Featured Speaker:
Sara J. Singer, MBA
Doctoral Fellow
Harvard University PhD Program in Health Policy
Boston, Massachusetts
Leveraging Front-line Expertise
(LFLE): A research-based intervention
to improve patient safety culture
October 25, 2006
Improving Safety Culture and Outcomes in
Health Care Research Team &
24 Participating Hospitals
Research support was provided by the Agency for Healthcare Research and
Quality and Wharton’s Fishman Davidson Center
Overview
1. Theory behind the intervention
2. Brief description of the intervention
3. Preliminary results from the
intervention
4. Intervention evaluation
Theory
Safety at Work
 Despite hazardous work environments,
some organizations have High Reliability
(consistently error-free) (Roberts 1990)
 Key Findings:
 Senior managers’ support is essential
(Alcoa…Southwest…Aircraft carriers)
 HROs focus on process reliability rather than
efficiency (Roberts 1990)
 Employees need sufficient training, motivation,
and staffing (Srivastava 1986)
 These factors are considered important
elements of “SAFETY CLIMATE”
Prior research
Measuring Safety Climate
 An important measure is the difference
between perceptions of senior managers’
and frontline employees’ (FLE)
 Senior managers’ perceptions are consistently
more positive than those of FLE (Singer et al.,
2003,2006)
 FLE perceptions better predict safety
performance (Singer et al., 2006)
 Senior managers might fail to allocate necessary
resources to improve systems (Auty & Long
1999, MacDuffie 1997)
 Improving systems often requires managerial
intervention (Tushman 1997, Tucker 2004)
The LFLE Intervention
 Systematic process to engage senior
managers with the front-lines of care
 Worksite observations: Seeing the work
environment first-hand, talking with front-line
staff in context—all with a patient safety lens
 Safety forums: Unit-based, on-site, multidisciplinary open-communication forums
designed to gather patient safety “helps and
hinderers” from front-line staff
 Debrief meetings: Interdisciplinary/ multi-level
teams organize, prioritize, and take
responsibility for safety issues identified from
worksite observations and safety forums
LFLE process and its purpose
Worksite observations
Understand context
Safety town forums
Gather wider feedback
Debrief meetings
Organize information, select items for resolution, assign responsibility
Promote follow-up
Communicate with unit
Communicate outcome of visits and meetings to unit staff
Set expectations, promote understanding
Focus on one area for 3-months,
through multiple perspectives
Month
1. Nov 05
2. Dec 05
3. Jan 05
4. Feb 05
5. Mar 06
6. Apr 06
7. May 06
8. Jun 06
9. Jul 06
10. Aug 06
Process of
Interest
Teleconference
training session
Emergency
Department:
Patient flow
Senior
Leader A
Senior
Leader B
Emergency
Perspective of
Department
Emergency
(perspective of Physician
nurse)
Safety Forum
Emergency Dept
Follow up on issues raised from Emergency Dept
Communicate results to ED staff
OR:
Operating
OR Surgeon
Communication/ Room Nurse
Perspective
teamwork
perspective
Town Meeting
OR/ PACU
Follow up on issues raised from OR/ PACU
ICU
Pharmacy
Maintenance of
(focus on ICU
equipment or
orders –
Respiratory
delivery)
Therapy
Town Meeting
ICU Departments
Follow up on issues raised from ICU
Senior
Leader C
Senior
Leader D
Pharmacy
(focus on
orders from
ED)
Laboratory
(focus on
orders
from ED)
PACU Nurse
perspective
Transfer of
patient to
unit
ICU physician
ICU Nurse
Hospital Participation
 32 out of the 92 survey hospitals
were randomly selected to participate
 8 declined to participate
 1 dropped out and was replaced
 Distributed by size and region, similar
to overall hospital sample
Preliminary assessment
 Intervention hospitals varied widely
 Commitment of hospitals based on their
senior managers’ early participation and
preparedness for the intervention
 Capabilities of hospitals based on their
current use of senior managers’ rounds,
forms style meetings, and related processes
 Assessment suggested most had similar
potential for a successful implementation
Preliminary Findings
 1,124 hinderers from the 24 hospitals
 183 worksite observations
 49 safety forums
 Two-thirds of all observations/forums were
in four units:
 ER/ED (26%)
 OR/PACU/Surgery (17%)
 Med-Surg ward (15%)
 ICU (10%)
Hinderers by unit
Dept.
#
Examples
ER/ED
380
Lengthy triage and registration process
Arm banding and use of 2 patient IDs
Verbal orders
Patients in hallways waiting for rooms
Slow response time for labs (imaging, rad)
Security on nights and weekends
ICU
212
Information relayed at transfer incomplete
Interruptions from external phone calls
Access to medications/Pyxis & pharma hours
OR/PACU/
206
Peri/Pre-OP/
Surgery
Keeping surgical equipment in working order
Med-Surg/ 148
Inpatient
Locating equip/supplies (wheelchairs, pumps)
Bariatric patients (OR table unsafe,
equipment not readily available, procedure)
Unlocked medication carts
Preliminary Analysis of ED Hinderers
Number/% ED
Equipment/
Supplies/Facility
Staff/Policy &
Procedures
Communication/
Documentation
Medication/
Pharmacy
Security
133
(35%)
113
(30%)
75
(20%)
33
(9%)
26
(7%)
Example
Ran out of O2 tanks
and regulators; these
go up with patients and
don't come back down
Lack of handwashing
between patients
Continued use of “Do
Not Use Abbreviations”
Dosages in wrong slots
in PYXIS (.2 in .4 slot)
Focus on nights &
weekends
Framework adapted from Frankel, A., et al. 2005.
Sample resolution for hinderers
Incoming phone traffic
overloads the staff–
Hospital 105
a) Switchboard supervisor helped
solve: calls sorted and sent to correct
department on the first transfer.
b) Voicemail in triage for non-urgent
communications and to pick up calls
when triage nurse is busy.
c) Charge nurse has cell phone and
uses for communicating with EMS,
bed placement, and Dr’s offices. A
‘blast fax’ is being sent to inform
community physicians.
All in-patients and out-patients’
names appear on the Pyxis
screen. According to the two
nurses, most of ED’s med
errors are wrong patient –
Hospital 47
Suggestion: Change program so that
only the patients in that dept appear
on the Pyxis screen
Wheelchair had no IV pole,
staff had no place to hang IV –
Hospital 88
Purchasing at least two IV poles for
wheelchairs, one each for ER and
Inpatient Unit
Benefit of seeing in context
 "I don't think the automatic door
would have been fixed without the
intervention. It was a small issue—
although an important one—so it
probably would have been overlooked
without the intervention. By having
senior administrators looking at the
problem, there was recognition of the
need to fix it.“ -VP of Nursing, Hospital 39.
Data from evaluation interview
18/24 evaluations reported
Were
Valuable?
Plan to
Continue?
Average
Number
(1 strongly
disagree: 5
strongly agree)
(1 strongly
disagree: 5
strongly agree)
Worksite
observations
4.6
3.8
Range: 2-61 visits
Median: 9 visits
Safety
forums
4.4
3.5
Range: 0-9 mtgs
Median: 3 mtgs
Attendance: 0-50
Median: 11 people
Debrief
meetings
4.2
N/A
N/A
Reported follow-up communication
 89% of the hospitals reported that staff
received or sometimes received follow-up
communication to issues raised
Form of communication
%
Hospital-wide verbal
Hospital-wide written
Unit-wide verbal
Unit-wide written
22%
28%
67%
56%
Obstacles to successful
implementation
 “Competing priorities” was cited as the
primary obstacle to resolving hinderers
(72%) and providing follow-up
communication (44%)
 Other impediments to resolving issues
raised by staff included:




Financial constraints (56%)
Long lead time, requiring budget request (44%)
Limited manpower/staff (33%)
Not enough time (33%)
Lessons learned
 Maintain flexibility in substituting people to do the
visits (i.e. if one senior manager has to cancel, the
visit continues with another person filling in)
 A clinical perspective helped non-clinician senior
managers make the most of worksite visits
 Benefit of middle managers’ participation & pre-work
 Brief unit staff in advance
 Use to focus senior manager attention on key issues
 Promotes agreement on priorities
 Problem resolution and communication required time
and attention, but these were difficult to maintain
Next Steps
Evaluating the Intervention
 We hypothesize that the data will show


Improvement in safety culture survey results over time
relative to non-intervention hospitals
Greater reduction in difference between responses of front
line employees & senior managers
 Positive changes towards improving safety
 Hospital interest in adoption and continuation of
intervention


“I think we cared about safety before, but we needed
something to focus us down on what to do to achieve it.
That’s what the Stanford intervention did. We’ll continue it.
From now on, it will be part of what we do.” CEO
“[The senior managers] were really hesitant to start the
town meetings, particularly, but once they got into it they
were like this is the greatest thing since sliced bread. They
really are into this.” Liaison