Statewide Patient Safety Culture: North Carolina HSOPS and Medical Office SOPS

Statewide Patient Safety Culture: North Carolina HSOPS and Medical Office SOPS

What is safety culture? The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management. What we believe Value communication Trust each other Perceive the importance of safety Are prepared and confident What we do Practice patterns of behavior that support health and safety Source: Organising for Safety: Third Report of the ACSNI (Advisory Committee on the Safety of Nuclear Installations) Study Group on Human Factors. Health and Safety Commission (of Great Britain). Sudbury, England: HSE Books, 1993. Accessed 1/11/16 at http://www.ahrq.gov/professionals/quality-patientsafety/patientsafetyculture/hospital/userguide/hospcult1.html

Sentinel Events Linked to Safety Culture Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission 2013 2014 3Q 2015 Human Factors (n=635) Human Factors (n=547) Human Factors (n=464) Communication (n=563) Leadership (n=517) Leadership (n=382) Leadership (n=547) Communication (n=489) Communication (n=343) http://www.jointcommission.org/assets/1/18/root_causes_event_type_2004-3q_2015.pdf The culture of safety the attitudes, beliefs, perceptions, and values that employees share in relation to safety that exists in most health care organizations is weak compared to many other high-risk, complex businesses. Source: http://www.ihi.org/education/ihiopenschool/courses/documents/course%20 Summaries.pdf p.14

Correlations between Safety Culture and Clinical Outcomes

Strong safety culture correlated with better clinical outcomes in NC NCQC replicated methods from national studies correlating safety culture (HSOPS) with good clinical outcomes NC hospitals are 7 times more likely to have a few patient safety events if they are also top HSOPS performers NC hospitals with high HSOPS scores have lower rates of infections after colon or abdominal hysterectomy surgeries

Correlation between HSOPS and Patient Safety Composite (PSI-90) National data shows correlation between HSOPS percent positive scores and clinical outcomes. NC data also shows safety culture scores related to clinical outcomes. 60% 50% 40% 30% 20% 10% 0% Hospitals with good culture scores Hospitals with bad culture scores Hospitals with few patient safety events Hospitals with many patient safety events PSI 90: Agency on Healthcare Research and Quality s Patient Safety Indicator 90 (PSI-90), a component of the HAC reduction program, which aggregates 11 key patient safety indicators. Defined at: http://www.qualityindicators.ahrq.gov/downloads/modules/psi/v50/techspecs/psi_90_patient_safety_for_selected_indicators.pdf *Mardon, Khanna et al. Exploring Relationships Between Hospital Patient Safety Culture and Adverse Events. Journal of Patient Safety, Vol.6 No.4. Dec. 2010. *NC Quality Highlights, November 2015.

Correlation between HSOPS and Surgical Site Infection Ratios COLCO/HYST SIR (lower is better) 2.50 2.00 1.50 1.00 0.50 NC Hospitals with Strong Patient Safety Culture Have Better Performance on Surgical Infection Measures 0.00 60% 62% 64% 66% 68% 70% 72% 74% 76% 78% 1.00 0.90 0.80 0.70 0.60 0.50 0.40 0.30 0.20 0.10 0.00 NC Hospitals with Strong Patient Safety Culture Have Lower Infection Ratios (COLO/HYST SIR) 0.46 Average HYST/COLO SIR Among Hospitals with Good Culture Scores (HSOPS 71%- 76%) 0.95 Average HYST/COLO SIR Among Hospitals with Poor Culture Scores (HSOPS 60%- 65%) Data from NC analyzed in a method similar to national study at: https://www.researchgate.net/publication/287159062_association_of_safety_culture_with_surgical_site_infection_outcomes)

Analysis of NC Hospital Survey on Patient Safety Culture (HSOPS)

NC Hospital Survey on Patient Safety Culture (HSOPS) Results Analysis includes ~97 hospitals ~50,000 respondents 80 unique surveys completed June 2014 June 2016 (some surveys cover multiple facilities) Source: The Patient Safety Group

NC HSOPS Key Results NC HSOPS average scores mirror US average Front-line staff report more challenges to patient safety culture than administrators do Staff say they are excellent at reporting patient safety events, but number of events reported matches the national average NC hospitals have strengths in Anesthesiology, Pediatrics work areas and in Organizational Learning composite

Percent Positive Responses NC HSOPS Composite Percent Positive Scores Mirror National Average NC HSOPS June 2014 - June 2016 100% 90% 82% 78% 80% 74% 72% 66% 68% 67% 70% 63% 60% 60% 53% 50% 46% 44% 40% 30% 20% 10% 0% NC HSOPS June 2014 - June 2016 NC Average US 50th Percentile US 90th percentile

NC Administrators Report Higher HSOPS Scores Than Staff Report 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 91% 89% 82% 78% NC HSOPS Comparing Staff to Administrative Percent Positive June 2014-June 2016 85% 86% 73% 71% 78% 81% 65% 67% 77% 74% 71% 67% 61% 59% 62% 53% 50% 46% 43% 63% Staff N=21399 Admin N=1549 NC administrators report scores 4% - 20% higher than staff, an average of 12% higher per composite.

NC HSOPS Discrepancy between Perceptions of Event Reporting and Number of Events Reported Question Level Responses on Frequency Of Events Reported, NC HSOPS 2014-2016 When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported? (D1) (47675 of 49911) When a mistake is made, but has no potential to harm the patient, how often is this reported? (D2) (47537 of 49911) When a mistake is made that could harm the patient, but does not, how often is this reported? (D3) (47339 of 49911) NC Hospitals 63% 62% 64% 63% 74% 74% 55% 60% 65% 70% 75% AHRQ Benchmark 60% 50% 40% 30% 20% 10% 0% Staff perceive reporting to be stronger than data shows. Frequency of Events Reported is 67% positive above national average. However, 57% of staff report they have not submitted any event reports in the last year. NC Number of Events Reported: In the past 12 months, how many event reports have you filled out and submitted? 57% No event reports 25% 1 to 2 event reports 11% 3 to 5 event reports 4% 2% 1% 6 to 10 event reports 11 to 20 event reports 21 event reports or more

NC HSOPS Work Areas Compared to National Benchmarks 3% or more above national benchmark for unit in green; 3% or more below national benchmark in red Dimension Anesthesi ology n=370 Emergenc y Departme nt n=3,109 Intensive Care Unit Laborator Medicine n=2,537 y n=1,660 n=5,795 Obstetrics Pediatrics Pharmacy n=1,905 n=932 n=1,343 Psychiatry /Mental Health Radiology n=1,148 n=2,518 Rehabilita tion n=2,132 Surgery n=5,516 Other Composit n=18,802 e Teamwork within units 90% 80% 88% 78% 83% 85% 90% 84% 79% 86% 89% 82% 79% 82% Supervisor promoting patient safety 86% 73% 77% 81% 80% 75% 80% 84% 75% 80% 85% 78% 78% 78% Organizational learning 80% 69% 72% 75% 78% 72% 76% 81% 73% 76% 80% 76% 71% 74% Hospital mgmt support for patient safety 69% 66% 63% 77% 71% 69% 70% 75% 67% 76% 79% 73% 73% 72% Overall perceptions of safety 73% 56% 61% 73% 64% 62% 67% 71% 60% 76% 79% 67% 65% 66% Feedback & communication about error 74% 63% 66% 68% 71% 64% 68% 72% 66% 70% 77% 69% 66% 68% Communication openness 75% 58% 64% 63% 64% 62% 70% 67% 58% 65% 73% 65% 60% 63% Frequency of events reported 66% 62% 63% 74% 70% 68% 67% 64% 71% 68% 71% 68% 66% 67% Teamwork across hospital units 59% 53% 59% 55% 60% 59% 63% 59% 55% 65% 65% 60% 61% 60% Staffing 67% 46% 52% 56% 52% 57% 57% 62% 53% 63% 65% 54% 50% 53% Hospital handoffs & transitions 47% 51% 53% 36% 46% 57% 52% 33% 44% 51% 45% 46% 44% 46% Non-punitive response to error 52% 36% 44% 41% 47% 40% 51% 57% 46% 46% 62% 48% 41% 44% Total Percent Positive 70% 59% 64% 64% 65% 64% 68% 67% 62% 69% 72% 65% 63% 64% NC strengths are in Anesthesiology, Pediatrics and Organizational Learning, with greater than 6 areas more than 3% above national average.

NC Hospital Survey on Patient Safety Culture (HSOPS) Trends and Comparison to National Trends

NC HSOPS Trends ~86 hospitals; 69 unique surveys ~51,000 in most recent survey group; ~44,000 respondents previous survey group Most-recent survey completed 2014-2016 compared to previous survey completed 2012-2014 Mirrors national average of 23 months between surveys Source: The Patient Safety Group

Percent Positive Responses NC HSOPS Composite Scores Show Minor Decrease Over Time NC HSOPS 2-Year Comparison 100% 90% 80% 82% 82% 79% 70% 78% 76% 74% 75% 72% 60% 67% 66% 68% 67% 68% 68% 63% 62% 61% 60% 50% 55% 53% 40% 44% 44% 30% 20% 10% 0% 47% 46% NC HSOPS (1st instance, administered in 2012-2014) NC HSOPS (2nd instance administered in 2014-2016) US 50th Percentile US 90th percentile

NC Worsening in Comparison to National Benchmarks Changes from 2009-2014 Changes from 2012-2016 AHRQ Benchmark change 2014 to 2016 Composite Overall perceptions of safety 1% -1% 1% Frequency of events reported 1% -1% 0% Supervisor/manager expectations a 0% -1% 2% Organizational learning - Continous 1% -2% 0% Teamwork within units 1% 0% 1% Communication openness 2% -1% 2% Feedback & communication about 2% 0% 1% Non-punitive response to error 3% 0% 1% Staffing -1% -2% -1% Hospital management support for 0% -3% 0% Teamwork across hosptial units 2% -1% 0% Hospital handoffs & transitions 2% -1% 1% Changes are small, but concerning. NC HSOPS scores have worsened in 9 dimensions between 2012 and 2016, whereas national benchmarks have improved in 7 dimensions and worsened in one dimension.

NC Medical Office Survey on Patient Safety Culture (MSOPS)

NC Medical Office Survey on Patient Safety Culture Analysis includes: 44 unique surveys/ ~12,000 respondents April 2014 Oct 2015 Key results: Averages mirror US average Survey of interest to ACO and system-wide work. Important to promote culture of safety across healthcare settings.

MSOPS Components 100% 80% 60% 40% 20% 0% Overall Rating on Patient Safety NC Medical Office SOPS June 2014- June 2016 Excellent Very Good Good Fair Poor Grade AHRQ Benchmark 100% 80% 60% 40% 20% 0% MSOPS grades medical offices on: Patient Centered Care Effective Care Timely Care Efficient Care Equitable Care Overall Rating Grade on Equitable Care NC Medical Office SOPS June 2014- June 2016 Excellent Very Good Good Fair Poor Grade AHRQ Benchmark

NC MSOPS Composite Scores Mirror National Average 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 88% 88% NC Medical Office SOPS Composite Percent Positive June 2014- June 2016 80% 82% 78% 78% 61% 84% 73% 50% Medical Office % Positive AHRQ Benchmark % Positive