Interpreting Safety Culture Survey
Results and Action Planning
Katherine Jones, PT, PhD
Anne Skinner, RHIA
June 17, 2011
HSOPS
Acronyms
AHRQ = Agency for Healthcare Research and Quality
HRO = High Reliability Organization
HSOPS = Hospital Survey on Patient Safety Culture
2
Objectives
1.
Define “culture of patient safety” (safety culture)
2.
Identify four components of safety culture
3.
Use tools and reports from survey results to:
HSOPS
1.
Identify change over time associated with patient safety
interventions and benchmark results to the national database
2.
Identify variation in safety culture by work area and job title in
HSOPS results
3.
Compare beliefs and behaviors within HSOPS dimensions to
identify practices needed to support safety culture
4.
Describe key practices that support safety culture
5.
Recognize potential for response shift bias among when evaluating
impact of patient safety interventions
6.
Recognize role of leadership in engineering culture change
7.
Develop an action plan to engineer key practices that support
safety culture
HSOPS
The Problem and Challenge…
“The problem is not bad people; the
problem is that the system needs to be
made safer . . .”
IOM (2000). To Err is Human: Building a Safer Health System
“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.”
IOM (2001). Crossing the Quality Chasm: A New Health System for
the 21st Century, p. 79
Chain of Impact at the Point of Care
Healthcare System
Structures & Processes
Organizational
Structures & Processes
Beliefs -- Culture – Behaviors
Individual Provider
Structures & Processes
Interpersonal
Care
Quality at Point of Care
Technical
Care
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 is a lens
through which organizations support providers at the point of care.
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.
5
HSOPS
What did you measure with HSOPS?
 Enduring, shared, LEARNED* beliefs and behaviors
that reflect an organization’s willingness to learn from
errors**
 Four 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

People who work in teams make fewer errors
*Schein, E. Organizational Culture and Leadership. 4th ed. San Francisco, CA:
John Wiley & Sons; 2010.
**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.
HSOPS
Beliefs Assessed with HSOPS
 Our processes are designed to prevent failure

“Our procedures and systems are good at preventing errors from
happening.”—national db 62% - 82%*
 We are committed to detect and learn from error


“When a mistake is made, but is caught and corrected before affecting the
patient, how often is this reported?”— national db 44% - 67%*
“Mistakes have led to positive changes here.”— national db 54% - 74%*
 We have a just culture—discipline is based upon risk taking

“Staff worry that mistakes they make are kept in their personnel file.”R—
national db 25% - 47%*
 People who work in teams make fewer errors


“People support one another in this department.” – national db79% - 92%
“When one area in this department gets really busy, others help out.”—
national db 59% - 78%*
*10th%ile and 90th%ile for 1032 hospitals reporting to AHRQ 2011
national comparative database
HSOPS
Three Levels
of Culture Behaviors
Beliefs &
Values
“…in many
organizations, values
reflect desired
behavior but are not
reflected in
observed behavior.”
Underlying
Assumptions
Schein, E.H. Organizational Leadership and Culture 4th ed. San Francisco:
8
John Wiley & Sons; 2010, p.24, 27.
HSOPS
Goals of Culture Assessment…why
did you measure safety culture?
 Identify areas of culture in need of improvement
 Increase awareness of patient safety concepts
 Evaluate effectiveness of patient safety interventions
over time
 Conduct internal and external benchmarking,
 Meet regulatory requirements
 Identify discrepancies between beliefs and observed
behaviors within subcultures and microcultures
Nieva, Sorra. (2003). Safety culture assessment: a tool for improving patient safety in healthcare
organizations. Qual Saf Health Care, 12(Suppl II), ii17-ii23.
9
HSOPS
Regulatory Requirement
Conduct HSOPS to meet Joint Commission
Leadership Standards (Standard LD.03.01.01)
http://www.jointcommission.org/NR/rdonlyres/D53206E8D42B-416B-B887-491B6D5AA163/0/HAP_LD.pdf
 Leaders regularly evaluate the culture of safety and
quality using valid and reliable tools
 Leaders prioritize and implement changes identified by
the evaluation
HSOPS
Four Components of Safety Culture
A culture of
safety is
informed. It
never forgets
to be afraid…
Reason, J. (1997). Managing the
Risks of Organizational Accidents.
Hampshire, England: Ashgate
Publishing Limited.
Battles et al. (2006). Sensemaking
of patient safety risks and hazards.
HSR, 41(4 Pt 2), 1555-1575.
11
S
E
N
S
E
= Flexible
M
T
A
R
K
U
I
S
N
INDIVIDUALS FEEL VALUED
T
G INDIVIDUALS ARE TREATED WITH RESPECT
HSOPS
How to Become an HRO: Engage in
Continuous Improvement
Measure
Beliefs
and
Behaviors
Implement
Practices
Action
Plan
HSOPS
Measure Beliefs and Behaviors with HSOPS
 Developed by AHRQ to provide healthcare organizations
with a valid tool to assess safety culture
http://www.ahrq.gov/qual/hospculture/
 42 items categorized in 12 dimensions

2 dimensions are outcome measures at dept/unit level

7 dimensions measure culture at dept/unit level

3 dimensions measure culture at hospital level
 2 additional items are outcome measures at dept/unit level

Number of Events Reported

Patient Safety Grade
HSOPS
HSOPS
 Original AHRQ Survey available
http://www.ahrq.gov/qual/patientsafetyculture/
 AHRQ Comparative Database for HSOPS

2011 Comparative Database for Benchmarking

1032 hospitals; 472,397 respondents

Stratis will submit your results to database

Report comparing your hospital to national data

Trending hospitals asked to describe
interventions
14
UNMC Rural HSOPS
HSOPS
 Available at www.unmc.edu/rural/patient-safety
 Developed by UNMC as part of AHRQ Partnerships
in Implementing Patient Safety Grant 05 -07
 Collapses work areas and position to reflect CAH
environment
 Allows sorting by Work Area/Position if > 5
respondents
 Creates valid benchmark data for CAHs
 Allows valid tracking of safety culture over time
within a CAH to evaluate patient safety interventions
 10 additional items added by UNMC to evaluate
TeamSTEPPS
15
Original AHRQ HSOPS
32%
Rural-Adapted AHRQ HSOPS
3.3%
16
Original AHRQ HSOPS
21%
Rural-Adapted AHRQ HSOPS
3.2%
Reason’s Components
Reporting Culture - a safe
organization is dependent on the
willingness of front-line workers to
report their errors and near-misses
Just Culture - management will
support and reward reporting;
discipline occurs based on risktaking
O = Outcome measure
U = Measured at level of unit/department
H = Measured at level of hospital
HSOPS Dimensions or
Outcome Measures
•Frequency of Events
Reported (O)
•Number of Events
Reported (O)
•Nonpunitive Response
to Error (U)
Reason’s Components
HSOPS Dimensions or
Outcome Measures
Flexible Culture - authority
patterns relax when safety
information is exchanged
because those with authority
respect the knowledge of
front-line workers
•Teamwork w/in Units (U)
•Staffing (U)
•Communication Openness (U)
•Teamwork ax Units (H)
•Hospital Handoffs (H)
•Hospital Mgt Support (H)
Learning Culture organization will analyze
reported information and then
implement appropriate
change
•Manager Actions (U)
•Feedback & Communication (U)
•Organizational Learning (U)
•Overall Perceptions (O)
•Patient Safety Grade (O)
HSOPS
Your Results
Resource
Purpose
Reports from
Excel Tool
ANALYSIS - Contains raw data
Generates spreadsheet to upload for national database
Instructions for interpretation
Demographics of respondents
Contains dimension and item level results in the aggregate, by
department, position, direct patient care, action planning sheet
Benchmark Tool
COMMUNICATION
Compare aggregate results to peer group (external benchmark)
Compare aggregate results over time
Compare results by work area and job title to the aggregate
Item Level Over
Time
COMPARISONS AND COMMUNICATION
Compare item level results over time and to peer group
Includes responses to teamwork questions
Comments
Coded by
Theme
CONTEXT
Open ended comments coded by culture-related themes
Provides respondents’ direct feedback
Action Plan
PLAN - Work sheet to anchor action plan in history, mission and
strategic goals; identify practices needed to support safe culture
HSOPS
Action Planning: What is needed
 Principle-drive NOT event-driven
 Planned approach NOT piecemeal
 Proactive NOT reactive
 Understand latent conditions

Anticipate the next error
 Focus on performance/behavior
Reason, J. (1997). Managing the Risks of Organizational Accidents.
Hampshire, England: Ashgate Publishing Limited.
Schein, E.H. Organizational Leadership and Culture 4th ed. San Francisco:
John Wiley & Sons; 2010.
HSOPS
Interpreting Results to Develop an Action Plan
 Anchor plan in history, mission, strategic goals
 Understand response rate (> 60% best)…are
results generalizable?
 Identify organization-wide areas

In need of improvement

Improved due to specific interventions
 Wrap your mind around reverse worded items
 Identify gaps between beliefs and behaviors
within 4 components
HSOPS
Interpreting Results to Develop an Action Plan
 Identify variation in microcultures by work area/job
title
 Relate open-ended comments to results
 Recognize potential for response shift bias in
repeat reassessments
 Consider how management uses information
 Explicit plan to strengthen 4 components within
depts by implementing specific practices that close
the gap between beliefs and behaviors
 Communicate results and plan
24
25
HSOPS
Lowest Scores
Handoffs and Transitions (35%)
Teamwork Ax Depts (40%)
Nonpunitive Response (45%)
Significant Changes
Feedback & Communication
about Error (+13%)
Teamwork W/in Units (+10%)
Overall Perceptions (+7%)
Teamwork Ax Units (-5%
Handoffs & Transitions (-5%)
ORGANIZATION WIDE AREAS
IN NEED OF IMPROVEMENT
HSOPS
REVERSE WORDED ITEMS
GAPS BETWEEN BELIEFS &
BEHAVIORS
Percent Positive 2011 HSOPS Database
(n=1032 Hospitals)
http://www.ahrq.gov/qual/hospsurvey11/hospsurv111.pdf
Gaps Between Beliefs & Behaviors
Reporting
Culture
Percent Positive 2011 HSOPS Database
(n=1032
Hospitals)
Just Culture
http://www.ahrq.gov/qual/hospsurvey11/hospsurv111.pdf
Teamwork Culture
Teamwork Culture
http://www.ahrq.gov/qual/hospsurvey11/hospsurv111.pdf
Learning Culture
Handoffs & Transitions
Surgery/OR (n=5)
Teamwork Across Units
Management Support for
Patient Safety
Acute/Skilled Care (n=21)
Staffing
Nonpunitive Response to
Error
Feedback &
Communication About
Error
Communication
Openness
Sample Hospital 2010 (n=106)
Teamwork Within Units
Organizational Learning Cont Improvement
Manager Actions
Promoting Patient
Safety
Frequency of Events
Reported
Overall Perceptions of
Patient Safety
Hospital Survey on Patient Safety Culture Composite Positive Responses
Comparison by Work Area 1
ED (n=9)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Why are microcultures different?
• Quantity, relevance, timeliness of information available
differs due to leadership
• Methods of information sharing differ
– Personal
– Through standard channels
– Teams do whatever it takes to get the right information to the
right people at the right time
• These methods reveal what is important to leaders
– My personal power and glory (pathologic)
– Maintenance of positions, rules, turf (bureaucratic)
– Mission of organization (generative)
Westrum, R. A typology of organizational cultures. Quality and Safety in
Healthcare 2004;13:22-27.
33
Handoffs & Transitions
Teamwork Across Units
Management Support for
Patient Safety
Staffing
Nonpunitive Response to
Error
Feedback &
Communication About
Error
Communication Openness
Teamwork Within Units
Organizational Learning Cont Improvement
Manager Actions
Promoting Patient Safety
Frequency of Events
Reported
Overall Perceptions of
Patient Safety
Hospital Survey on Patient Safety Culture Composite Positive Responses
Comparison by Job Title
Sample Hospital 2010 (n=106)
Admin/Mgt (n=11)
Nurse (n=23)
100%
Allied Health (n=20)
Clinical Support Staff (n=11)
Non-Clinical Support Staff (n=33)
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Action Planning: A Reporting culture is
engineered by implementing practices
 Practices/Tools







Reporting Form
Near miss log
Chart audit
Secret Shopper
Safety Briefings
Leadership
WalkRoundsTM
Bulletin board/
suggestion
box/telephone
hotline
 Successful reporting
systems (Leape, 2002)

Nonpunitive

Confidential

Independent

Expert analysis

Timely

Systems-oriented

Responsive
HSOPS
Reporting Action Plan & Aims
We need to strengthen our REPORTING CULTURE because:
Just 1/3 of all respondents agreed that “near misses” are frequently
reported.
Comment: “There is a strong belief by some staff that errors are
recorded and held against staff….”
We can do this by:
(1) educating all employees about the role of near miss reporting—
learning about risks and hazards in systems without harming
patients; ( 2) implementing use of a “near miss” reporting log in all
departments; (3) including discussion of near misses at
departmental briefs (including sift change), huddles, and debriefs;
and (4) including discussions of near misses in regular Leadership
WalkRounds.
HSOPS
Action Planning: A Just culture is
engineered by implementing practices
Practices/Tools
 Understanding human error (Reason 2003, 2006)
 Active errors (sharp end)
 Latent errors
 Just Culture and behavior (Marx, 2001)
 Conduct: human error, negligence, reckless, intentional
rule violation
 Disciplinary decision-making: outcome-based, rulebased, risk-based
 Unsafe Acts Algorithm
 Disruptive Behavior Policy/Standards
Execute Just Culture . . . UNSAFE ACTS ALGORITHM
NO
Were the actions
as intended?
Evidence of illness
or substance use?
NO
Knowingly violated
safe procedures?
Pass substitution
test? (Could
someone else
have done the
same thing)?
NO
YES
History of
unsafe acts?
NO
YES
YES
Were the
consequences
as intended?
YES
Were procedures
available, workable,
intelligible, correct
and routinely used?
Known medical
condition?
NO
YES
NO
Deficiencies in
training, selection,
or inexperienced?
YES
Substance abuse
without mitigation
YES
NO
YES
Blameless
error
Blameless error,
corrective training,
counseling indicated
NO
System induced
violation
YES
NO
Possible reckless
violation
Sabotage,
malevolent damage
Culpable
Substance use
with mitigation
System induced
error
Possible negligent
behavior
Gray Area
Blameless
Adapted from James Reason. (1997). Managing the Risks of Organizational Accidents.
HSOPS
Just Culture Action Plan & Aims
We need to strengthen our JUST CULTURE because:
35% of all respondents DISagreed with the reverse-worded
statement, “Staff worry that mistakes they make are kept in their
personnel file.”
Comment: “There is a strong belief by some staff that errors are
recorded and held against staff….”
We can do this by:
(1) educating all staff about the impact of human error on patient
safety and the role of just and fair culture in patient safety program;
(2) implementing the use of the Unsafe Acts Algorithm by all
managers to transparently determine individual vs. system
accountability in adverse events.
Action Planning A Flexible culture is engineered by
implementing practices
“Could definitely use more TeamSTEPPS
training. Some questions difficult to answer.”
Team Strategies &
Tools to Enhance
Performance &
Patient Safety
http://teamstepps.ahrq.gov
“TeamSTEPPS has brought some very
positive changes in the hospital…we do
Huddle each morning before the hospital
Huddle..”
“TeamSTEPPS training has changed the way
I think about my job, and the communication
processes in my department.”
“TeamSTEPPS and Service Excellence is
working. Did create chaos for a short time.”
“I don't feel very comfortable with the
TeamSTEPPS program. It’s a great program;
we just haven't practiced using it enough to
make us comfortable with all the strategies or
tools.”
HSOPS
Flexible Action Plan & Aims
We improved/need to strengthen our FLEXIBLE (TeamworkOriented) CULTURE :
91% of acute/skilled respondents agree that they support one another;
71% help each other out when it gets busy
84% of all respondents agree they will speak up but only 53% will do so
to those with more authority
23% of all respondents DISagreed with the reverse-worded statement,
“Problems often occur in the exchange of information across hospital
units.”
We can continue to improve by: Ensuring consistent use of briefs,
huddles, debriefs and seeking/offering task assistance within
departments; use of the Two Challenge Rule and CUS to make it
psychologically safe for staff to speak up to those with more authority;
and use of structured communication during hand-offs and transitions
(SBAR, I PASS the BATON) across hospital departments.
Action Planning: Reporting, Just, and Flexible
practices support Learning
Ultimately, the
willingness of workers
to report depends on
their belief that the
organization will
analyze reported
information and then
implement appropriate
change—organizational
practices support a
learning culture.
Practices/Tools
 Individual RCA
 Aggregate RCA
 FMEA
 Safety Briefings
 Leadership
WalkRoundsTM
 Close the loop with
reporting…feedback
HSOPS
Learning Action Plan & Aims
We improved/need to strengthen our LEARNING CULTURE
61% of all respondents agree they are given feedback about
changes put into place based upon event reports
70% agree that “Mistakes have led to positive changes here.”
We can continue to improve by :(1) including front line staff in
retrospective (root cause analysis) and prospective (failure mode
and effect analysis) organizational learning, (2) conducting
Leadership WalkRounds focused on proactive discussion of risks
and hazards, (3) use of briefs, huddles, and debriefs in all
departments to integrate organizational learning into daily work.
Response Shift Bias
HSOPS
 Definition: tendency for an individual to overestimate
their knowledge, skills, and behaviors in a pretest
because their understanding of a concept is limited prior
to the program intervention.
 We have patient safety problems in this department.
(73% before TS “shift” to 67% after)
 (R)Problems often occur in the exchange of information
across hospital departments. (45% before TS “shift” to
36% after)
44
Conclusion: HSOPS Guides Implementation of
an Infrastructure for Patient Safety
Interaction between effective
practices results in sensemaking
Sensemaking requires data,
which is interpreted within the
context of the experiences of
those in direct contact with
patients*
Sensemaking can not occur
without data, trust and
teamwork
Leaders drive sensemaking
*Battles et al. (2006). Sensemaking of patient
safety risks and hazards. HSR, 41(4 Pt 2),
1555-1575.
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45
HSOPS
Shift Towards a Culture of Safety
Lessons Learned
HSOPS
Behaviors support an informed safe culture
 Measure safety culture using appropriate survey and
effective data collection methods
 Create an infrastructure that supports reporting
 Adhere to principles of just culture
 Implement team training to support a flexible culture
 Learn from error in the context of daily work (Safety
Briefings and Leadership WalkRounds)
 Teams must systematically learn from events using
individual RCA and aggregate RCA to learn from multiple
non-harmful errors
47
Lessons Learned
HSOPS
Leaders manage culture or it manages them….
 Create a compelling positive vision
 Define the change goal as solving a performance
problem…not “changing culture”
 Provide formal training in groups
 Ensure new behaviors lead to success, satisfaction

Provide opportunities for practice, coaching, feedback

Provide positive role models

Provide support groups for learning problems
 Create structures consistent with new way of
thinking/working/behaving
Schein, E.H. Organizational Leadership and Culture 4th ed. San
Francisco: John Wiley & Sons; 2010.
HSOPS
Diffusion of Innovations…
“Getting a new idea adopted, even
when it has obvious advantages, is
difficult. Many innovations require
a lengthy period of many years
from the time when they become
available to the time when they are
widely adopted.” – Rogers in
Diffusion of Innovations, p. 1
49
HSOPS
The Responsibility of Leadership
“Our systems are too complex to expect merely
extraordinary people to perform perfectly 100%
of the time. We as leaders have a responsibility
to put in place systems to support safe
practice.”
James Conway,
former VP and COO Dana Farber Cancer Institute
HSOPS
Contact Information
Katherine Jones, PT, PhD
kjonesj@unmc.edu
Anne Skinner
askinner@unmc.edu
Web site where tools are posted
www.unmc.edu/rural/patient-safety