NH Patient Safety Culture Survey (AHRQ) Beth Hercher, QI Specialist Patient Safety Team April 2009...

NH Patient Safety Culture Survey (AHRQ)

Beth Hercher, QI SpecialistPatient Safety Team

April 2009Patient Safety Restraint CollaborativeLearning Session 2

Acronyms

AHRQAgency for Healthcare Research and QualityNH SOPSNursing Home Survey of Patient Safety

“The right carefor every person,every time.”

CMS Vision Statementfor the National Healthcare Quality Improvement Program

• Safe

• Timely

• Effective

• Efficient• Equitable

• Patient-centered The Institute of Medicine

The “Right Care”

• “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

Foundation: Organizational Culture

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 onPatient Safety Culture

• Developed by Agency for HealthcareResearch 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

NH Patient SafetyCulture Dimensions

• 42 Items assess the following 12 dimensionsof patient safety culture:

1. Communication openness2. Compliance with procedures3. Feedback and communication about incidents4. Handoffs5. Management support for resident safety6. Nonpunitive response to mistakes

NH Patient SafetyCulture Dimensions, cont.

7. Organizational learning – continuous improvement8. Overall perceptions of resident safety9. Staffing10. Supervisor/Manager expectations and actions

promoting resident safety11. Teamwork12. Training and skills

• Resident safety “grade” (Excellent to Poor)• Overall recommendation of nursing home to

friends

• Final formatted survey• Survey User’s Guide providing instruction on

data collection and analysis• Microsoft Excel data entry and analysis tool

NH SOPS Toolkit

• 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 HomeData Entry and Analysis Tool

• 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 yourfirewall accepts macros before downloading

SOPS Nursing HomeData Entry and Analysis Tool, cont.

Home Page

Data EntryOnly 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 HomeData 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

Recommendations to Friends Comparative Results

TeamSTEPPS:Team Strategies and Tools to EnhancePerformance and Patient Safety

• Developed by the Agency for Healthcare Research and Quality and the Department of Defense

• Purpose: To enhance performanceand 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 ofcommunication among providers:

• Between your facility and an outside provider• Within your facility

Communication within your facility

• When contacting medical staff for orders• Reporting off at shift change• Upon being assigned a new patient

Times when good communication is crucial:

Communicationwithin your facility, cont.

• When the patient has had achange in condition

• When there has been a change in thePlan of Care

Times when good communication is crucial:

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.

TEAMSTEPPS 05.2Mod 3 05.2 Page 36

Essentials

Next Steps

May-June 2009-Baseline SurveyConduct paper survey toolResponse feedback entered into data analysis

July 31, 2009Data analysis tool submitted to QSource

Next Steps, cont.

May-June 2010-Re-measurementRe-administer paper survey toolResponse feedback entered into data analysis

July 31, 2010Data analysis tool submitted to QSource

Thank You!Patient Safety Team1.800. 528.2655Beth HercherLaurie GyscekSusan duLaneyBarbara 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

NH Patient Safety Culture Survey (AHRQ) Beth Hercher, QI Specialist Patient Safety Team April 2009...

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