Patient Safety Culture as a measure of patient Safety

Solvejg Kristensen ▪ Senior advisor MHSc Stud PhD ▪ [email protected] The Danish National Clinical Quality Improvement Programme ESQH Office for Quality Indicators ▪ Central Denmark Region Danish Center for Healthcare Improvement ▪ Aalborg Universitet

BACKGROUND & TERMINOLOGY The term safety culture was first applied in the aftermath of the Chernobyl nuclear reactor disaster in 1986. This nuclear power plant had safety management processes and trained operatives using clear procedures, but deficiencies in the attitudes to safety in the organization leading to the world's worst nuclear disaster


There are many conflicting and complex definitions of what constitutes ‘safety culture’




Safety culture refers to the way patient safety is thought about, structured and implemented in an organisation




The essence of safety culture resides in employee's beliefs about the importance of safety, including their values, norms, attitudes and basic assumptions




It is demonstrated through attitudes, accepted norms and behaviors. It is about how things work and "the way things are done around here"

CULTURE MODEL

Artifacts'

Values & norms

Basic assumptions Efter: Edgar H. Schein, Organizational Culture and Leadership, 2004

PATIENT SAFETY CULTURE Amplified by the behaviors of leaders Evident in the behaviors of individuals and groups

PATIENT SAFETY CULTURE

Visible in the way work get’s done on a day to day basis

Embedded in a network of organisational practices

Shared beliefs, values, and assumptions

MATURITY OF SAFETY CULTURE

Why waste our time on safety?

We do something when we have an incident

We have systems in place to manage all likely risks

We are always on the alert for risks that might emerge

Risk management is an integral part of everything that we do

Maturity enhances = the culture gets more and more positive

LINNEAUS EURO-PC is supported by the EU under FP7, Grant Agreement no. 223424 Ref.: Professor Dianne Parker, MaPSaF, Patient Safety 2006 NPSA, Birmingham 1.- 2. Februar

DIMENSIONS OF PSC Through a qualitative meta-analysis the seven subcultures of patient safety culture were identified as:
Leadership culture
Teamwork culture
Culture of evidence-based practice
Communication culture
Learning culture
Just culture
Patient-centered culture James Reason has suggested that safety culture consists of five elements:
Informed culture
Reporting culture
Learning culture
Flexible culture
Just culture Sammer CE, Lykens K, Singh KP, Mains DA, Lackan NA. What is patient safety culture? A review of the literature. J Nurs Scholarsh 2010 Jun;42(2):156-65. Reason, J.T. (1997) Managing the Risks of Organisational Accidents. Ashgate, Aldershot

JUST CULTURE A Just Culture is:
an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour
forward looking, encourages openness
both attitudinal as well as structural as some personal attitudes and corporate styles can enable or facilitate the unsafe acts and conditions that are the precursors to impairment of patient safety A Just Culture must:
Satisfy demands for accountability
Contribute to learning and improvement Reason, J.T. (1997) Managing the Risks of Organisational Accidents. Ashgate, Aldershot

CULTURAL FEATURES Feature of a positive patient safety culture?









All employees identifying and resolving safety issues Employees looking for opportunities to help others and intervene when needed Reinforcement of safer behaviors by everyone Employees accepting accountability for safety of the patients Employee openness to coaching and feedback Desire to provide resources to improve patient safety Willingness to share, communicate and learn Employees are encouraged to raise issues and suggestions

Less desirable patient safety culture traits could include e.g.






Concerns about safety are consistently not addressed No learning is achieved from adverse events Employees are reluctant to report incidents No one is held accountable for their safety responsibilities Safety management representation is kept out of key decision-making processes

APPROACHES TO SAFETY IMPROVEMENT Technology Design Equipment Engineering

Systems

Numbers of incidents

Certification Competence Procedures/rules Risk Assessment

Culture Attitudes Behaviour Leadership Accountability

Time Ref. Hudson P. Implementing safety culture in a major multi-national. Safety Science 2007;45(6):697-722.

MANAGEMENT & CULTURE










A robust safety culture is the combination of attitudes and behaviours that best manages the inevitable dangers created when humans, who are inherently fallible, work in extraordinarily complex environments Leaders are the keepers and guardians of psychological safety, they must build a robust safety culture, and a learning organisation Management is charged with establishing the right possibilities and direction, vision and systems, which in turn will be reflected in the quality and safety culture Ref. Berwick DM. Continuos improvement as an ideal in Health care. N Engl J Med 1989; 320: 53-6

OBJECTIVEs OF PSC METHODS
Gain information about the values, attitudes, perceptions, competencies, commitment, and patterns of behavior of staff and managers
Provide information about variations across time for different disciplines and of different departments/hospitals/ regions/nations
Direct interventions to improve the safety
Monitor success of initiatives

EVALUATION OF PSC The Hospital Survey on Patient Safety Culture (HSOPSC) Agency for Healthcare Research and Quality (AHRQ), USA J. Sorra and V. Nieva 2004.

Manchester Patient Safety Assessment Framework (MPSaF) National Primary Care Research and Developmental Centre, University of Manchester, UK. S. Kirk, D. Parker et. al. 2004

The Safety Attitudes Questionnaire (SAQ) The University of Texas (USA) J.B. Sexton, E.J. Thomas. 2003.

COVERAGE OF PSC METHODs HSOPSC • • • • • • • • • • • •

Supervisor expectations and actions promoting safety Organisational learning – continuous improvement Teamwork within hospital units Teamwork across hospital units Communication openness Feedback and communication about error Non-punitive response to error Staffing Hospital management support for patient safety Hospital handoffs and transitions Frequency of event reporting Overall perceptions of safety

MaPSaF • • •

• • • • • •

Commitment to continuous improvement Priority given to patient safety What causes patient safety incidents? How are they identified? Investigating patient safety incidents Organisational learning following a patient safety incident Communication Staff and safety issues Staff education and training about safety issues Team and partnership working

SAQ • • • • • •

Teamwork Climate Safety Climate Stress Recognition Job Satisfaction Perceptions Management Work Conditions

PSC & PATIENT SAFETY PROBLEMS
No causal effect has been established between PSC and clinical outcomes, this relationship seems complex and non-linear
A simultaneous improvement in PSC and a reduction in specific patient problems has been documented
Improvement in PSC has been documented in studies that conducted • • •

team training or implemented patient safety rounds or multi-faceted improvement programs


These interventions have severe management engagement in common

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. Weaver SJ, Lubomksi LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strategy: a systematic review. Ann Intern Med 2013 Mar 5;158(5 Pt 2):369-74.

PSC - TEAM TRAINING Team training refers to a set of structured methods for optimizing teamwork processes, such as communication, cooperation, collaboration, and leadership
20 studies examined team training or tools to support team communication as interventions to promote safety culture





perioperative care areas: 10 labor and delivery or pediatrics: 5 medical general floors or intensive care: 2 other care areas or a mix of care areas: 3


Effect of intervention




improvement in staff perceptions of safety culture (N=16 studies) improvements in care processes (e.g. decreased care delays or increased use of structured communication) (N=5 studies) improvements in patient safety outcomes (N=5 studies)

1. Weaver S et al. Promoting a culture of safety as a patient safety strategy: a systematic review. Ann Intern Med 2013 Mar 5;158(5 Pt 2):369-74.

PSC & EXCECUTIVE WALK AROUNDS Walk rounds aim to show leadership commitment to safety, foster trust and psychological safety, and provide support for front-line providers to proactively address threats to patient safety
8 studies evaluated walk rounds (either executive or interdisciplinary)
Effect of interventions
All 8 studies reported improvement in staff perceptions of safety culture
improvements in perceptions of care processes (e.g.. quality of collaboration) or patient safety outcomes (e.g. improvement in mean number of days since last event) (N= 3 studies)

1. Weaver S et al. Promoting a culture of safety as a patient safety strategy: a systematic review. Ann Intern Med 2013 Mar 5;158(5 Pt 2):369-74.

PSC & MULTIFACETED INTERVENTIONS
8 studies evaluated the Comprehensive Unit-Based Safety Programme (CUSP)
Effect of interventions






improvements in staff perceptions of safety culture, including perceptions of teamwork (N=6 studies) improvements in care processes, such as second-stage labor care (38) and timely resolution of safety concerns (N=2 studies) improvements (although statistically nonsignificant or not statistically tested) in nursing turnover (N=2 studies) reduction in length of stay (N=1 study) reductions in infection rates (N=1 study)

1. Weaver S et al. Promoting a culture of safety as a patient safety strategy: a systematic review. Ann Intern Med 2013 Mar 5;158(5 Pt 2):369-74.

CUSP

CUSP is a structured strategic framework for safety improvement that integrates communication, teamwork, and leadership to create and support a culture of patient safety that can prevent harms. The following five steps from CUSP equip frontline providers with the tools, metrics, and framework to tackle the challenges of quality improvement:
Step 1. Staff are educated on the science of safety
Step 2. Staff complete an assessment of patient safety culture.
Step 3. A senior hospital executive partners with the unit to improve communications and educate leadership
Step 4. Staff learn from unit defects
Step 5. Staff use tools, including checklists, to improve teamwork, communication, and other systems of work

THE KEY-STONE PROJECT (I) CUSP was first applied in 2003 on a large scale in the Keystone Project, (N= 100 ICUs in Michigan) The Keystone Project:
Reduced the rate of central line-associated blood stream infections by two-thirds within 3 months
Decreased the rate of central line-associated blood stream infections to the point where these infections became rare events in the participating ICUs, which continued to sustain this reduction 3 years after first adopting CUSP
Saved more than 1,500 lives and nearly $200 million in the program's first 18 months

THE KEY-STONE PROJECT (II) The Keystone Project also reported that
a patient's chance of dying decreased by about 24 percent in Michigan after the program was implemented compared to only 16 percent in surrounding Midwestern states where the program was not implemented
ICUs where CUSP was implemented cut by more than 70 percent the rate of pneumonia in patients who were on ventilators. This reduction was sustained for the duration of the study's follow-up, a period of up to two and a half years
60 percent of the 80 ICUs evaluated went 1 year or more without an infection, and 26 percent achieved 2 years or more. Smaller hospitals sustained zero infections longer than larger hospitals

Improvement begins with I?? Arnold H. Glasow

Solvejg Kristensen ▪ [email protected]