No Slide Title

Report
Teamwork, Safety Culture,
and Patient Satisfaction
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Teamwork and Its Relation to
Patient Safety Culture,
Patient Experience &
Outcomes
TeamSTEPPS National Conference
Nashville, TN
June 21, 2012
Steve Hines, PhD, HRET
Joann Sorra, PhD, Westat
[email protected]
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Objectives
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Discuss teamwork, patient safety culture,
patient experience and patient safety and
quality measures
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Describe measure options
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Identify data collection and analysis
challenges & recommend strategies to
overcome these challenges
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Discuss how to use the data to improve
patient safety and quality
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90-minute Agenda
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Tag team approach
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Open Q&A after each section
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Small group discussion and reporting back
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Background/Introduction
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TeamSTEPPS and Measurement
• An impressionistic view of the landscape:
what happens in TS implementations?
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Why Measurement is So Challenging
• Implementation doesn’t work
• Focus is quality improvement, not
measurement
• Focus is often on stories, not data
• TS is part of broader effort to create a
safety culture
• Some changes don’t warrant collecting
data
• Compelling impact data is hard to produce
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Why Compelling Impact Data is Hard
• Clear agreement about outcomes TS
should be affecting is often lacking
• Links between improved teamwork and
ultimate outcomes are often not specified
TeamSTEPPS
TS
Readmission
Discharge planning
Huddles/Task assistance
Readmission
Fewer readmits
Improved pt
Increased medication
understanding
Compliance
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Why Compelling Impact Data is Hard
• Measurement of intermediate processes is
time consuming and challenging
• Data is hard to collect for extended period
• If measures aren’t believed, then value of
collecting them is small
• No surprise most TS implementations lack
strong proof of impact—even when they
really make one
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Measurement Options:
Unit or Task-Specific Options
Broader Measures of Culture &
Satisfaction
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Unit and Task Specific Measures
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What these are: assessments of micro-level
processes or outcomes directly linked to the
use of a part of TS on a specific task or in a
particular unit
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Characteristics:
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Sometimes created to assess TS
implementation
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Typically unique to specific hospital or unit
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Often linked to problem unit is trying to
overcome
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Relatively easy and quick to collect
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Can be perceptual or observational
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Unit and Task Specific Measures
• Why they’re useful:
 See whether TS tool is actually being used
 Forces leaders and staff to talk about
underlying causes of undesired outcomes
 See whether specific process causing
problems is changing
 Can be created by unit staff, which helps get
their buy-in and interest
 Provides evidence of progress useful for
sustaining implementation efforts
 Key element of PDSA cycles required in most
TS implementations
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Unit and Task Specific Measures
• Evaluating these measures
 Are they linked to specific TS tools being
introduced
 Is there agreement that the process or shortterm outcomes matter and should change
when TS is used?
 Can the data be collected and shared quickly
and efficiently (or existing data be used)?
 Will staff and leadership be excited when the
measure improves?
 Is there a good match between the scope of
the TS implementation and the universe of
activities being measured?
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SOPS, CAHPS & Outcome Measures
• AHRQ Surveys on Patient Safety Culture
 www.ahrq.gov/qual/patientsafetyculture
• Consumer Assessment of Healthcare
Providers and Systems (CAHPS)
 www.cahps.ahrq.gov
• Outcome measures
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What is Patient Safety Culture?
“The way we do things around here”
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Why Assess Patient Safety Culture?
• Raise staff awareness
• Diagnose & assess the status of patient
safety culture
• Identify strengths & areas for improvement
• Evaluate the impact of patient safety
initiatives
• Examine trends & track change over time
• Satisfy directives or regulatory
requirements
• Compare with other organizations
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AHRQ SOPS Surveys
• Assess provider & staff opinions about
patient safety culture in
 Hospitals (2004)
 Nursing homes (2008)
 Medical offices (2009)
 Retail pharmacies (Expected Summer 2012)
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HSOPS Patient Safety Culture Measures
1. Supervisor/manager expectations & actions promoting
patient safety
2. Organizational learning--continuous improvement
3. Teamwork within units
4. Communication openness
5. Staffing
6. Management support for patient safety
7. Teamwork across units
8. Handoffs & transitions
9. Feedback & communication about error
10. Nonpunitive response to error
11. Frequency of event reporting
12. Overall perceptions of patient safety
Number of events reported in past 12 months
Patient safety “grade” (Excellent to Poor)
HSOPS Composite Average
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What is Patient Experience?
Quality from the patient’s perspective”
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Aspects of care for which patients are the
best or only source of information
Communication
with providers
Access to care
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CAHPS Surveys
• Health Plan
• Clinician & Group
 12-Month Survey
 Patient-Centered Medical Home
 Visit Survey
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Surgical Care
American Indian
Dental Plan
Experience of Care & Health Outcomes (ECHO)
Home Health Care
Hospital
In-Center Hemodialysis
Nursing Home
• Supplemental Item Sets
 Children with Chronic Conditions, People with Mobility
Impairments, Cultural Competence, Health Information
Technology, Health Literacy
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Hospital CAHPS Measures
1. Communication with nurses
2. Communication with doctors
3. Communication about medicines
4. Responsiveness of hospital staff
5. Discharge information
6. Pain management
7. Hospital environment (clean & quiet)
8. Overall rating of hospital (0 worst to 10 best)
9. Willingness to recommend to family & friends
(Definitely no, Probably no, Probably yes, Definitely yes)
HCAHPS Composite Average
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Data Collection and
Analysis Challenges &
Recommended Strategies
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Criteria for Successful Measurement
• Will: Must believe it’s a priority
 Sometimes it’s not until it is
 Delaying measurement is risky, but so is
obsessing over measurement
• Thought: Must pick and plan carefully
 Understand how processes lead to outcomes
 Select measures aligned with how TS is being
used
 Make sure data can be collected and shared
 Be clear about short- and long-term
measurement plans
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Criteria for Successful Measurement
• People:
 Need someone who understands
measurement concepts & practicalities
 Need project leaders/champions supportive of
effort
 Don’t kill the data collector or they will kill your
project
• Systems:
 Can they be leveraged to get needed data
 If created, are they viable and do they avoid
redundancies
 Avoid overdesigning them
• Resources: Estimate them accurately
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HSOPS & HCAHPS Survey Modifications
• For comparison and benchmarking—don’t
modify standardized surveys
 Changes affect the comparability of your
results to other sites
• Adding questions to the HSOPS
 As a rule: Add new, custom questions to the
end of surveys (before background
demographics questions)
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HSOPS Survey Buy-in
• Obtain senior leadership buy-in from the
start
• Important, but challenging to engage
physicians in the survey
 Identify which physicians to include and which
“units” they should respond about
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Deciding Whom to Survey
• Who should be included?
 The goal is representativeness
• HSOPS
 Many hospitals administer the survey in-house
without a vendor
 All staff, or sample of all staff from all work
areas/unit (90% of hospitals)
• HCAHPS
 Certified vendors administer the patient
survey using strict guidelines
 http://www.hcahpsonline.org/qaguidelines.aspx
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Maximizing HSOPS Response
• Modes—Paper gets highest response:
 Web (66% of hospitals); 51% response rate
 Paper (21%); 61% response rate
 Web & Paper mixed (13%); 49% response rate
• Advance publicity & communication is
critical
• Visible leadership support needed through
newsletters, emails from the CEO/
President, and Department Managers
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Maximizing HSOPS Response
• For web surveys, need staff access to
computers with intranet/internet
• Monitor response statistics & report
department/unit response rates
• Multiple contacts and reminders in all
modes
• Consider incentives
 Raffles for gift cards, printable cafeteria meal
ticket upon web survey completion, ice cream
socials or pizza parties for units with 75%
response
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Frequency of HSOPS Administration
• Depends on purposes of the data
 To assess impact of an intervention?
 To get regular diagnosis/assessment of
patient safety culture?
• On average, hospitals administer the
HSOPS every 20 months
• Culture changes slowly
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Expected Levels of Change
• 650 trending hospitals in AHRQ
comparative database
 Ave increase of 1 percentage point (range of 0
to 2) on the composites from previous to most
recent administration
 Lots of variability within and across hospitals
• A 5 percentage-point difference is not easy
to achieve
 But is meaningful and oftentimes statistically
significant at the hospital level
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Data Analysis
• Goals are to identify strengths and areas for
improvement
• HCAHPS (% responding “Always” or giving
highest rating;“top box” scores)
• HSOPS (% positive response--Strongly
agree/Agree on positively worded items)
• Percentages are easier to understand;
better than averages (e.g.,4.3 out of 5)
 When conducting linkage analyses, can use
either % scores or mean scores
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HSOPS Data Analysis
• Excel Data Analysis and Reporting Tool
 Available via email at
[email protected].gov
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Drilling Down Into the HSOPS Data
• By staff position
• By work area/unit
 Unit-level results make the data more relevant
for staff
 Action planning and improvement initiatives
often done at unit level
• Rule of 5
 Do not report responses for groups with fewer
than 5 respondents
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Using the Data to Improve
Patient Safety and Quality
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Overview
• Data doesn’t change anything—but using
data can
• Keys to using it well:
 Making connections between data sources
that matter
 Linking measures you use to outcomes
everyone understands and cares about
 Embedding data into initial project planning
and midcourse project adjustments
 Communicating it with people that matter
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Linking HSOPS & HCAHPS
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The IOM has emphasized the importance
of both establishing a culture of safety &
delivering patient-centered care
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Thousands of hospitals administer these
surveys, so it is important to examine the
relationship between these measures
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To examine relationships at the hospital
level, you need data from a sufficient
number of hospitals
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Challenges to Linking Measures
• Different departments manage data
collection
 Staff and patient safety culture surveys vs.
patient experience surveys vs. infection rate
data vs. other measures
• In-house time, resources, capability
• Not enough data in a single hospital to
achieve enough power to detect results
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HSOPS-HCAHPS Analysis
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Data from 73 hospitals
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HSOPS data from 2005 to 2007
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HCAHPS data from 2005 to 2006
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Relationships With Hospital
Characteristics
HSOPS
• Smaller hospitals
than larger hospitals
• Non-teaching hospitals
• Government hospitals
than teaching hospitals
non-govt hospitals
HCAHPS
• Smaller hospitals
than larger hospitals
• Government hospitals
non-govt hospitals
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HSOPS-HCAHPS Results
• Hospitals with better patient safety cultures
had patients who rated the hospital higher
on quality of care
 Correlation:
r = .41
 Regression controlling for hospital
characteristics: β = .33
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Hospital SOPS & Patient Experience
Sorra, Khanna, Dyer, Mardon & Famolaro. Exploring Relationships Between Patient Safety Culture and Patients’
Assessments of Hospital Care. Under review as of October 2011.
HSOPS Measures Related to
Overall HCAHPS Composite Average
1. Supervisor/manager expectations & actions promoting
patient safety
2. Organizational learning--continuous improvement
3. Teamwork within units
4. Communication openness
5. Staffing
6. Management support for patient safety
7. Teamwork across units
8. Handoffs & transitions
9. Feedback & communication about error
10. Nonpunitive response to error
11. Frequency of event reporting
12. Overall perceptions of patient safety
Number of events reported in past 12 months
Patient safety “grade” (Excellent to Poor)
HSOPS Composite Average
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HCAHPS Measures Related to
Overall HSOPS Composite Average
1. Communication with nurses
2. Communication with doctors
3. Communication about medicines
4. Responsiveness of hospital staff
5. Discharge information
6. Pain management
7. Hospital environment (clean & quiet)
8. Overall rating of hospital (0 worst to 10 best)
9. Willingness to recommend to family & friends
(Definitely no, Probably no, Probably yes, Definitely yes)
HCAHPS Composite Average
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HSOPS-HCAHPS Conclusions

Strongest correlation between composites:
HSOPS Adequacy of staffing & HCAHPS
Patients’ perceptions of responsiveness of staff
(r = .55)

Strongest regressions between HSOPS
composites & HCAHPS composite average:
 Organizational learning (β = .38)
 Adequacy of staffing (β = .37)
 Teamwork within units (β =.37)
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HSOPS &
AHRQ Patient Safety Indicators (PSIs)

Rates of adverse events per 1,000 patients
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HSOPS and PSI data from 179 hospitals
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8 indicators and an overall PSI composite
Iatrogenic pneumothorax (PSI 6)
Selected infections due to medical care (PSI 7)
Accidental puncture and laceration (PSI 15)
Postoperative:
Hemorrhage or hematoma (PSI 9)
Physiologic & metabolic derangements (PSI 10)
Respiratory failure (PSI 11)
Sepsis (PSI 13)
Wound dehiscence in abdominopelvic surgical patients (PSI 14)
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Rate—PSI
Event
Composite
Average Adverse
PSI Composite
(Cases
per 1,000)
Hospital SOPS & PSI Adverse Event Rates
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Higher patient safety culture scores
associated with lower adverse event rates
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r = -.36
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8
6
4
2
0
40%
45%
50%
55%
60%
65%
70%
75%
80%
Composite Average (Percent Positive Score)
Average HSOPS
Hospital
Patient Safety Culture Score
Mardon, Khanna, Sorra, Dyer & Famolaro. Dec 2010. Exploring Relationships Between Hospital Patient Safety Culture and Adverse
Events. Journal of Patient Safety, Vol 6 (4), pp. 226-232.
Further Linkage Analysis
• Obtain larger numbers of sites
• Examine data collection periods that help
determine the causal relationships between
these measures
• Examine relationships
 At the unit level
 In other settings
 Medical Office SOPS & Clinician-Group CAHPS
 Medical Office SOPS & Outpatient quality and safety
 Between other measures
 HSOPS and employee engagement surveys
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HCAHPS and Outcomes
• Higher hospital-level patient satisfaction
(overall & for discharge planning) was
related to
 Lower 30-day readmission rates for AMI,
heart failure and pneumonia
 Boulding, Glickman, Manary et al. 2011. The Amer
J of Managed Care;17(1):41-48.
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HCAHPS and Outcomes
• Higher hospital-level patient satisfaction
(overall rating & willingness to
recommend) was related to:
 HQA process measures
 AHRQ PSIs for medical and surgical
complication rates
 Isaac, Zaslavsky, Cleary, & Landon, 2010. Health
Services Research; 45(4); 1024-1040.
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HCAHPS and TeamSTEPPS
• Why it’s a useful measure to consider
 Affects hospital’s bottom line, so people care
 Reinforces value of including patients and
families on teams
 Evidence that better teamwork can improve pt
satisfaction
 Auerbach et al. Effects of a multicentre teamwork and
communication programme on patient outcomes:
results from the Triad for Optimal Patient Safety
(TOPS) project. BMJ Qual Saf. 2012 Feb;21(2):118-26
 Armour et al. Team training can improve operating
room performance. Surgery. 2011 Oct;150(4):771-8.
 Available data with some ability to link to specific
parts of hospital
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HCAHPS and TeamSTEPPS
• Things we’ve noticed working with
HCAHPS
 Communication dimensions almost perfectly
predict willingness to recommend and overall
satisfaction
 Focus on satisfaction, neglect of
dissatisfaction (which better predicts other
outcomes of interest)
 Links between specific dimensions and
outcomes TS projects are targeting (i.e.
readmissions/staff gave information about
recover; ADEs/staff explained meds well)
 Lots of room for improvement
 Between-hospital variation tricky to interpret 52
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Action Planning for Improvement
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Step 1: Understand Your Results
• Identify strengths & areas for improvement
 Select 2-3 areas for improvement to avoid
focusing on too many issues at once
• Discuss survey results to arrive at deeper
understanding of underlying issues
 Consider conducting focus groups
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Step 2: Communicate & Discuss Results
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Step 3: Implement Action Plans
• In 2010, top 5 actions taken by HSOPS
hospitals
 Improved fall prevention program (56%)
 Conducted root cause analysis
 Implemented SBAR (Situation-BackgroundAssessment-Recommendation)
 Improved compliance with Joint Commission
National Patient Safety goals
 Held education/patient safety fair for staff
• Implemented TeamSTEPPS (18%)
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Questions &
Group Discussion
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