CUSP/Stop CAUTI Collaborative

1. Content Call 6 – Supplement 5/17/11 Document 2 CUSP/Stop CAUTICollaborative Supplement – Preparing for the HSOP Survey 5/17/2011 Carol Hafley, MHA, BSN, RN Assistant Director Missouri Center for Patient Safety Jefferson City, MO chafley@mocps.org 573-636-1014 x227

2. The “Secret Ingredient”Comprehensive Unit-Based Patient Safety Program • Form a unit CUSP team with executive sponsorship • Measure unit culture • Educate staff on Science of Safety • Identify defects using the Staff Safety Assessment; prioritize defects • Learn from one defect per quarter • Implement team/communication tools

3. Why Measure Unit Culture? • Determine how bedside staff are feeling related to communication and recognizing defects • Diagnose and assess the current status of patient safety culture. • Identify strengths and areas for patient safety culture improvement. • Examine trends in patient safety culture change over time. • Measure/evaluate the cultural impact of patient safety initiatives and interventions. • CUSP is the intervention that will help you improve culture results • Results will be discussed during coaching call 5 – unit culture action plan development

4. AHRQ’s Hospital Survey on Patient Safety (HSOPS) 42 items assess 12 dimensions of patient safety culture 1. Communication openness 2. Feedback & communication about error 3. Frequency of event reporting 4. Handoffs & transitions 5. Management support for patient safety 6. Nonpunitive response to error 7. Organizational learning--continuous improvement

5. AHRQ’s Hospital Survey on Patient Safety (HSOPS) 8. Overall perceptions of patient safety 9. Staffing 10. Supv/mgr expectations & actions promoting patient safety 11. Teamwork across units 12. Teamwork within units Patient safety “grade” (Excellent to Poor)

6. HSOPS Process • The HSOPS webinars scheduled this week and next will walk through this process and the timeline – survey will be open beginning the middle of June and go through mid-July. • Each Team Leader must identify how many staff members on the unit will be surveyed – all staff should take the survey! • Physicians – including residents, physician assistants • Licensed Staff – RNs, RTs, LPNs, therapists, pharmacists, dietician etc. • Non-licensed Staff – CNAs, technicians (i.e. EKG tech), Unit Clerks, Housekeepers, etc. • Goal is reaching a 60% response rate • You will receive weekly response rate updates from MHA.

7. HSOPS Process: If the unit has recently completed a safety survey • If units have already taken a patient safety culture survey and the following is true: • A) survey occurred within the last 6 months • B) unit received at least a 60% response rate • C) there have been no major staff, leadership, or structural changes in the unit, such as • Staff turnover/layoffs • Changes in medical staff or medical staff model (i.e. open vs. closed unit) • Change in manager . . . then you do not need to take it again – you will need to discuss with Carol how to get your results imported.

8. HSOPS Process: Getting a 60% Response Rate • Value it! • Explain to staff why filling out the survey is so important – showcase specific examples from the unit that help validate that culture improvement is important for all staff • Spend time in your next Team Meeting planning how you will reach 60% : • Engage your physician champion to encourage physicians to take the survey • Make the survey accessible to all staff • Email the URL vs. Putting URL on one computer accessible to all staff – both are options • Make it a challenge – if the unit reaches 60%, get some sort of incentive (i.e recognition, small gift, pizza or ice cream party, etc.)

9. Upcoming Dates • Attend ONE HSOPS Training Webinar (May 16, 19, 23, or 26). No need to register, just join the meeting. • June 1, 2011 – Data Collectionfor CAUTI rates and prevalence begins!! • June 10, 2011 – Kick Off Meeting in Columbia, Courtyard by Marriot, 8 AM to 3 PM. Invitation was emailed on May 11. Please RSVP and register so we can get a head count!