Transcript NH Patient Safety Culture (AHRQ) Presentation

NH Patient Safety Culture
Survey (AHRQ)
Beth Hercher, QI Specialist
Barbara Meadows, QI Specialist
Patient Safety Team
October 2009
Patient Safety Restraint Collaborative
Learning Session 3
“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
April 2009 Learning Session 2
• Final formatted survey
• Survey User’s Guide providing instruction on
data collection and analysis
• Microsoft Excel data entry and analysis tool
Timeline
• May-June 2009 surveys conducted
• July 31, 2009 individual data analysis tools
submitted back to QSource
• October 2009 presentation of aggregate data
analysis
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.
Nursing Home Survey on
Patient Safety Culture (NH SOPS)
• 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
What the Survey Is Used for:
• Assess patient safety culture
• Develop interventions to raise staff awareness
for patient safety issues
• 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
NH SOPS
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.
Home Page
AHRQ Survey Designed to Measure
1) Two overall patient safety outcomes
a. Nursing Home Recommendation
b. Rating on Resident Safety
2) Twelve dimensions of culture related
to patient safety
Recommendations to Friends
Comparative Results
Composite Level Results
Comparative results are based on 40 pilot nursing homes
Definition of Composite Results
• Composite results measure the12 different
domains of patient safety
• Calculated by averaging the percent positive
responses of the items within the domain
• Positive response is the percent of responses
that were rated a 4 or 5 (agree/strongly agree)
Definition of Composite Results, cont.
• Composite score tells you the average
percentage of people who responded
positively to the survey items
• Summarize overall how positively people
answered the items in each safety culture
dimension
Baseline Survey
• 36 IPG facilities conducted survey
• Top three opportunities:
– Staffing
– Nonpunitive response to mistakes
– Communication openness
AHRQ Patient Safety Culture Survey:
Composite-Level Comparative Results
IPG GROUP AVERAGE
PILOT
BENCHMARK
50%
12. Staffing
49%
11. Nonpunitive Response to Mistakes
52%
10. Communication Openness
56%
9. Handoffs
61%
8. Teamwork
59%
7. Compliance with Procedures
67%
6. Training & Skills
69%
5. Management Support for Resident Safety
72%
4. Organizational Learning
81%
3. Supervisor Expectations & Actions Promoting Resident Safety
85%
2. Feedback and Communication About Incidents
85%
1. Overall Perceptions of Resident Safety
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
JCAHO Sentinel Events
20
What You Need to Succeed
•Administrative and clinical leadership
commitment to quality and safety
•Data for learning, not judgment
•Organization-wide, systematic approaches
to improvement
•Culture change/teamwork
•Conduct informal “RCA”
•ASK frontline staff and feed back data regularly
Strategies and Tools
to Enhance Performance
and Patient Safety
Effective Team Members
 Are better able to predict the needs of other team
members
 Provide quality information and feedback
 Engage in higher level decision-making
 Manage conflict skillfully
 Understand their roles and responsibilities
 Reduce stress on the team as a whole through better
performance
“Achieve a mutual goal through interdependent
and adaptive actions”
23
TeamSTEPPS:
• Developed by the Agency for Healthcare
Research and Quality and the
Department of Defense
• Purpose: To enhance performance and
patient safety
Teamwork Exercise
• Divide up into your facility teams
• Decide who will be your team leader
TeamSTEPPS Emphasis:
• Teamwork and communication
• Communication and teamwork skills are
essential to providing quality care and
preventing medical errors
Essentials
Mod 3 05.2 Page 27
TEAMSTEPPS 05.2
Briefing Checklist
TOPIC
Who is on core team?
All members understand
and agree upon goals?
Roles and responsibilities
understood?
Plan of care?
Staff availability?
Workload?
Available resources?
28
Huddle
Problem solving
– Hold ad hoc, “touch-base”
meetings to regain
situation awareness
– Discuss critical issues
and emerging events
– Anticipate outcomes
and likely contingencies
– Assign resources
– Express concerns
29
Debrief
Process Improvement
• Brief, informal information exchange and
feedback sessions
• Occur after an event or shift
• Designed to improve teamwork skills
• Designed to improve outcomes
– An accurate reconstruction of key events
– Analysis of why the event occurred
– What should be done differently next time
30
Debrief Checklist
TOPIC
Communication clear?
Roles and responsibilities
understood?
Situation awareness
maintained?
Workload distribution?
Did we ask for or offer
assistance?
Were errors made or
avoided?
What went well, what
should change, what
can improve?
31
Essentials
Scenario Part 1
Mrs. Smith, at 70 yrs old, fell while walking
her dog. Following the surgery to repair
the hip fracture, it is determined that she
will require rehabilitation in the nursing
home. The family lives out of state.
What TeamSTEPPS tool would be
effective here?
Mod 3 05.2 Page 32
TEAMSTEPPS 05.2
Essentials
5 days later…..
While assisting Mrs. Smith, Annie, the new
C.N.A., notices a reddened area on the
coccyx. She understands from her recent
team training that this could be a problem if
she doesn’t inform the team.
Using TeamSTEPPS tools, what is Annie’s
next step?
Mod 3 05.2 Page 33
TEAMSTEPPS 05.2
Essentials
What occurs next is crucial….
The team lead has had several shift
problems and is running late. Though she
hears Annie’s report, she states “We’ll just
leave it for the next shift, get Mrs. Smith
dressed and down to the activities room.”
What tool does Annie need?
Mod 3 05.2 Page 34
TEAMSTEPPS 05.2
Essentials
Mod 3 05.2 Page 35
TEAMSTEPPS 05.2
When Communication is Crucial
• When the patient has had a
change in condition
• When there has been a change in the
Plan of Care
• When reporting off at shift change
• Upon being assigned a new patient
Streamlining Communication
Effective communication is:
• Complete
• Clear
• Brief
• Timely
Essentials
SBAR Prep
• Situation – the punch line in 5-10 seconds
• Background – the context, objective data, how
did we get here
• Assessment – what is the problem ?
• Recommendation – what do we need to do ?
Mod 3 05.2 Page 38
TEAMSTEPPS 05.2
Essentials
Mod 3 05.2 Page 39
TEAMSTEPPS 05.2
Excercise
SBAR
Essentials
Next step…reporting out
The team lead recognized Annie’s
concerns; they agree to go to the room
together and check the reddened area.
The area is deep red, 6cm and the resident
reports pain on assessment.
What TeamSTEPPS tool would help the
team lead in her communication to the
physician?
Mod 3 05.2 Page 41
TEAMSTEPPS 05.2
Essentials
Mod 3 05.2 Page 42
TEAMSTEPPS 05.2
Next Steps
May-June 2010
Re-administer paper survey tool
Response feedback entered into data analysis
tool
July 31, 2010
Data analysis tool submitted to QSource
Thank You!
NH Patient Safety Culture
Team Contacts:
Beth Hercher, ext. 2640
Barbara Meadows, ext. 7202
1.800.528.2655
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