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DRAFT – final pending AHRQ approval CUSP for Safe Surgery (SUSP) Kickoff Webinar 1 April 28 , 2014 and April 30, 2014

April 28 , 2014 and April 30, 2014

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CUSP for Safe Surgery (SUSP) Kickoff Webinar. April 28 , 2014 and April 30, 2014. Some quick administrative announcements. You need to dial into the conference line to hear audio: Dial in Number: 1-800-311-9401 Passcode: 83762 - PowerPoint PPT Presentation

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Page 1: April 28 ,  2014 and April 30, 2014

DRAFT – final pending AHRQ approval

CUSP for Safe Surgery (SUSP)Kickoff Webinar

1

April 28, 2014 and April 30, 2014

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Some quick administrative announcements

2

You need to dial into the conference line to hear audio:

– Dial in Number: 1-800-311-9401

– Passcode: 83762

Please contact your Coordinating Entity for a copy of these slides if you have not already received them

We will make a recording of this webinar available to you.

We want you to interact with us today. You can:

– Type comments in the chat box.

– Or even better, speak up.

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Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it is the only thing that ever has.

-- Margaret Mead

“”

3

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SUSP Kickoff Agenda

4

Introductions

SUSP Project Overview

Building your SUSP Team

Intro to Building and Measuring Safety Culture

Current Team Experiences

Next Steps

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INTRODUCTIONS

Meet the SUSP National Project Team

5

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Peter Pronovost, MD, PhD, FCCM

Principal Investigator

Cliff Ko, MD, MS, MSHA, FACSPrincipal Investigator

Charles Bosk, PhDPrincipal Investigator

Ethnographer

6

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Deb Hobson, RNState Coach

Content Expert

Julius Pham, MD, PhDState Coach

Content Expert

Liza Wick, MDState Coach

Content Expert

Bradford Winters, MDState Coach

Content Expert

7

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Mike Rosen, PhDState Coach

Content Expert

Lisa Lubomski, PhDState Coach

Content Expert

Sallie Weaver, PhDState Coach

Content Expert

Sean Berenholtz, MD, MHS, FCCM

State CoachContent Expert

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Tricia Francis, MA, MS, PMPSUSP Project Manager

Kathryn Taylor, RN, MPHSUSP Program Manager

Kristina Weeks, MHSCo-Investigator

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Cathy Van De Ruit, PhDEthnographer

Ksenia Gorbenko, PhD, MA

Ethnographer

Jeremiah BowmanAmerican College of

Surgeons

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Erin Hanahan, MPHSUSP Senior Research

Coordinator

Mary Twomley, MSSUSP Senior Research

Coordinator

Laura Vail, MSSUSP IT Specialist

Nasir Ismail, MSSUSP Safety Culture

Coordinator

11

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Poll – Who is on the call?

12

What is your role in your clinical area?Surgeon

Quality improvement practitioner

Infection preventionist

OR Nurse

OR technician

Anesthesiologist

OR manager

Other

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SUSP PROJECT OVERVIEWSEAN BERENHOLTZ, MD, MHS, FCCM

We have embarked on a unique journey.

13

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Learning Objectives

14 DRAFT – final pending AHRQ approval

After this session, you will be able to:

Distinguish SUSP approach from that of other national improvement projects

Describe the connection between SUSP and safety culture work as structured in the Comprehensive Unit-based Safety Program (CUSP)

List the steps for developing a local SSI prevention bundle

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Why is Your SUSP Work Important?1

15

1 in 25 people will undergo surgery

7 million (25%) complications follow in-patient surgeries

1 million (0.5 – 5%) deaths follow surgery

50% of all hospital adverse events are linked to surgery AND are avoidable

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Surgical Care Improvement Project (SCIP)2

16

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Respond in the chat.

17

In our institution, near perfect compliance with SCIP measures did not result in decreased SSI rates.

– Have other people on the call observed the same trends?

– Why might that be?

Engagement Questions

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SUSP is CUSP for Safe Surgery

18

What is SUSP?

National improvement effort

Designed to reduce surgical site infections (SSI) and other surgical complications.

CUSP is the acronym for “Comprehensive Unit-based safety program”

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This project will teach you to embed adaptive work (CUSP) in your technical work (surgical care).

Unlike other SSI prevention projects, you will develop your own SSI prevention ‘bundle.’

– There is no one ‘right’ bundle for SSI prevention

– Engage frontline staff to identify local defects

What is SUSP?

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Agency for Healthcare Research and Quality

20

AHRQ-funded projectIndividual hospitals participate until August 31, 2015

Participation is free

Participation is open to hospitals– Of all sizes

– In all 50 states

– For any surgical procedure type

What is SUSP?

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SUSP Leverages Leaders In The Field

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SUSP Enrollment by Coordinating Entity

22

International HospitalsLocated in Canada and UK

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SUSP Enrollment by Coordinating Entity

23

Coordinating Entity Qty

Coordinating Entity Qty

Armstrong Institute 44 Maryland Hospital Association 19

Arkansas Hospital Association 10 Massachusetts Hospital

Association 8California Hospital Association 2 Michigan Health & Hospital

Assoc 46

Colorado Hospital Association 8 New Jersey Hospital Association 14

Connecticut Hospital Association 7 North Carolina Quality Center 3

Florida Hospital Association 11 Nevada Hospital Association 5Georgia Hospital Association 16 Premier Healthcare Alliance 10Hawaii Safer Care SUSP Collaborative 14 Tennessee Hospital

Association 10Iowa Healthcare Collaborative 13 VHA 14

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SUSP Enrollment by Cohort

24

Cohort 1

Cohort 2

Cohort 3

Cohort 4

Cohort 5

0 50 100 150 200 250 300

10

113

161

203

256

Cumulative enrollment

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Our Shared Project Goals

25

To achieve significant reductions in surgical site infection and surgical complication rates

To achieve significant improvements in safety culture

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Key Concepts: Adaptive And Technical Work

26

TechnicalWork

Adaptive WorkSweet

Spot

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Technical Work Adaptive WorkProcedural components of work, like performing skin prep

The ‘intangible’ components of work, like ensuring an OR team holds each other accountable for quality skin prep

Work that we know we ‘should’ do, like letting skin prep dry before incision

Work that shapes the attitudes, beliefs, and values of clinicians, so they consistently perform tasks the way they know they ‘should’

Work that lends itself to checklists or protocols

Culture change is not a checklist

Key Concepts: Technical and Adaptive Work

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Intervention Requires Technical & Adaptive

1995

1997

1999

2001

2003

2005

2007

2009

2011

0

40

80

120

160

0 2 32640

5660675350

907594

116149

93

152

Reviewed by The Joint Commis-sion

Regardless of procedure mag-nitude

Num

ber

of E

vent

s Re

view

ed b

y TJ

C

A. Sentinel Event Alert: Wrong-sided surgery Aug 98

B. Sentinel Event Alert: Follow-up review of wrong-sided surgery Dec 01

C. Wrong Site Surgery Summit I Jan 03

D. Universal Protocol 2004

E. Wrong Site Surgery Summit II Feb 07

F. Revised Wrong Site Surgery Definition Jun 10

AB

CD

EF

Despite years of technical intervention, rates rose

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CUSP is a model to guide adaptive work3

29

1. Educate staff on the science of safety

2. Identify defects

3. Partner with a Senior Executive

4. Learn from defects

5. Improve teamwork and communication

Comprehensive Unit-based Safety Program (CUSP)

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How is SUSP different?

30

Informed by science and backed with evidence

Led by clinicians and supported by management

Guided by national and local measures

National implementation tailored to local context

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Building on Previous State Level Success

31

Michigan Keystone ICU program

Reductions in central line-associated blood stream infections (CLABSI) 4,5

Reductions in ventilator-associated pneumonias (VAP) 6 Improvements in safety climate 7

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…And National Level Highlights

32

National On the CUSP: Stop BSI program8

A national initiative to implement a proven culture change model, CUSP, and interventions to prevent CLABSI. A total of 1,071 ICU’s in 45 states

A 43% reduction in CLABSI rates

The number of ICU’s that achieved CLABSI rate of zero, more than doubled.

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Hospital-acquired Infection Rates Drop

33

Safety Climate Teamwork Climate0

10

20

30

40

50

60

70

80

90

100

84% 82%

23% 22%

2004 2007

“Needs improvement”: Less than 60% of respondents reporting good safety or teamwork culture

Statewide in 2004, 82-84% needed improvement, in 2007 22-23%7

While Safety Culture Increases

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Colorectal NSQIP SSI Rate at Hopkins9

34

This Improvement Model Works In The OR

Q3 09 Q4 09 Q1 10 Q2 10 Q3 10 Q4 10 Q1 11 Q2 11 Q3 11 Q4 11 Q1 12 Q2 12 Q3 12 Q4 12 Q1 13 Q2 13 Q3 13 Q4 130%

5%

10%

15%

20%

25%

30%

35%

40%

45%

42%

17%

29%

26%

16%

20%

10%

18%

21%

24%

15%

21%

13%

18%

12%

5%

15%

2%

Time Period

SSI R

ate

(%)

CUSP kickoffAntibiotic deficienciesaddressed

Pre-op warmingEnhanced sterile techniqueIntervention checklist Briefing/Debriefing

Mechanical bowel prep with oral antibiotics

SSI InvestigationBowel Prep KitsEHR support

Skin prep protocolPre-op wash clothes

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Lap tray had 137 instruments including many unnecessary implements

JHH unionized employees process open instruments, while contractors process lap instruments.

Reduced lap tray instruments by 60% to 54 key instruments.

Fewer instruments to count and turnover saves money and time.

Problem

Barriers

Intervention

Impact

Case Study: Laparoscopic GI Surgery Trays

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137 instruments 54 instruments

Case Study: Laparoscopic GI Surgery Trays

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Frontline providers questioned the inconsistent use of antibiotic irrigation between surgeons

Prominent surgeons used antibiotic irrigation

A literature review yielded no evidence to support continued use, so removed from hospital formulary

$537,000 annual savings on antibiotic irrigation WITH surgeon buy-in

Problem

Barriers

Intervention

Impact

Case Study: Antibiotic Irrigation

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Case Study: Antibiotic Irrigation

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SUSP Project Management Guide

39

We have developed monthly modules to guide you through this process.

Each module has ‘deliverables’ for your team, to help you keep your work on track.

Your Coordinating Entity sets up monthly coaching calls to enable horizontal learning.– Share what you learn on state coaching calls.– You will learn as much (if not more) from each other

as you will from us!Checking In: Any questions about your Coordinating Entity?

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SUSP Project Structure

40

Kick-off / Project Initiation

Onboarding Phase (Months 1 – 6)– Module 1: How To Use The SUSP Portal: A Training Call for

Facilitators– Module 2: Train Everyone on the Science of Safety & Identifying

Defects– Module 3: Engage Senior Executives in SSI Prevention Work– Module 4: Debrief your Safety Culture Scores and SSI data– Module 5: Build your SSI Prevention Bundle – Module 6: Perform an SSI Investigation

Implementation Phase (Months 7 – 14)

Sustainability Phase (Months 15 – 18)

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SUSP Project Structure

41

Onboarding Phase (Months 1 – 6)

Implementation Phase (Months 7 – 14) – Module 7: Implement your SSI Prevention Bundle

– Module 8: Cohort 5 SUSP Team’s Experience

– Module 9: Emerging Evidence: A Surgeon’s Perspective

– Module 10: Learn from Defects I

– Module 11: Learn from Defects II

– Module 12: Optimize Briefings and Debriefings

– Module 13: Audit Your Briefing and Debriefing Process

– Module 14: Annual progress call

Sustainability Phase (Months 15 – 18)

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SUSP Project Structure

42

Onboarding Phase (Months 1 – 6)

Implementation Phase (Months 7 – 14)

Sustainability Phase (Months 15 – 18)– Module 15: HSOPS Re-administration and Culture Debriefing

– Module 16: Sustain and Spread Your Surgical Safety Improvements

– Module 17: Learn From Defects

– Module 18: Deep Rooting Your Data/Sign Off

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Polling Question

43

How ready is your organization to enable frontline participation in improvement work and address frontline patient safety priorities?

– Totally ready

– Getting ready

– Not ready at all

– Not sure

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References

44

1. World Health Organization. New Scientific Evidence Supports WHO Findings: A Surgical Safety Checklist Could Save Hundreds of Thousands of Lives. http://www.who.int/patientsafety/challenge/safe.surgery/en/. Accessed August 7, 2013.

2. Centers for Medicare and Medicaid Services. National Impact Assessment of Medicare Quality Measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/NationalImpactAssessmentofQualityMeasuresFINAL.PDF. Published March 2012. Accessed August 7, 2013.

3. The Joint Commission, Sentinel Event Data. http://www.jointcommission.org/assets/1/18/Event_Type_Year_1995-2011.pdf;29. Accessed August 8, 2013.

4. Pronovost P, Needham D Berenholtz S, et al. An Intervention to Decrease Catheter-related Bloodstream Infections in the ICU. N Engl J Med. 2007;356(25):2660.

5. Pronovost P, Goeschel C, Colantuoni E, et al. Sustaining Reductions in Catheter Related Bloodstream Infections in Michigan Intensive Care Units: Observational Study. BMJ. 2010; 340:c309.

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References

45

6. Berenholtz S, Pham J, Thompson D, et al. Collaborative cohort Study of an Intervention to Reduce Ventilator-associated Pneumonia in the Intensive Care Unit. Infect Control Hosp Epidemiol. 2011; 32(4): 305–314.

7. Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Medicine. 2011 May;(39(5):934-9.

8. Website of the National Implementation of the Comprehensive Unit-based Safety Program to Eliminate Health Care-Associated Infections. http://www.onthecuspstophai.org/. Accessed August 7, 2013.

9. Wick et al. Implementation of a Surgical Comprehensive Unit-Based Safety Program to Reduce Surgical Site Infections. J Am Coll Surg. 2012; 215 (2).

10. The Joint Commission. J Qual Patient Saf. 2010;36:252-6http://www.ahrq.gov/cusptoolkit/

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BUILDING YOUR SUSP TEAMMIKE ROSEN, PHD

Who is in the room with you?

46

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Polling Question

47

Do you have a SUSP team?– Yes– No

If so, who is on your team?– Anesthesiologist– CRNA– Infection Preventionist– OR nurse– QI lead– Scrub tech

– Senior Executive– Surgeon– Surgical clinical reviewer– Surgical floor nurse– other

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Learning Objectives

48

After this session, you will be able to:

Develop a strategy to engage frontline and executive team members in SUSP work

Utilize basic strategies to encourage surgeon participation in SUSP work

Identify SUSP team members and plan your first meeting

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Kevin Driscoll CRNACRNA Lead

Deb Hobson RN“Coach”

Tracie Cometa RNLead RN

Mary Grace Hensel RNManager OR

Sean Berenholtz MDAnesthesia Lead

Lucy Mitchell RNNSQIP SCR

Elizabeth Wick MDSurgery Lead

Renee Demski MBASenior Director QualityJohns Hopkins Medicine

Steph Mullens CSTLead Tech

49

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Perioperative SUSP Team Members

50

Essential Team MembersSurgeonsAnesthesiologistsCRNAsCirculating nursesScrub nurses / OR techsPerioperative nursesExecutive partnerNurse leaders

Enhancing Team MembersPhysician assistantsNurse educatorsAnesthesia assistantsInfection preventionistsOR directorsPatient safety officersChief quality officersAncillary staff

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The SUSP Team

51

Understands that patient safety culture is LOCAL

Composed of engaged frontline providers who take ownership of patient safety

Includes staff members who have different levels of experience

Tailored to include members based on clinical intervention

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SUSP Team Logistics

52

Meets regularly

– Weekly ideal

– Monthly at a minimum

Has adequate resources including protected time

– 2 to 4 hours per week for a team leader, surgeon, anesthesia, nurse, and infection preventionist

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Enter response in the chat.

53

How can you protect 2 – 4 hours of time per week for your SUSP team leaders?

Polling Question

Activity: Brainstorm how to prioritize the need for protected time.

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SUSP Teams’ Group Processes

54

Effective Group

Processes

Norms

Role Clarity

Effective Team Communication

Conflict Resolution

Education and

Engagement

Leadership Buy-in and

Support

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Role of Senior Executive Partner

55

• Helps the team prioritize improvement efforts• Helps the team navigate organizational bureaucracy• Ensures the SUSP team has resources to fix problems• “Comes out of the office” to meet monthly with members

of health care team in their clinical area

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Finding an Executive Partner

56

Contact hospital management to determine which senior executive will best fit the perioperative area and the following criteria:– Director level or above

– Available to round for at least one hour per month

– Approachable and comfortable with sensitive topics

Set up a meeting to introduce the project, provide a tour of the perioperative area, and share unit-level information

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Role of Surgeon Leader

Serves as role model for SUSP activities

Meets with SUSP team at least monthly

Participates in monthly senior executive partnership meetings

Communicates with physician group as needed

Assists with implementation of interventions

57

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Engage Surgeons on the SUSP Team

58

Identify surgeon leaders

Explain this role

Formalize plan for

communications

Listen to surgeon concerns

Develop plans to address concerns

Reward surgeon leaders

Determine best vehicle for

communication

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Practical Tips for Scheduling SUSP Meetings

59

Incorporate SUSP meetings into ongoing educational activities to ease scheduling challenges– Regularly scheduled nurse training– Grand rounds for physicians– Invite RNs to join grand rounds

Offer incentives for participating

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You Have Access To Some Helpful Tools

60

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Team Roles and Responsibilities Form

61

Additional CUSP Tools

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Next Steps

62

Recruit a team lead, nurse lead, surgeon lead, and executive partner along with other team members

List team member names and contact information on the CUSP for Safe Surgery Team Member Form and post the form in a central location

Schedule your SUSP meetings for 6 to 12 months

Complete CUSP for Safe Surgery Roles and Responsibilities Form during your first meeting

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Polling Question

63

Do you think that your team can influence your organization to enable frontline participation in improvement work and address frontline patient safety priorities?

– We can definitely influence our organization

– We might be able to influence our organization

– We can’t influence our organization

– Not sure

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AN INTRODUCTION TO BUILDING AND MEASURING SAFETY CULTURESALLIE WEAVER, PHD

The “adaptive” glue that helps bond safe teams

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Learning Objectives

65

After this session, you will be able to:

Define safety culture

Describe why a safety culture is important for improvement efforts

Explain the SUSP safety culture measurement process

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What is Safety Culture?

Image source: Marysia Tomaszewska, August 8, 2012, used under a Creative Commons License

66

Perceived priority of safety relative to other goalsCulture is the compass team members use to guide their behaviors, attitudes, & perceptions on the job– What will I get praised for?– What will I get reprimanded for?– What is the “right” thing to do?

Culture provides the context for team success.

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Core Aspects of a Safety Culture1

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Safety Culture Is Related To Outcomes2,3,4,5,6,7,8

68

Patient outcomes– Patient care experience– Infection rates, sepsis– Postoperative hemorrhage, respiratory failure,

accidental puncture / laceration– Treatment errors

Clinician outcomes– Incident reporting, burnout, turnover

Why Safety Culture Matters

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Why Safety Culture Matters9,10,11,12

69

Safety culture influences the effectiveness of other safety and quality interventions– Can enhance or inhibit effects of other

interventions

Safety culture can change through intervention– Best evidence for culture interventions that use

multiple components

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CUSP & Safety Culture

Measure safety culture at the start of the SUSP project– Provides a baseline to diagnose barriers and facilitators that can

impact improvement efforts– Then will be measured again 12 months following start of

improvement efforts

Use reliable and valid survey instrument– Hospital Survey on Patient Safety (HSOPS)

CUSP is a proven intervention that will help you improve your culture results

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Example: HSOPS Questions & Composite Scores

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10 Composite Scores (“Dimensions”)

No. of Questions

Example Question

1. Supervisor/manager expectations & actions promoting patient safety 4 B1. My supervisor/manager seriously considers

staff suggestions for improving patient safety.

2. Organizational learning-continuous improvement 3 A9. Mistakes have led to positive changes here.

3. Teamwork within unit 4 A1. People support one another in this unit.

4. Communication openness 3 C4. Staff feel free to question the decisions or actions of those with more authority.

5. Feedback & communication about error 3 C1. We are given feedback about changes put into place based on event reports.

6. Nonpunitive response to error 3 A8. Staff feel like their mistakes are held against them. (negatively worded)

7. Staffing 4 A2. We have enough staff to handle the workload.

8. Hospital management support for patient safety 3 F8. The actions of hospital management show that

patient safety is a top priority.

9. Teamwork across hospital units 4 F4. There is good cooperation among hospital units that need to work together.

10. Hospital handoffs & transitions 4 F5.Important patient care information is often lost during shift changes. (negatively worded)

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4 Outcome Variables No. of Questions

Example Question

1. Overall perceptions of safety 4 A15. Patient safety is never sacrificed to get more work done.

2. Frequency of event reporting 3 D1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?

3. Patient safety grade (of hospital unit)

1 E1. Please give your work area/unit in this hospital an overall grade on patient safety.

4. Number of events reported in the last 12 months

1 G1. In the past 12 months, how many event reports have you filled out and submitted?

Example: HSOPS Questions & Composite Scores

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Polling Question

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Has your hospital collected data about your work area’s culture of safety in the previous 12 months? – Yes

– No

– Not sure

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Have Existing HSOPS Data?

74

Have you collected data about the safety culture in the last twelve months? If yes:

When was this data collected and how? (Online or Paper Survey, In-person Interview)

Who has access to this data?

What aspects of culture were measured and what data was captured?

Where are copies of the raw data (spreadsheets) and reports (PDF file with charts and graphs)?

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Key Role of HSOPS Survey Coordinator

Coordinate entire HSOPS survey administration process

Work with hospital and work area leadership to distribute survey materials and information

Facilitate survey completion and answer any questions

Participate in training webinars and conference call to learn how to use the SUSP Online Portal

Enter data from all work area(s) completing the HSOPS survey in the SUSP Online Portal

Monitor survey response rate in the SUSP Online Portal

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Tip: SUSP Online Portal can be found at https://armstrongresearch.hopkinsmedicine.org/susp.aspx

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Next Steps

Complete the SUSP Portal Registration Form, if you have not already done soIdentify an HSOPS Survey coordinator to attend a training call– May 12th (10 - 11am EDT) or – May 14th (4 - 5pm EDT)

Determine if your hospital has completed a safety culture survey in the past 12 monthsCohort 5 teams will collect and upload HSOPS data during the following times:– Baseline: May 12th through July 7th, 2014– Follow-up: May 20th through July 9th, 2015

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References

1. Schein E. Organizational culture and leadership, 4th edition. San Francisco, CA: Jossey-Bass. 2010.

2. Huang DT, Clermont G, Kong L, Weissfeld LA, Sexton JB, Rowan KM, Angus DC. Intensive care unit safety culture and outcomes: a US multicenter study. Int J Qual Health Care. 2010 Jun;22(3):151-61.

3. MacDavitt K, Chou SS, Stone PW. Organizational climate and health care outcomes. Jt Comm J Qual Patient Saf. 2007 Nov;33(11 Suppl):45-56.

4. Mardon RE, Khanna K, Sorra J, Dyer N, Famolaro T. Exploring relationships between hospital patient safety culture and adverse events. J Patient Saf. 2010 Dec;6(4):226-32.

5. Singer SJ, Falwell A, Gaba DM, Meterko M, Rosen A, Hartmann CW, Baker L. Identifying organizational cultures that promote patient safety. Health Care Manage Rev. 2009 Oct-Dec;34(4):300-11.

6. Sorra J, Khanna K, Dyer N, Mardon R, Famolaro T. Exploring Relationships Between Patient Safety Culture and Patients' Assessments of Hospital Care. J Patient Saf. 2012 Jul 10. [Epub ahead of print].

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References

7. Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and Quality. September 2004.

8. Weaver SJ. A configural approach to patient safety climate: The relationship between climate profile characteristics and patient safety. Doctoral dissertation. University of Central Florida. 2011.

9. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Dziekan G, Herbosa T, Kibatala PL, Lapitan MC, Merry AF, Reznick RK, Taylor B, Vats A, Gawande AA; Safe Surgery Saves Lives Study Group. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf. 2011 Jan;20(1):102-7.

10. Morello RT, Lowthian JA, Barker AL, McGinnes R, Dunt D, Brand C. Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Qual Saf. 2012 Jul 31. [Epub ahead of print]

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References

11. Van Noord I, de Bruijne MC, Twisk JW. The relationship between patient safety culture and the implementation of organizational patient safety defences at emergency departments.. Int J Qual Health Care. 2010 Jun;22(3):162-9.

12. Weaver, S. J., Dy, S., Lubomski, L., & Wilson, R. Promoting a culture of safety. In R.M. Watcher, P.G. Shekelle, P. Pronovost (Eds.). Making healthcare safer: A critical analysis of the evidence of patient safety practices (AHRQ report # TBD). Rockville, MD. In press.

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John Muir Medical Center

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 John Muir Medical Center SUSP Experience Video

SUSP Team Experience

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NEXT STEPSERIN HANAHAN, MPHMARY TWOMLEY, MS

We’re in this together.

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Polling Question

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What percentage of organizational change efforts fail?- 0 - 20%- 21 - 40%- 41 - 60%- 61 - 80%- 81 - 100%

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Preparing to Lead

In a postmortem, an autopsy is performed to learn why a patient died. While it may be helpful to those interested in the results, it does not help the central figure in the medical drama—the patient.

The PreMortem Exercise is used to identify potential barriers and vulnerabilities to project success before they occur. It builds intuition and sensitivity to future problems.

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Step 1

Imagine that we are 2 years into the future and, despite all of the team’s efforts, the project has failed—catastrophically. Things have gone completely wrong on a number of fronts.

Now, ask: – What does the worst case scenario look like?

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Premortem Exercise

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Step 2

Generate the reasons for failure.

Spend 10 minutes recording the reasons you believe this failure occurred.

Now, ask:

– What could have caused our project to fail?

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Premortem Exercise

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Step 3

Prioritize your list of potential reasons for failure.

Address the top 2 or 3 concerns.

Now, ask:– What specific actions can you take to avoid or

manage these concerns?

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Premortem Exercise

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Step 4

Throughout your project, periodically review the potential problem list with your team.

This process will raise team awareness to problems that may be emerging and allow them to anticipate solutions.

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Premortem Exercise

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Premortem Summary

1. Two years out, what does the worst case scenario look like?

2. What could have caused your project to fail?

3. What specific actions can you take to avoid or manage these issues?

4. Review and anticipate potential problems throughout the project.

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SUSP Portal Project Planning Resources

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Coaching call schedule for your Coordinating Entity

SUSP Project Management Guide

CUSP for Safe Surgery Team Membership Form

CUSP for Safe Surgery Roles and Responsibilities Form

Webinar archives

URL: SUSP Online Portal can be found at https://armstrongresearch.hopkinsmedicine.org/susp.aspx

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WRAP UP

How will the SUSP Project look in your hospital?

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Summary of Next Steps

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Return SUSP Portal Registration Form

Identify an HSOPS Survey coordinator to attend a training call – May 12th (10-11am EDT) or

– May 14th (4-5pm EDT)

Schedule your Kickoff SUSP meeting

– List team members and contact information on the CUSP for Safe Surgery Team Membership Form and post in centrally

– Complete CUSP for Safe Surgery Roles and Responsibilities Form during your first meeting

Complete the pre-mortem exercise and prepare to share your findings during coaching call

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What’s Next?

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Remember, We Are Here To Help!

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Ask questions during coaching calls

Contact the SUSP helpdesk at [email protected]

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Kickoff Webinar Evaluation

https://www.surveymonkey.com/s/cohort_5_onboarding

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Your feedback is very important to us.

Please take the time to help us understand how to best support you.

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