Transcript NH Patient Safety Culture Survey (AHRQ)

NH Patient Safety Culture
Survey (AHRQ)
Beth Hercher, QI Specialist
Patient Safety Team
April 2009
Patient Safety Restraint Collaborative
Learning Session 2
Acronyms
AHRQ
Agency for Healthcare Research and
Quality
NH SOPS
Nursing Home Survey of Patient Safety
“The right care
for every person,
every time.”
CMS Vision Statement
for the National
Healthcare Quality
Improvement Program
The “Right Care”
• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-centered
The Institute of Medicine
Foundation: Organizational Culture
• “How we do things here”
• Unique challenges, but similar to all other
Nursing Homes in TN
– Opportunities for Improvement
– Aspects of brilliance!
• Administrative and Medical Leadership
commitment to quality and safety
• Data for learning, not judgment
• Organization-wide, systematic approaches
to improvement
Teamwork/Quality Improvement Is…
• An Attitude!!!
– Professional life
– Personal life
Examples of Teamwork/QI “Attitude”
•
•
•
•
We’re good people and care about what we do
We need (re)education and (re)training
Our processes need to be improved
We need to be held accountable, not “judged”
(words, tone of voice, body language, facial
expression)
• Process and outcome data is for learning,
not judgment
• Together Everyone Accomplishes More
• Our differences are our strengths
Why Teamwork/Continuous Quality
Improvement (CQI)?
• It’s good business!
– Eliminate waste
– Improve work flow
– Manage time
– Improve the work environment
– Design systems to avoid mistakes
– Enhance the producer/customer relationship
Taken from: “The Improvement Guide,” Langley and Nolan et al, 1996
Team Member Responsibilities
• Understand/“own” the goals (be engaged)
• Offer perspectives and ideas/work for
consensus
• Participate in meetings, discussions,
decisions, and activities
• Follow through on action items, tasks, etc.
• Share knowledge, skills, experience, expertise
• Respect other team members’ opinions;
avoid negative comments
• Build team cohesiveness through participation
Safety Culture Definition
• 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 an organization’s health and
safety management.
Organizations with Positive Safety
Culture
• Characterized by communications founded on
mutual trust
• Shared perceptions of the importance of safety
• Confidence in the efficacy (capacity) of
preventive measures
Nursing Home Survey on
Patient Safety Culture
• Developed by Agency for Healthcare
Research and Quality (AHRQ)
• Designed specifically for nursing home staff
• Asks for their opinions about the culture of
patient safety in nursing homes
The Survey Used for:
• Diagnostic tool to assess patient safety culture
• Intervention to raise staff awareness for patient
safety issues
• Mechanism to evaluate the impact of patient
safety improvement initiatives
• Track changes in patient safety culture over
time
NH Patient Safety
Culture Dimensions
• 42 Items assess the following 12 dimensions
of patient safety culture:
1. Communication openness
2. Compliance with procedures
3. Feedback and communication about incidents
4. Handoffs
5. Management support for resident safety
6. Nonpunitive response to mistakes
NH Patient Safety
Culture Dimensions, cont.
7. Organizational learning – continuous
improvement
8. Overall perceptions of resident safety
9. Staffing
10. Supervisor/Manager expectations and actions
promoting resident safety
11. Teamwork
12. Training and skills
• Resident safety “grade” (Excellent to Poor)
• Overall recommendation of nursing home to
friends
NH SOPS Toolkit
• Final formatted survey
• Survey User’s Guide providing instruction on
data collection and analysis
• Microsoft Excel data entry and analysis tool
SOPS Nursing Home
Data Entry and Analysis Tool
• Westat has designed a data entry and analysis
tool to display results from the new nursing
home survey
– Input individual survey data
– Create graphs and tables to display your survey
results overall and by various demographics
– Analyze which patient safety culture dimensions
may need additional attention
– Share the results with others in your organization. All
results are printable.
SOPS Nursing Home
Data Entry and Analysis Tool, cont.
• Tool is meant for a single nursing home with a
minimum of 5 respondents
• Can upload the tool directly into the upcoming
nursing home data submission system
• Each tool will handle data entry of up to 2,500
individual survey responses
• You must have at least Microsoft Excel 2002 or
higher to use the tool
• This tool uses Excel macros. Make sure your
firewall accepts macros before downloading
Home Page
Data Entry
Only enter data in green cells
Item Level Results
Item results will be displayed only where there are more
than 2 respondents answering an item
SOPS Nursing Home
Data Entry and Analysis Tool, cont.
Composite Level Scores are the average percent of
positive responses for each patient safety culture area.
Composite level scores are not calculated when an item
in a composite has less than 3 respondents.
Composite Level Results
Comparative results are based on 40 pilot nursing homes
Composite Level Comparative Results
Composite Level Comparative Results
Recommendations to Friends
Comparative Results
TeamSTEPPS:
Team Strategies and Tools to Enhance
Performance and Patient Safety
• Developed by the Agency for Healthcare
Research and Quality and the
Department of Defense
• Purpose: To enhance performance
and patient safety
TeamSTEPPS, cont.
Emphasis:
• Teamwork and communication
• Communication and teamwork skills are
essential to providing quality care and
preventing medical errors
Communication
• Satisfaction surveys show that greatest
areas of concern involve some form of
communication breakdown
Two broad categories of
communication among providers:
• Between your facility and an outside provider
• Within your facility
Communication
within your facility
Times when good communication is crucial:
• When contacting medical staff for orders
• Reporting off at shift change
• Upon being assigned a new patient
Communication
within your facility, cont.
Times when good communication is crucial:
• When the patient has had a
change in condition
• When there has been a change in the
Plan of Care
Streamlining Communication
• Consistent format
• Easy way to organize information
• Way to assure all important
information is communicated
Streamlining Communication, cont.
Effective communication is:
• Complete
• Clear
• Brief
• Timely
Streamlining Communication, cont.
SBAR
Essentials
Mod 3 05.2 Page 36
TEAMSTEPPS 05.2
Next Steps
May-June 2009-Baseline Survey
Conduct paper survey tool
Response feedback entered into data analysis
tool
July 31, 2009
Data analysis tool submitted to QSource
Next Steps, cont.
May-June 2010-Re-measurement
Re-administer paper survey tool
Response feedback entered into data analysis
tool
July 31, 2010
Data analysis tool submitted to QSource
Thank You!
Patient Safety Team
1.800. 528.2655
Beth Hercher
Laurie Gyscek
Susan duLaney
Barbara Meadows
This presentation and related materials were developed by QSource, the Medicare Quality Improvement Organization for
Tennessee, under contract with the Centers for Medicare & Medicaid Services (CMS), a division of the Department of Health
and Human Services. Contents do not necessarily reflect CMS policy. QSOURCE-TN-109.62-2008-16