Patient Safety Culture Measurement and Improvement

1. Mark Fleming Saint Mary’s University Patient Safety Culture Measurement and Improvement Mark.fleming@smu.ca

2. Objectives • Understand the nature and importance of culture and relationship with patient safety • Evaluate current culture • Measure, track, monitor culture • Develop a strategic plan for safety culture measurement and improvement • Implement culture improvement strategies • Identify barriers to improvement

3. We can't solve problems by using the same kind of thinking we used when we created them Albert Einstein

4. Importance of culture • “Health care organizations must develop a culture of safety such that an organization's care processes and workforce are focused on improving the reliability and safety of care for patients.” (p. 14; IOM, 1999) • “The biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm.” (p. 79; Crossing the Quality Chasm, 2001)

5. Culture and patient safety PatientSafety Patient Safety Culture Norms and Behaviour Enabler/ Barrier Patient Safety Interventions

6. Patient safety culture • A culture of safety can be defined as an integrated pattern of individual and organizational behaviour, based upon shared beliefs and values, that continuously seeks to minimize patient harm that may result from the processes of care delivery (Kizer, 1999).

7. Patient safety culture elements • Leadership commitment to safety • Organizational resources for patient safety • Priority of safety versus production • Effectiveness and openness of communication • Openness about problems and errors • Organizational learning • Frequency of unsafe acts (Singer et al. 2003)

8. Measurement and Improvement • Organizational level • Major system wide change process requiring significant resources • Step change in patient safety outcomes • Unit level • Focused intervention • Incremental improvement

9. 1. Investigate • Build expertise in safety culture • Form small assessment and improvement team • Select appropriate instrument • Agency for Health Care Research and Quality • Hospital survey on patient safety (79 items) (Sorra & Nieva, 2004) • Safety Attitudes Questionnaire • SAQ (60 items) (Sexton & Thomas 2003) • York University • Modified Stanford (32 items) (Ginsburg et al, 2009)

10. York University Modified Stanford • Based on PSCI and Capital Health questionnaire • Organizational leadership for safety • Unit leadership for safety • Perceived state of safety • Shame and repercussions • Learning • Good psychometrics (alpha’s .66-.86) • Currently used by Accreditation Canada • Large Canadian data set

11. 2. Initiate • Obtain Informed senior leadership support • Involve health care staff • Planning and implementation of assessment • Keep staff informed about progress

12. 3. Implement • Collect data • Interpret results • Feedback results to staff

17. Unit level assessment and improvement • Conduct safety culture survey (e.g. MSI ) • Group exercise • Representative group of frontline caregivers • 30 – 60 minutes to complete • Helps to make sense out of culture survey results and create actions for improvement • Normalizes patient safety culture conversations

19. 4. Improve • Involve cross section of staff in development of improvement plan • Implement an improvement plan • Monitor the implementation of plan • Evaluate effectiveness of plan • Assess change in culture

20. Patient Safety Culture Improvement Tool (PSCIT) • Perceptions are based in reality • i.e. perceptions of leadership commitment reflect their interactions with leaders • Organisations and units with different cultures have different practices • Safety culture improvement involves system change • e.g. perceptions of leader commitment is improved through training and evaluating safety leadership practices

21. Patient safety culture elements • Leadership • Senior Manager • Clinical Manager • Physician • Risk analysis • Workload management • Sharing and learning • Resource management

22. Example element

23. How to use the audit • Self assessment of systems supporting the safety culture • Completed by unit or department to assist in identifying opportunities to improve • Completed by senior management team to form basis for improvement workshop

24. Improving patient safety culture • Leadership • Judged by actions not words • Solution focused approach • Assess current culture • Work at team level to develop local action plan • Implement changes • Reassess culture • Health care specific challenges • Unclear management control • Limited acceptance of need to change

25. Taking Action • Culture is shared by group members • Groups consist of individuals • Culture change requires individuals to change their values, beliefs and behaviour • Cultural change can begin at the: • Organizational level • Unit level • Individual level • So what are you going to do to change the culture?

26. Summary • Creating a culture of patient safety is crucial • The culture determines what behaviours are acceptable and unacceptable • Patient safety culture consists of a number of dimensions • It is important to understand the current culture before trying to change it • Cultural change can be conducted at the organisational or unit level

27. References • Kizer, K. W. 1999. Large system change and a culture of safety. In: Enhancing Patient Safety and Reducing Errors in Health Care. Chicago, IL: National Patient Safety Foundation • Ginsburg L, Gilin D, Tregunno D, Norton P G, Flemons W. and Fleming M(2009) Advancing measurement of patient safety cultureHealth Services Research Vol 44 no 1 pp205-223 • Sexton JB, Paine LA, Manfuso J, Holzmueller CG, Martinez EA, Moore D, Hunt DG, & Pronovost PJ.(2007) A check-up for safety culture in "my patient care area". Joint Commission journal on quality and patient safety. Nov;33(11):699-703, 645 • Fleming, M. and Wentzell, N. (2008) Patient Safety culture improvement tool: development and guidelines for use. Healthcare QuarterlyVolume 11 Special issue pp10-15 • Jackson, J. Sarac, C. and Flin R. (2010) Hospital safety climate surveys: measurement issues Current Opinion in Critical Care , 16:632–638