HSOPS Analysis and Interpretation. Using The Pa,ent Safety Group (PSG)

HSOPS Analysis and Interpretation Using The Pa,ent Safety Group (PSG)

Objectives Describe post-survey activities Explain how to generate reports from PSG Identify HSOPS interpretation strategies

Results, Next Steps and Utilization 1. Export data reports from vendor app, i.e PSG. 2. Analyze and interpret the data 3. Communicate the results 4. Develop an action plan 5. Implement the action plan 6. Track improvement Leonard M, Frankel A, Federico F, Frush K, Haraden C, eds. The Essential Guide for Patient Safety Officers. Oakbrook Terrace, IL: Joint Commission Resources, Institute for Healthcare Improvement; 2013

Generate/Export Reports 1. Log into PSG 2. Select Reports from the Programs menu 3. Click on AHRQ Hospital Culture Survey

Generate/Export Reports 4. Choose Report Type from available menu. 5. Select preferred unit (s) from the Program menu. 6. Complete dates for Display field.

Generate/Export Reports 7. Select survey(s) from the Survey Report Generator. 8. Choose appropriate filters, benchmark, and other features. 9. Click Generate Report

Report Features Filters Hospital Unit Position Events Years in Unit Profession Years Hospital Years Weekly Hours Interaction Staff Comments Benchmark Comparisons Significant difference identification

What did you measure with HSOPS? Attitudes, beliefs, perceptions, and values related to patient safety within your hospital. Hospital-level (3 dimensions) Unit/Department-level (7 dimensions) Outcome measures (2 dimensions, 2 outcome questions) Just Culture (6 questions)

HSOPS Breakdown Ten Dimensions of culture pertaining to patient/resident safety. 1. Communication openness 2. Feedback and communication about error 3. Handoffs and transitions 4. Management support for patient safety 5. Nonpunitive response to error 6. Organizational learningcontinuous improvement 7. Staffing 8. Supervisor/manager expectations and actions promoting safety 9. Teamwork across units 10. Teamwork within units Four overall patient/resident safety outcomes: 1. Overall perceptions of patient/resident safety 2. Frequency of events reported 3. Number of events reported 4. Overall patient safety grade

Hospital-Level 1,2 Pa#ent Safety Culture Dimension 1. Hospital management support for pa,ent safety 2. Teamwork across hospital units 3. Hospital handoffs and transi,ons Defini#on: The extent to which Hospital provides a work climate that promotes pa,ent safety and shows the pa,ent/resident is top priority Hospital units cooperate and coordinate with one another to provide the best care for pa,ents/ residents. Important pa,ent care informa,on is transferred across hospital/facility units and during shih changes

Unit/Department-Level 1,2 Pa#ent Safety Culture Dimension 1. Supervisor/manager expecta,ons & ac,ons promo,ng safety Defini#on: The extent to which Supervisors/managers consider staff sugges,ons for improving pa,ent safety, praise staff for following pa,ent/resident safety procedures, and do not overlook pa,ent safety problems. 2. Organiza,onal learning con,nuous improvement Mistakes have led to posi,ve changes and changes are evaluated for effec,veness. 3. Teamwork within units Staff support each other, treat each other with respect, and work together as a team. 4. Communica,on openness 5. Feedback and communica,on about error 6. Nonpuni,ve response to error Staff freely speak up if they see something that may nega,vely affect a pa,ent/resident and feel free to ques,on those with more authority. Staff are informed about errors that happen, given feedback about changes implemented, and discuss ways to prevent errors. Staff feel that their mistakes and event reports are not held against them and that mistakes are not kept in their personnel file. 7. Staffing There are enough staff to handle the workload and work hours are appropriate to provide the best care for pa,ents/residents.

Outcome Measures 1,2 Pa#ent Safety Culture Dimension 1. Overall percep,ons of pa,ent safety 2. Frequency of events reported Defini#on: The extent to which Procedures and systems are good at preven,ng errors and there is a lack of pa,ent safety problems. Mistakes of the following types are reported: 1. Mistakes caught and corrected before affec,ng the pa,ent/ resident 2. Mistakes with no poten,al to harm the pa,ent/resident 3. Mistakes that could harm the pa,ent/resident but do not Additional Outcome Measures Overall patient safety grade (Unit-level) Number of events reported

Just Culture Questions 1. My supervisor emphasizes learning rather than blame when staff make mistakes. (Measures responses to Human Error) 2. When staff take shortcuts that put patient safety at risk, supervisors or managers work with them to change their behavior. (Measures responses to At-Risk Behavior) 3. Staff who see other staff doing something unsafe for patient care tell them it is unsafe. (Measures peer to peer coaching) 4. Regardless of a person's job position, management applies the same disciplinary policy to everyone working in this hospital, including physicians. (Measures equity) 5. When a patient safety event happens, hospital management looks at more than staff actions to determine what led to the event. (Measures search for causes)

Safety Culture Element Reporting - Employees feel safe reporting safety concerns. Reporting is valued and used for learning. HSOPS Dimensions or Outcome Measures Frequency of Events Reported Number of Events Reported Just - Errors are not punished. HR policies support justice and accountability. Managers use a consistent approach Non-punitive Response to Error Feedback and Communication about Error Communication Openness Flexible - (Teamwork and Communication) People adapt effectively to changing demands. Those in authority respect the knowledge of frontline staff. Authority patterns relax when safety information is exchanged. Communication is accurate, timely, and verified. Teamwork within Units Teamwork across Units Hospital Handoffs Communication Openness Staffing Learning - Employees learn from experience and participate in continuous improvement. Organization analyzes reported safety events and addresses system issues. Organizational Learning Overall Perceptions of Patient Safety Patient Safety Grade Feedback and Communication about Error Manager Actions Promoting Safety Hospital Management Support

Interpret Positive Responses Type Example Ques#on (s) Posi#ve Responses Posi#vely Worded Ques#on Pa,ent Safety is never sacrificed to get more work done. Our procedures and systems are good at preven,ng errors from happening. Strongly Agree Agree Always Most of the Time Reverse Worded Ques#on It is just by chance that more serious mistakes don t happen around here. We have pa,ent safety problems in this unit. Strongly Disagree Disagree Never Rarely

Representativeness or Unrepresentative Mess? 60% Response rate

Low Response Rates? Discuss and get feedback Be tentative Use debrief as focus group

Dimensions > 60%

Dimensions < 60%

PSG Detailed Graph

Dimension < 60% positive

Benchmark to Hospital Over Time

Benchmark to Hospital and To National Results

Where you stand depends on where you sit Feedback and Communication About Error 80% Percent positive responses 70% 60% 50% 40% 30% 20% C2 C4 C6 Physicians 2007 Physicians 2008 Nurses 2007 Nurses 2008 Overall 2007 Overall 2008 Physicians 2008 Benchmark Nurses 2008 Benchmark Overall 400+ C2 C4 C6 We are given feedback about changes put into place based on event reports. We are informed about errors that happen in this unit. In this unit, we discuss ways to prevent errors from happening again.

Open Comments Safety Concern-Staffing Lack of Just Culture Evidence of Teamwork Lack of Effective Teamwork Patient Safety Systems F/ back My concerns are primarily based on staffing. Our particular management wants all nurses to be cross trained in Med-Surg, ER, OB. We have graduate nurses that work ER, we have nurses with minimal OB experience scheduled to do OB patients. That might be fine in a larger hospital, where there are many nurses to bounce ideas off of. I do not believe this is quality, safe care for our patients. Also we have no accountability in poor job performance and exhibiting an "attitude" on the job. When I work with nurses willing to help each other, the job goes well. On weekends and nights we are expected to do too many roles, i.e. respiratory, pharmacy, admitting, ward clerk, draw blood. Our staffing is a problem.

Communicate Results Share feedback broadly Make information useful Legitimize the collection effort Hold separate debrief sessions Cater feedback reports to your audience Source: User's Guide: Hospital Survey on Patient Safety Culture. September 2004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/ patientsafetyculture/hospital/userguide/index.html

Results Discussion Questions Discuss: Do these results reflect our reality? Do any of these results surprise you? What should we keep doing to maintain the good perceptions in our high scoring areas? What should we change to improve the perceptions in our low scoring areas?

TOOL - Survey Feedback Report Survey Feedback Report Template http://www.ahrq.gov/professionals/quality-patient-safety/ patientsafetyculture/hospital/resources/hospcult.ppt Survey background, measures, methodology Demographic data about respondents Main findings (strengths and areas for improvement) Slide w/chart per dimension Staff comments statistics and trends

TOOL Debriefing Plan Debrief planning template https://cdn.community360.net/app/jh/susp_content/toolkits_&_resources/hsops/ Template_Debriefing_Plan_Safety_Culture_Survey_Final_2012_08_13.docx Identify and prioritize elements to improve Encourage open discussion Planning template - How many debriefing sessions - Who will facilitate - When/where - Who s responsible for taking notes - If multiple, who will collate notes - How will the team ensure follow-up on action items

TOOL Culture Check-up Tool Culture Check-up Tool https://cdn.community360.net/app/jh/susp_content/toolkits_&_resources/ HSOPs/culturecheckup.docx Productive culture dialogue Statement/item to be discussed Score (% positive) What does this mean to you? How accurate does the score reflect your experience? How would this area look if we were 100%? Identify one action for improvement Next steps and how will we accomplish?

TOOL Action Planning Tool University of Nebraska Medical Center http://www.unmc.edu/patient-safety/surveys/ interpret-results.html HSOPS Background Inventory of Safe Culture Practice Action Plan Template Presentations on understanding results

References 1. 2014 User Comparative Database Report: Hospital Survey on Patient Safety Culture. March 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/ patientsafetyculture/hospital/2014/index.html 2. User's Guide: Hospital Survey on Patient Safety Culture. September 2004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/ patientsafetyculture/hospital/userguide/index.html 3. Survey Feedback Report http://www.ahrq.gov/professionals/quality-patient-safety/ patientsafetyculture/hospital/resources/hospcult.ppt

Safety Culture Contact Latoshua LeGrant, ASQ CQIA Performance Improvement Specialist, Culture llegrant@ncha.org (919) 677-4134