Instructional Slide:
How To Use This Template Presentation
This template PPT presentation is intended to illustrate some of the ways the NYSPFP
culture of safety survey report can be used to present your hospitals data to
leadership within your hospital.
The PPT can be adapted for use in the following ways:
1. Hospital-specific data should be inserted into this PPT template where noted
with an X or annotated in the notes for the slide.
2. Hospitals should insert data from their 2013 Culture of Safety Survey Hospital
Specific Results to slides 9–15. This data can be accessed on the NYSPFP Web
site: https://www.nyspfp.org/Members/myData.aspx under the heading,
“Building Culture and Leadership.” Note that the charts and commentary
provided in the slides that follow are for illustrative purposes only and refer to a
report created for a fictional hospital.
NYSPFP encourages hospitals to adapt this PPT to the their hospital-specific needs
related to the AHRQ safety culture dimensions.
Please contact your NYSPFP Project Manager if you have any questions.
Thank you.
Hospital Re-Survey on Patient
Safety Culture
St. Elsewhere Hospital
January 2014
Background
• The AHRQ Culture of Safety (CoS) survey examines dimensions of
organizations’ culture of patient safety to assist in identifying
strengths and areas for patient safety culture improvement, as well
as to evaluate the impact of patient safety initiatives and
interventions on hospital safety culture.
• This is the second administration of the survey through NYSPFP; the
first was administered to XXX respondents between March-May,
2012.
• The most current survey was administered to XXX respondents in
September-October, 2013.
• Comparing results from both surveys allows us to measure the
differences in scores, and identify priority focus areas.
CoS Survey Measures
•
The CoS survey is designed to measure four patient safety “outcomes”:
1.
2.
3.
4.
•
Overall perceptions of safety
Frequency of events reported
Number of events reported
Overall patient safety grade
The CoS also measures ten dimensions of culture pertaining to patient
safety:
1. Teamwork within and across units
6. Communication openness
2. Organizational learning-continuous
improvement
7. Feedback and communication about
error
3. Staffing
8. Frequency of events reported
4. Non-punitive response to error
9. Hospital management support for
patient safety
5. Supervisor expectations and actions
promoting safety
10. Hospital handoffs and transitions
4
High-Level Overview
• HOSPITAL performed the second
administration of the AHRQ CoS survey, as a
participant in the NYS Partnership for Patients
(NYSPFP) on 09/09/2013 through 10/04/2013.
• X% increase/decrease in response rate to CoS
Survey
• X% increase/decrease in staff rating the
overall safety as excellent at HOSPITAL
CoS Respondent Demographics
• In this report, data are available for X staff
positions
• Staff who worked for X years at HOSPITAL were
most likely to respond (X% of responses)
2013
2012
Respondent Demographics
X%
X%
Worked directly with patients
X%
X%
Patient Care assistants
X%
X%
Registered Nurses
X%
X%
Unit Clerks
X%
X%
Physicians
Overview of NYSPFP CoS Re-Survey Results
65%
Of hospitals conducted the survey out of 172 participating
NYSPFP hospitals
52%
Average AHRQ CoS Survey Response Rate
X%
HOSPITAL’S Response rate (N = X responses)
X%
HOSPITAL’S staff rating overall safety grade as “Excellent” in
2013 compared to X% in 2012
Dashboard View CoS Survey Results:
Overall Safety Grade Assigned by Staff
2013
2012 Grade (All respondents)
X%
X% Excellent
X%
X% Very Good
X%
X% Acceptable
X%
X% Poor
X%
X% Failing
Overview of Composite Statistics
Composite Statistics of Overall Hospital Safety Measurements
Spring 2012
Fall 2013
2013 NYSPFP Mean
2012 National Mean
2013 NYSPFP target based on 90th percentile
100%
90%
80%
Overall Score
70%
60%
50%
40%
77%
71%
62%
30%
59%
48%
20%
36%
10%
0%
Hospital Management Support For Patient Safety
Teamwork Across Hospital Units
Composite Hospital Safety Measurements
Hospital Handoffs & Transitions
Dashboard View CoS:
Safety Measurement for Work Areas
Composite Statistics of Safety Measurements for Work Areas/Units
Sample Hospital
2013 NYSPFP Mean
2012 National Mean
2013 NYSPFP target based on 90th percentile
100%
90%
80%
60%
50%
96%
95%
40%
74%
58%
56%
50%
50%
4
30%
69%
66%
Nonpunitive
Response to
Error
20%
Teamwork
within units
Organizational
Learning Continuous
Improvement
3
Overall
Perceptions
of Safety
2
0%
Staffing
5
10%
1
Overall Score
70%
Supervisor
Expectations
& Actions
Promoting
Safety
Communication
Feedback and
Openness
Communications
About Error
Composite Work Area Safety Measurements
Frequency
of Events
Reported
Greatest Increase in Scores by
Dimension
% Increase from
2012
NYSPFP Percentile
Supervisor expectations
and actions promoting
safety
X%
> Xth percentile
Overall perception of
safety
X%
< Xth percentile
Hospital management
support for patient
safety
X%
Between X – Xth
percentile
Greatest Decrease in Scores by
Dimension
% Decrease from
2012
NYSPFP Percentile
for 2013
Hospital Hand-offs and
Transitions
X%
At Xth percentile
Staffing
X%
Between Xth –
Xthpercentile
Frequency of events
reported
X%
< Xth percentile
Areas of Strength
Domain
2013 scores compared to 2012
Supervisor expectations and actions
promoting safety
X% Increase/Improvement
(also one of the most improved areas)
Teamwork within units
X% Increase
Non-punitive response to error
X% Increase
All dimensions at or above NYSPFP 90th
percentile and national mean
Areas for Improvement
Domain
2013 scores compared to 2012
Frequency of events reported
X% Decrease
Overall perception of safety
X% Improvement
Organizational Learning – continuous
improvement
Unchanged (X%)
All dimensions at or below the NYSPFP 25th
percentile and national mean
Summary of Priority Action Items
• Domains of Focus:
– Frequency of events reported
– Overall perception of safety
– Handoffs
– Staffing
Suggested Next Steps
•
Phase 1: 1-3 months
– Disseminate results to department and unit managers
– Share results with staff through “town hall” meetings and solicit staff
suggestions on improvements
– Hold focused groups to explore root causes, analyze differences between
units/departments or staff position to determine opportunities to strengthen
systems
•
Phase 2: 3-6 months
– Develop hospital and departmental strategic action plans based on above.
– Examples of targeted interventions:
• Standardize hand-off processes, including rolling-out training on
TeamSTEPPS principles such as SBAR or I PASS THE BATON
• Improve event reporting system(s): is system easy to access, user-friendly,
does staff receive feedback routinely?
• Implement strategies to further promote patient safety and performance
improvement
•
Phase 3: 6-18 months
– Re-survey