety culture improvement: 1. Understand your survey results. 2. Communicate and discuss the survey results. 3. Develop focused action plans. 4. Communicate action plans and deliverables. 5. Implement action plans. 6. Track progress and evaluate impact. 7. Share what works. Page 37

8.0 References AHRQ (2012). Hospital Survey on Patient Safety Culture. Data Entry and Analysis Tool. Gauld, R, et al (2011) The clinical governance development index: results from a New Zealand study Halligan, M., Zecevic, A. (2011). Safety culture in healthcare: a review of concepts, dimensions, measures and progress. Quality Safety in Healthcare 2011. HIQA, (2012). National Standards for Safer Better Healthcare. Dublin: Health Information Quality Authority. Macleod, D and Clarke, N. (2009). Engaging for success: enhancing performance through employee engagement. London, UK: Department for Business Innovation and Skills National Health Service (NHS) Employers (2011). Engaging your staff: the NHS staff engagement resource. Supporting you to increase staff engagement in your organisation. Retrieved 9 th October 2012 from http://www.nhsemployers.org/employmentpolicyandpractice/staff-engagement-toolkit Nieva, A.F, Sorra, J. (2003) Safety Culture assessment: a tool for improving patient safety in healthcare organizations. Quality and Safety in Health Care. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013). Chaired by Robert Francis QC. London: The Stationary Office Sorra J, Famolaro T, Yount ND, et al. Hospital Survey on Patient Safety Culture 2014 User Comparative Database Report. (Prepared by Westat, Rockville, MD, under Contract No. HHSA 290201300003C). Rockville, MD: Agency for Healthcare Research and Quality; March 2014. AHRQ Publication No 14-0019- EF. Sorra J.S, Nieva., V, F, Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004. Page 38

9.0 List of Figures Figure 1: Figure 2: Figure 3: Figure 4: Figure 5: Figure 6: Figure 7: Figure 8: Figure 9: Figure 10: Figure 11: Figure 12: Figure 13: Figure 14: Figure 15: Figure 16: Average % Positive Response by Dimension with AHRQ comparisons % Responses to Teamwork within Wards/Departments % Responses to Supervisor/Manager Expectations & Actions Promoting Patient Safety % Responses to Organisational Learning Continuous Improvement % Responses to Hospital Management Support for Patient Safety % Responses to Overall Perceptions of Patient Safety % Responses to Feedback and Communication about Error % Responses to Communication Openness % Responses to Frequency of Incidents Reported % Responses to Teamwork across Wards/Departments % Responses to Staffing % Responses to Hospital Handoffs & Transitions % Responses to Non Punitive Response to Error % Responses to Overall Grade on Patient Safety % Responses to Number of Events Reported % Positive Responses to Open Disclosure Questions 10.0 List of Tables Table 1: Survey Period and Numbers of Participating Hospitals in each Phase Table 2: Average and Range of Responses Across Hospitals Table 3: Numbers and Percentages of Hospitals and Respondents by Survey Tool Table 4: Numbers and Percentages of Respondents and Staff Census Headcount by Staff Position Table 5: Numbers and Percentages of Respondents by Direct Interaction with Patients Table 6: Numbers and Percentages of Respondents by Years Worked in Current Ward/Department Table 7: Numbers and Percentages of Respondents by Hours Worked per Week Table 8: % Responses to Clinical Governance Development Questions Table 9a: Description and Interpretation of Comparative Statistics Table 9b: Interpretation of Comparative Statistics for Examples Table 10: Comparative Statistics for % Positive Responses to Dimensions 1-12 Table 11: Comparative Statistics for % Positive Responses to Dimensions 1-12 Questions Table 12: Comparative Statistics for % Positive Response to Dimension 13 Table 13: Comparative Statistics for % Positive Response to Dimension 14 Table 14: Comparative Statistics for Clinical Governance Development Index Score Table 15: Comparative Statistics for % Positive Responses to Open Disclosure Questions Page 39

11.0 List of Appendices Appendix A: Adapted AHRQ Survey Tool for Individual hospitals and the Hospital Groups Appendix B: Respondent Characteristics Appendix C: Clinical Governance Development Index Score Page 40

Appendix A: Adapted AHRQ Survey Tool A review of available international culture survey tools were explored and surveys applicable to many health service areas were considered. It was agreed that the survey that best met the needs within Irish healthcare was the survey tool developed by the Agency for Healthcare Research (US). The Agency for Healthcare Research Hospital Survey on Patient Safety Culture (AHRQ 2004) was adapted to the Irish healthcare setting, through minor changes in terminology, and with the addition of specific questions on Clinical Governance Development and Open Disclosure, which are two initiatives currently being developed and implemented. The inclusion of Clinical Governance questions were drawn from the New Zealand Clinical Governance Development Index (CGDI, 2011) and the Clinical Governance Development Programme (HSE, 2012). The Open Disclosure questions were obtained from the Open Disclosure project, established in 2010. Page 41

Appendix A: Adapted AHRQ Survey Tool Page 42