Challenges to Improving Safety at the Point of Care

Building Infrastructure: Lessons Learned from Critical Access

Hospitals

Katherine Jones, PT, PhDAnd TeamSupported by AHRQ Grant 1 U18 HS015822AHRQ Knowledge Transfer National Rural Health AssociationNebraska Department of HHS

AHRQ Annual Meeting Sept. 9, 2008

Objectives

Knowledge: Patient safety infrastructure requires common knowledge of a theoretical framework to achieve sensemaking

Skill: Assess culture and implement change; comply with Joint Commission Leadership Standards (LD.03.01.01)

Attitude: Believe that key safety culture practices create the infrastructure that organizations must use to support frontline workers who improve quality and keep patients safe

3

Critical Access Hospitals (CAHs)Critical Access Hospitals (CAHs) Limited to Limited to

25 inpatient 25 inpatient bedsbeds

96 hour 96 hour average length average length of stayof stay

Receive cost-Receive cost-based based reimbursement to reimbursement to maintain access maintain access to care in rural to care in rural areasareas

1,289 CAHs 1,289 CAHs concentrated in concentrated in Midwest; ¼ of Midwest; ¼ of general general community community hospitals in UShospitals in US

4

What does a CAH look like?What does a CAH look like?

5

Healthcare SystemStructures & Processes

OrganizationalStructures & Processes

Individual ProviderStructures & Processes

Quality at Point of CareInterpersonalCare

TechnicalCare

Chain of Impact at the Point of CareChain of Impact at the Point of Care

The quality, safety and value of care can be no better than the structures The quality, safety and value of care can be no better than the structures and processes used by providers in direct contact with the patient. Culture and processes used by providers in direct contact with the patient. Culture determines how organizations support providers at the point of care. determines how organizations support providers at the point of care.

Nelson et al. (2002) Joint Commission Journal on Quality Improvement, 28, 472-493.Nelson et al. (2002) Joint Commission Journal on Quality Improvement, 28, 472-493.Swuste P. (2008). Human Factors and Ergonomics in Manufacturing, 18, 438-453.Swuste P. (2008). Human Factors and Ergonomics in Manufacturing, 18, 438-453.

Culture

6

How can organizations effectively How can organizations effectively support providers at the point of care? support providers at the point of care?

AHRQ-supported research with Critical Access Hospitals AHRQ-supported research with Critical Access Hospitals (CAHs) provides evidence consistent with Dr. Clancy’s (CAHs) provides evidence consistent with Dr. Clancy’s message: “How to translate research into improvement:”message: “How to translate research into improvement:” InfrastructureInfrastructure Capacity Capacity IncentivesIncentives

Implementing a Program of Patient Safety in Small Rural Implementing a Program of Patient Safety in Small Rural HospitalsHospitals

Evaluating the Effect of TeamSTEPPSEvaluating the Effect of TeamSTEPPSTMTM Training on the Training on the Culture of Safety in Critical Access HospitalsCulture of Safety in Critical Access Hospitals

7

Implementing a Program of Patient Safety in Small Rural Hospitals

One of 17 AHRQ PIPs grants funded 7/05 – 6/07 (AHRQ Grant 1 U18 HS015822)

Purpose: To implement the patient safety practices of voluntary medication error reporting and organizational learning in 24 Critical Access Hospitals.

Aim 1: Develop the organizational infrastructure for reporting and analyzing medication errors that is needed to identify system sources of error.

8

Evaluating the Effect of TeamSTEPPSTM Training on the Culture of Safety in

Critical Access Hospitals Funding through AHRQ and Nebraska DHHS

Purpose: To implement the patient safety practice of teamwork and communication training in 25 Critical Access Hospitals.

Aim 1: Evaluate the impact of the TeamSTEPPS training program on safety culture using the rural-adapted version of the AHRQ Hospital Survey on Patient Safety Culture.

9

The Components of an Effective The Components of an Effective Patient Safety System*Patient Safety System*

The components are: (1) monitoring progress/maintaining vigilance, (2) knowledge of epidemiology of patient safety risks and hazards, (3) development of effective practices and tools, (4) building infrastructure for effective practices, and (5) achieving broader adoption of effective practices

*Farley DO, Damberg CL, Ridgely MS, et al. Assessment of the AHRQ patient safety initiative final report—Evaluation report IV. Rand Organization; 2008 Technical Report No. 563. http://www.rand.org/pubs/technical_reports/TR563/.

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Phase One: Reporting in an Effective Phase One: Reporting in an Effective Patient Safety SystemPatient Safety System

Four CAHs in Nebraska sought help from UNMC to make sense of their medication errors. Four CAHs in Nebraska sought help from UNMC to make sense of their medication errors. 1.1. Understand the epidemiology of medication errorsUnderstand the epidemiology of medication errors2.2. Develop effective tools: process maps, reporting forms, databaseDevelop effective tools: process maps, reporting forms, database3.3. Monitor progress: benchmarking reports and assistance to manage process changeMonitor progress: benchmarking reports and assistance to manage process change4.4. AHRQ funding supported an infrastructure—subscriptions to MEDMARX,, education about AHRQ funding supported an infrastructure—subscriptions to MEDMARX,, education about

disclosure of errors, just culture, root cause analysisdisclosure of errors, just culture, root cause analysis5.5. AHRQ funding enabled broader adoption of these practices across 35 CAHs in three states AHRQ funding enabled broader adoption of these practices across 35 CAHs in three states

1. Knowledge of Epidemiology of Medication Errors

2. Tool: Process MapsForms, Database

3. Monitor Progress: Benchmarking reports,Change management

4. Building Infrastructure: 14 CAHs report to MEDMARX,Safety culture education

5. Achieving Broader Adoption: 35 CAHs report to MEDMARX,Ongoing NCPS RCA education

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Sensemaking Tools From Sensemaking Tools From PIPS Grant: Process map, PIPS Grant: Process map, Reporting FormReporting Form

Order generated by physician; other

qualified personnel

Written order?

Write down and read back verbal or telephone orders to the provider.

NO

Order written in chart

Author of order flags chart or folds order sheet in half and places chart on desk.

RN transcribes order to handwritten paper MAR, dates, times and signs off. One copy of MAR generated.

MAR placed in notebook on top of med cart.

Problem with order?

Nurse clarifies order with prescriber.

YES

YES

NO

Prescribing

Documen-tation and Order Processing

Preparation/Dispensing

Palm pilot available to verify drug-drug interactions and dosage.

No policy to check drug-disease interactions or appropriateness of drug for renal function prior to drug preparation.

Orders faxed to pharmacist for verification of dosage and interactions daily.

Two nurses to check MAR against original orders every 24 hours. Both sign verifying check was completed.

Consultant pharmacist reviews MAR daily.

Policy/process being developed.

Weekday?

YES

NO

Weekday? YES

NO

Policy/process being developed.

Policy to date and time, no inappropriate abbreviations or trailing 0s, no blanket orders (i.e. resume home meds).

Double check transcription before initial administration of meds.

Palm pilot available to verify drug-drug interactions and dosage.

MAR used to obtain daily meds from med cart. Nurse uses MAR and unit doses to verify right dose, right time, right drug, right route at med cart just outside of patient's room.

Nurse administers medication using two means of patient identification and to identify medication and purpose as it is given to pt.

Nurse documents medication given on MAR at med cart.

Nurse monitors patient's response to medication

High alert medication?

Insulin, heparin, dopamine, PCA pump settings, continuous morphine usually double checked by another nurse.

Administration

YES

NO

Bulk stock and unit doses placed in patient bins in med cart. Bins marked by room number.

MAR or Carbon copy of order sheet used by nurse to obtain meds from pharmacy (unit dose and bulk stock). Bulk stock bottles signed out of pharmacy.

No policy in place.YES

Pediatric?High alert medication?

Double check right dose, right time, right drug, right route by another nurse.

Policy in place for certain high alert pediatric medications.

NO

NO

YES

Order generated by physician; other

qualified personnel

Written order?

Write down and read back verbal or telephone orders to the provider.

NO

Order written in chart

Author of order flags chart or folds order sheet in half and places chart on desk.

RN transcribes order to handwritten paper MAR, dates, times and signs off. One copy of MAR generated.

MAR placed in notebook on top of med cart.

Problem with order?

Nurse clarifies order with prescriber.

YES

YES

NO

Prescribing

Documen-tation and Order Processing

Preparation/Dispensing

Palm pilot available to verify drug-drug interactions and dosage.

No policy to check drug-disease interactions or appropriateness of drug for renal function prior to drug preparation.

Orders faxed to pharmacist for verification of dosage and interactions daily.

Two nurses to check MAR against original orders every 24 hours. Both sign verifying check was completed.

Consultant pharmacist reviews MAR daily.

Policy/process being developed.

Weekday?

YES

NO

Weekday? YES

NO

Policy/process being developed.

Policy to date and time, no inappropriate abbreviations or trailing 0s, no blanket orders (i.e. resume home meds).

Double check transcription before initial administration of meds.

Palm pilot available to verify drug-drug interactions and dosage.

MAR used to obtain daily meds from med cart. Nurse uses MAR and unit doses to verify right dose, right time, right drug, right route at med cart just outside of patient's room.

Nurse administers medication using two means of patient identification and to identify medication and purpose as it is given to pt.

Nurse documents medication given on MAR at med cart.

Nurse monitors patient's response to medication

High alert medication?

Insulin, heparin, dopamine, PCA pump settings, continuous morphine usually double checked by another nurse.

Administration

YES

NO

Bulk stock and unit doses placed in patient bins in med cart. Bins marked by room number.

MAR or Carbon copy of order sheet used by nurse to obtain meds from pharmacy (unit dose and bulk stock). Bulk stock bottles signed out of pharmacy.

No policy in place.YES

Pediatric?High alert medication?

Double check right dose, right time, right drug, right route by another nurse.

Policy in place for certain high alert pediatric medications.

NO

NO

YES

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Sensemaking Tools From PIPS Grant: Sensemaking Tools From PIPS Grant: Transform data into informationTransform data into information

Error Severity Jan - June 2007 (31 CAHs submitted 2,799 reports)

C (reaches pt, no harm)50%

B (near-miss)20%

A (potential error)28%

D (reaches pt, monitoring)

2%

F (harm, hospitalization)

0%

E (temporary harm)

0%

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Phase Two: Assessing Progress in Phase Two: Assessing Progress in an Effective Patient Safety Systeman Effective Patient Safety System

Second action research cycle of our PIPS GrantSecond action research cycle of our PIPS Grant

1.1. Knowledge that reporting is the foundation of a culture of safety; working definition Knowledge that reporting is the foundation of a culture of safety; working definition

2.2. Need an effective tool to assess cultureNeed an effective tool to assess culture

3.3. Monitor progress and assess change in culture due to reporting infrastructureMonitor progress and assess change in culture due to reporting infrastructure

4.4. Build rural quality improvement infrastructure by adapting HSOPS to the rural environmentBuild rural quality improvement infrastructure by adapting HSOPS to the rural environment

5.5. Achieved broader adoption of rural-adapted version of HSOPS by disseminating it to QIOs Achieved broader adoption of rural-adapted version of HSOPS by disseminating it to QIOs and contracting with the National Rural Health Association and contracting with the National Rural Health Association

1. Knowledge: working definition,role of culture in patient safety

2. Tools: AHRQ HSOPS using Dillmantailored design method, Benchmark Graphs,Unsafe Acts Algorithm

3. Monitor Progress: Assess change in culturedue to practices

4. Building Infrastructure: Rural adaptation of HSOPS to assess rural microcultures

5. Achieving Broader Adoption: PIPS TOOLKIT, Develop service to conduct HSOPS in CAHs for NRHA

Working Definition of Safety Culture

Enduring, shared beliefs and behaviors that reflect an organization’s willingness to learn from errors*

Three beliefs present in a safe, informed culture** Our processes are designed to prevent failure We are committed to detect and learn from error We have a just culture that disciplines based on risk

*Wiegmann. A synthesis of safety culture and safety climate research; 2002.http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/02-03.pdf **Institute of Medicine. Patient safety: Achieving a new standard of care. Washington, DC: The National Academies Press; 2004.

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What are the components of What are the components of safety culture?safety culture?

Reporting – staff report Reporting – staff report their errorstheir errors

Just – reporting is Just – reporting is rewarded, clear line rewarded, clear line between acceptable & between acceptable & unacceptable behaviorunacceptable behavior

Flexible – authority Flexible – authority patterns relax when safety patterns relax when safety information is exchangedinformation is exchanged

Learning – action is taken Learning – action is taken based on safety based on safety information systemsinformation systems

INFORMED = SAFE INFORMED = SAFE

LEARNINGLEARNING

FLEXIBLEFLEXIBLE

JUSTJUST

REPORTINGREPORTINGReason, J. Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing Limited; 1997.

16

How can organizations effectively How can organizations effectively support providers at the point of care?support providers at the point of care?

Use the AHRQ Hospital Survey on Patient Safety Use the AHRQ Hospital Survey on Patient Safety Culture (HSOSPS) to identify and monitor Culture (HSOSPS) to identify and monitor impairments in organizational learning at the level impairments in organizational learning at the level of units/departments and staff positions of units/departments and staff positions

Implement effective practices within each of the Implement effective practices within each of the four components of a safe culture that address four components of a safe culture that address impairments within microsystemsimpairments within microsystems

Ensure interactions between the practices to Ensure interactions between the practices to engineer an infrastructure—a culture—that engineer an infrastructure—a culture—that supports organizational learningsupports organizational learning

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How does HSOPS identify impairments in organizational learning?

HOSPS measures staff perceptions of the beliefs and HOSPS measures staff perceptions of the beliefs and behaviors that support a safe culturebehaviors that support a safe culture

HSOPS is a valid, reliable instrument comprised of 51 items HSOPS is a valid, reliable instrument comprised of 51 items categorized in 12 dimensions categorized in 12 dimensions

12 dimensions reflect the four components of an informed, 12 dimensions reflect the four components of an informed, safe culturesafe culture

A tool to evaluate, plan, reevaluate patient safety programs;A tool to evaluate, plan, reevaluate patient safety programs; Small rural hospitals require support to use it effectivelySmall rural hospitals require support to use it effectively

Nieva, Sorra. (2003). Safety culture assessment: a tool for improving patient safety in healthcare organizations. Qual Saf Health Care, 12(Suppl II), ii17-ii23.

Jones, Skinner, Xu, Sun, Mueller. The AHRQ Hospital Survey on Patient Safety Culture: a tool to plan and evaluate patient safety programs. In Henriksen et al., Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 2. Culture and Redesign . AHRQ Publication No. 08-0034-1. Rockville, MD: Agency for Healthcare Research and Quality; August 2008.

18

Benchmark HSOPS Graph of Benchmark HSOPS Graph of Aggregate Hospital ResultsAggregate Hospital Results

Comparison of Positive Composite Survey Results to Peer Group Minimum and Maximum

0%

10%

20%

30%

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50%

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Min for 24 CAHs Your Hospital Max for 24 CAHs

19

Comparison of Positive Hospital Composite Survey Results to Nurse and Non-Nurse Results

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Your Hospital Nurses Non-Nurses

HSOPS Graph Comparing Nurse HSOPS Graph Comparing Nurse to Aggregate Hospital Resultsto Aggregate Hospital Results

20

Benchmark HSOPS Graph of Benchmark HSOPS Graph of Aggregate Results 2005 and 2007Aggregate Results 2005 and 2007

Safety Culture Survey CompositeDundy County Hospital

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Hospital2005

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Max Positive Responsefor 26 CAHs (2007)

21

Interactions Between ComponentsInteractions Between ComponentsHSOPS Items: Nurses at Dundy County Hospital 2005 and 2007

%+

05

%+

07

Effective Practices

Outcome: Our procedures, systems are good at preventing errors.

31% 3% High Reliability Organization

Learning: We are given feedback about changes put into place based on event reports.

44% 72% QI, RCA, Leadership WalkroundsTM, Safety Briefings

Flexible: Staff feel free to question the decisions and actions of those with more authority.

13% 50% Structured Communication skills: SBAR, CUS, DESC

Just: When an event is reported, it feels like the person is being reported and not the problem.

31% 50% Education about human error, Unsafe Acts Algorithm

Reporting: When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported.

25% 65% Systematic reporting system using standard taxonomies

Known medicalcondition?

NO NO NO YES

NOYES

YES

YES

YESNO

YES

YES

NOYES

YESNO

Adapted from James Reason. (1997). Managing the Risks of Organizational Accidents.

Culpable Gray Area Blameless

NO

Were the actions as intended?

Evidence of illness or substance use?

Knowingly violated safe procedures?

Pass substitutiontest? (Could someone else have done the same thing)?

History of unsafe acts?

Were the consequencesas intended?

Were proceduresavailable, workable, intelligible, correct and routinely used?

Deficiencies in training, selection, or inexperienced?

Substance abusewithout mitigation

Sabotage, malevolent damage

Substance usewith mitigation

Possible recklessviolation

System inducedviolation

Possible negligentbehavior

System inducederror

Blameless error, corrective training, counseling indicated

Blameless error

NO

Culpable Gray Area Blameless

NO

Were the actions as intended?

Evidence of illness or substance use?

Knowingly violated safe procedures?

Pass substitutiontest? (Could someone else have done the same thing)?

History of unsafe acts?

Were the consequencesas intended?

Were proceduresavailable, workable, intelligible, correct and routinely used?

Deficiencies in training, selection, or inexperienced?

Substance abusewithout mitigation

Sabotage, malevolent damage

Substance usewith mitigation

Possible recklessviolation

System inducedviolation

Possible negligentbehavior

System inducederror

Blameless error, corrective training, counseling indicated

Blameless error

NO

Execute Just Culture . . . UNSAFE ACTS ALGORITHMwww.unmc.edu/rural/patient-safety click on Just Culture

23

Phase Three: Integrating Team Training Phase Three: Integrating Team Training in an Effective Patient Safety Systemin an Effective Patient Safety System

Third action research cycle Third action research cycle 1.1. Knowledge that a culture of safety in high reliability organizations is engineered from Knowledge that a culture of safety in high reliability organizations is engineered from

interacting practices of the four components of culture within microsystems (units/positions)interacting practices of the four components of culture within microsystems (units/positions)2.2. HSOPS results indicated the need for training in teamwork and communication.HSOPS results indicated the need for training in teamwork and communication.3.3. We conducted the train the trainer course in 25 CAHs in April 2008; will add 7 more in 2009We conducted the train the trainer course in 25 CAHs in April 2008; will add 7 more in 20094.4. We are building a community of TeamSTEPPS coaches/trainers across the stateWe are building a community of TeamSTEPPS coaches/trainers across the state5.5. We will reassess safety culture in 25 CAHs in March 2009We will reassess safety culture in 25 CAHs in March 2009

1. Knowledge that a culture of safety isengineered from interacting practices

2. Tool: TeamSTEPPSTM

5. Monitor Progress: Reassess change in cultureMarch 2009

4. Building Infrastructure: Creating a rural TeamSTEPPS community

3. Achieving Broader Adoption: Train the trainer in 25 CAHs

24

HSOPS Identifies Readiness HSOPS Identifies Readiness for Teamwork Training for Teamwork Training

TeamSTEPPS TeamSTEPPS training must be training must be supported by supported by systematic error systematic error reporting, just reporting, just culture practices, culture practices, and use of learning and use of learning tools such as tools such as individual and individual and aggregate RCA, aggregate RCA, Leadership Leadership WalkRounds, and WalkRounds, and Safety BriefingsSafety Briefings

25

SENSEMAKING

TRUST

Conclusion:Infrastructure for Effective Practices

Interaction between effective practices results in sensemaking within macro- and microsystems of careSensemaking requires data, which is interpreted within the context of the lived experiences of those in direct contact with patientsSensemaking can not occur without data from reporting, trust and teamwork

“Once the AHRQ survey identified areas for improvement, through the grant, we spent the next year working on those areas. The education and training on teamwork, communication, and RCA gave us tools we hadn’t heard of. We have seen our organization change from one that makes the same errors over and over to one that analyzes errors and attempts to learn from them.”

Infrastructure: Lessons Learned Infrastructure: Lessons Learned from from

Dundy County, NebraskaDundy County, Nebraska

27

Rural Adaptation of HSOPSRural Adaptation of HSOPS

Original HSOPS designed for large urban Original HSOPS designed for large urban hospitalshospitals 14 different work areas14 different work areas 14 different staff positions14 different staff positions Sort by work area or position if Sort by work area or position if >> 11 11

Rural-adapted HSOPS for hospitals with Rural-adapted HSOPS for hospitals with << 50 50 bedsbeds 12 different work areas - 12 different work areas - 12% choose “other”12% choose “other”

Collapsed multiple departments to Acute/Skilled Care Collapsed multiple departments to Acute/Skilled Care Added Long-term care, Home Health Care, TherapiesAdded Long-term care, Home Health Care, Therapies

6 different job titles - 6 different job titles - 8% choose “other”8% choose “other” Sort by work area or job title if Sort by work area or job title if >> 5 5

1/3 in national database choose “other”

28

Original AHRQ HSOPS Work Area Demographics

Rural-Adapted HSOPS Work Area Demographics

2008 Comparative Database Report: 33% of 160,196 respondents choose “other”

UNMC CAH Comparative Database: 12% of 4,117 respondents choose “other”

Rural Adaptation of HSOPSRural Adaptation of HSOPS

29

2008 Comparative Database Report: 22% of 160,196 respondents choose “other”

UNMC CAH Comparative Database: 8% of 4,117 respondents choose “other”

Original AHRQ HSOPS Staff Position Demographics

Rural-Adapted HSOPS Staff Position Demographics

Rural Adaptation of HSOPSRural Adaptation of HSOPS

30

Where can I get the HSOPS?Where can I get the HSOPS? Original HSOPS From the AHRQ websiteOriginal HSOPS From the AHRQ website

http://www.ahrq.gov/qual/hospculture/ http://www.ahrq.gov/qual/hospculture/ Click on Hospital Survey Toolkit Click on Hospital Survey Toolkit

Rural-adapted version for CAHs with 25 or fewer beds Rural-adapted version for CAHs with 25 or fewer beds from UNMC web site (see our poster in the from UNMC web site (see our poster in the mmAHRQAHRQet et Place CaféPlace Café ) )

http://www.unmc.edu/rural/patient-safety http://www.unmc.edu/rural/patient-safety Click on Click on Hospital Survey on Patient Safety Culture ResourcesHospital Survey on Patient Safety Culture Resources

Contact informationContact informationKatherine Jones, PT, PhDKatherine Jones, PT, PhD Anne Skinner, RHIAAnne Skinner, RHIAkjonesj@unmc.edukjonesj@unmc.edu askinner@unmc.edu askinner@unmc.edu

31

Contact InformationContact Information

Katherine Jones, PhD, PTKatherine Jones, PhD, PTkjonesj@unmc.edukjonesj@unmc.edu

Anne SkinnerAnne Skinneraskinner@unmc.edu askinner@unmc.edu

Web site where tools are posted Web site where tools are posted www.unmc.edu/rural/patient-safetywww.unmc.edu/rural/patient-safety

Supported by AHRQ Grant 1 U18 HS015822National Rural Health AssociationNebraska Department of HHS