Nordic experience with Safety Culture Survey Resources download from: homepage.mac

1. Nordic experience with Safety Culture SurveyResources download from:http://homepage.mac.com/johnovr/FileSharing2.html 1 John �vretveit, Director of Research, Professor, Karolinska Medical Management Centre Sweden and Professor of Health Management, Faculty of Medicine, Bergen University 3/28/2012

2. 2012-03-28 2

3. 2012-03-28 3

4. .t . . . . 4

5. Report Draws on role as coordinator for Nordic patient safety research network & International Quality improvement research network Sweden: 5 hospitals approx 2000 people surveyed Norway: Stavanger & Akershus studies Denmark: Copenhagen hospitals study Finland: considering AHRQ vs IHI versions 5 3/28/2012

6. Why we wanted a survey tool Diagnosis to show possible intervention points and problem areas Compare units/organisations to discover and learn from �best cultures/practice� Assess impact of changes on before/after responses to questions 6 3/28/2012

7. Sweden: study requirements a)describe the different �pictures� which different surveys provide � differences and strengths and weaknesses of each b)describe what the surveys really measure, by comparing aggregate data from units which should be the same to find out if same data is produced, by comparing different instruments and asking subjects views about validity and in other ways c)assess reliability by comparing matched subjects responses and test-retest reliability d) assess sensitivity to registering different changes e) describe how data from these related to real changes and activities (comparing survey data to observational and interview data). 7 3/28/2012

8. Criteria for assessing surveys include: Practical Value assessed by managers for action and making more informed decisions Use for identifying best practice units Time and cost to administer and analyse Scientific Value for research use to studying change and influences on performance Validity (global) Sensitivity 8

9. 3/28/2012 9 How to measure?. Typological approaches: Competing Values Framework Harrison�s Organizational Ideology Questionnaire Quality Improvement Implementation Survey Dimensional instruments: Organizational Culture Inventory Hospital Culture Questionnaire Nursing Unit Culture Assessment Tool Practice Culture Questionnaire MacKenzie�s Culture Questionnaire Survey of Organizational Culture Corporate Culture Questionnaire Core Employee Opinion Questionnaire Hofstede�s Organizational Culture Questionnaire Organizational Culture Survey (Scott et al. (2003) HSR)

10. 3/28/2012 10 Publicly available safety culture survey instruments California 15 hospitals study (Singer et al. 2003 (Stanford/PSCI survey 2001) AHRQ 2004 survey IHI survey Weingart et al. 2004 employee survey instrument Manchester patient safety tool (MaPSaT) 2005 

11. 3/28/2012 11 Metaphors for culture - the iceberg tt

12. 3/28/2012 12 Previous research - John�s assessment most are attitude surveys tell us about climate not culture, often without theoretical basis, rarely build on previous instruments. more research combining ethnographic and survey pictures needed Unclear for which purpose each instrument most useful and perspective it gives.

13. 3/28/2012 13 What research can contribute To safer patient care Is there a link between culture and safety performance? Can you predict safety performance using culture assessment? Theory explaining any causal pathways What changes which aspects of culture in which situations?

14. 3/28/2012 14 UK-Sweden senior leaders views

15. Swedish experience so far Pilot: One hospital 100 questionnaires in 10 departments (10 staff at each unit). (acute care, primary healthcare, psychiatrics and geriatrics) Interviews with 20 Longer than IHI, but easier to fill-in Main study: AHRQ apprx 2000 administered � currently analysing Large variations Similarities and differences to AHRQ averages possibly signficant - preliminary findings � next slides contact Jessica.lindberg@karolinska.se 15

16. Svarsfrekvenser

17. BIGGEST DIFFERENCE TO USA I12 H�gsta ledningens st�d till patients�kerhetsarbete Sjukhusledningen eller motsvarande har skapat ett arbetsklimat som fr�mjar patients�kerheten Sjukhusledningens eller motsvarandes agerande visar att patients�kerheten har h�gsta prioritet Sjukhusledningen eller motsvarande vekar endast intressera sig f�r patients�kerheten n�r en negativ h�ndelse har intr�ffat

18. I1 Ben�genhet att rapportera h�ndelser N�r ett misstag intr�ffar och r�ttas till innan det p�verkar patienten, hur ofta rapporteras det? N�r ett misstag intr�ffar som inte kan skada patienten, hur ofta rapporteras det? N�r ett misstag intr�ffat som skulle kunnat skada patienten, men inte gjorde det, hur ofta rapporteras det?

19. I6 L�randeorganisation Vi arbetar aktivt f�r att f�rb�ttra patients�kerheten Misstag har lett till positiva f�r�ndringar h�r N�r vi har inf�rt f�r�ndringar f�r att f�rb�ttra patients�kerheten utv�rderar vi deras effektivitet

20. BIGGEST VARIATION BETWEEN SWEDISH HOSPITALSI3 Sj�lvskattad patients�kerhetsniv� G�r en generell bed�mning av patients�kerheten p� din v�rdenhet.

21. I2 Sammantagen s�kerhetsmedvetenhet Vi g�r aldrig avkall p� patients�kerheten f�r att hinna mer V�ra rutiner och system �r bra p� att f�rhindra att fel intr�ffar Det �r ren tur att inga allvarligare misstag sker h�r Vi har problem med patients�kerheten inom den h�r v�rdenheten

22. I5 Min n�rmaste chefs agerande kring patients�kerhet Min n�rmaste chef ger ber�m n�r han eller hon ser att en uppgift utf�rs i enlighet med fastst�llda patients�kerhetsrutiner Min n�rmaste chef beaktar p� allvar personalens f�rslag till f�rb�ttringar av patients�kerheten N�r arbetsbelastningen �kar vill min n�rmaste chef att vi �kar tempot, �ven om det inneb�r att vi m�ste ta genv�gar Min n�rmaste chef l�tsas inte om de patients�kerhetsproblem som upptr�der om och om igen

23. I7 Samarbete inom v�rdenheten P� v�r v�rdenhet st�ttar personalen varandra N�r det �r mycket arbete som m�ste utf�ras snabbt arbetar vi tillsammans som team f�r att f� arbetet avklarat Inom den h�r v�rdenheten behandlar personalen varandra med respekt N�r det blir hektiskt f�r n�gon del inom v�rdenheten, kommer vi andra och hj�lper till

24. Norway: Stavanger studies 400 bed hospital, 10 departments 1919 questionnaires returned (55% rr) Investigate fit of proposed factor structure using Confirmatory factor analysis (CFA) Internal consistency of dimensions: Cronbach�s alpha Discriminant validity: intercorrelation among concepts and MANOVA 24

25.  Concurrent validity: degree to which dimensions influenced outcome variables included in HSOPSC 25

26. Stavanger studies: Findings Factor analyses: factorial model fitted the data well. poor internal consistency - �Organizational learning�continuous improvement�, - improved when �mistakes have led to positive changes here� removed Surprise: safety culture dimension exerted several negative influences on �Number of events reported (last 12 months)�, - suggests this outcome variable is invalid. 26 3/28/2012

27. Stavanger studies: Findings Can be used in Norwegian hospital settings. Psychometric properties satisfactory �Number of events reported� is not a good outcome measure. Research challenges: Getting high/unbiased survey response rate Using correct statistical methods to avoid Type I and Type II errors. Ref: Olsen in: �vretveit, J Sousa, P (2008) Quality and Safety Improvement Research, Portugal School of Public Health Publisher: Lisbon. 27

28. Denmark: Copenhagen hospitals study (n=10k) . 28 3/28/2012

29. Denmark: Copenhagen hospitals study . 29 3/28/2012

30. Denmark: Copenhagen hospitals study . 30 3/28/2012

31. Conclusions: Copenhagen hospitals study . 31 3/28/2012

32. Denmark: Copenhagen hospitals study Comparisons with similar regions in DK & comparison over time in a repeat survey in 2 years Comparing with data from clinical databases and surveys of patient satisfaction. Results given to department managers �required to report their follow-up. Provided: tools and ideas how to react on problem areas. Results contribute to the Region�s patient safety action plan & used in leadership development. Acknowledgements to: Marlene Madsen Dansk mdyrloev@ruc.dk Institut for Medicinsk Simulation, Amtssygehuset i Herlev 32

33. Norway: Akershus Sexton (SAQ 2006) study . 33 3/28/2012

35. And this is the SAQ Short Form 2006. You can�t read this from where you sit. But here it is on paper (del ut). The copyright belongs to professor Bryan Sexton at the Johns Hopkins University Quality and Safety Research Unit. He�ll let anyone use it � gladly � but one has to inform/ask him, and acknowledge the authors behind it in one�s report And this is the SAQ Short Form 2006. You can�t read this from where you sit. But here it is on paper (del ut). The copyright belongs to professor Bryan Sexton at the Johns Hopkins University Quality and Safety Research Unit. He�ll let anyone use it � gladly � but one has to inform/ask him, and acknowledge the authors behind it in one�s report

39. I8 �ppenhet i kommunikationen Personalen s�ger, utan att tveka ifr�n, om de ser n�got som kan p�verka v�rden av patienterna negativt N�r de med h�gre status/st�llning tar beslut eller utf�r handlingar v�gar personalen ifr�gas�tta Personalen �r r�dd f�r att st�lla fr�gor n�r n�got inte verkar st� r�tt till

40. I9 �terf�ring och kommunikation kring avvikelser Vi f�r �terkoppling om de f�r�ndringar som genomf�rs baserade p� avvikelserapporter Vi informeras om de misstag som g�rs inom v�r v�rdenhet P� den h�r v�rdenheten diskuterar vi hur vi ska undvika att fel intr�ffar igen

41. I10 En icke straff- och skuldbel�ggande kultur Personalen upplever att deras misstag l�ggs dem till last N�r en avvikelse rapporteras k�nns det som att det �r personen som utpekas ist�llet f�r problemet Personalen oroar sig f�r att de misstag de gjort sparas i personalakten

42. I11 Arbetsbelastning och personalt�thet Vi har tillr�ckligt med personal f�r att klara arbetsbelastningen Personalens arbetspass (planerad + eventuell �vertid) p� den h�r v�rdenheten �r l�ngre �n vad som �r bra f�r v�rden av patienterna Vi anv�nder personal fr�n bemanningsf�retag/tillf�llig personal mer �n vad som �r bra f�r v�rden av patienterna Vi arbetar under mycket h�rd press och f�rs�ker utf�ra alltf�r mycket, alltf�r snabbt

43. I13 Samarbete mellan v�rdenheterna Det r�der ett gott samarbete mellan de v�rdenheter som beh�ver arbeta tillsammans V�rdenheterna samarbetar bra f�r att ge patienterna den b�sta v�rden V�rdenheterna inom sjukhuset eller motsvarande kan inte samverka p� ett bra s�tt Det �r ofta otryggt att arbeta tillsammans med personal fr�n andra v�rdenheter

44. �I14 �verl�mningar och �verf�ringar av patienter och information Skiftbyten �r problematiska f�r patienterna p� den h�r v�rdenheten Viktig information om v�rden av patienterna g�r ofta f�rlorad mellan arbetspass/skiftbyten t.ex. mellan kv�ll/natt Problem uppst�r ofta vid informationsutbytet mellan v�rdenheter Saker och ting "faller mellan stolarna" d� patienter �verf�rs fr�n en v�rdenhet till en annan