HSOPS Action Planning: Improving Safety Culture

Transcription

1 HSOPS Action Planning: Improving Safety Culture

2 New AHRQ Action Planning Tool

3 AHRQ Action Planning Secure Leadership Support Form an Action Planning Team Define Your Goals What areas do you want to focus on? What are your goals? What initiatives will you implement? Plan Your Initiatives Who will be affected and how? Who can lead the initiative? What resources are needed? What are possible barriers and how can they be overcome? How will you measure progress and success? What is the timeline? Communicate your Action Plan How will you share the action plan and with whom?

4 Action Planning Tool University of Nebraska Medical Center interpret-results.html HSOPS Background Inventory of Safe Culture Practice Action Plan Template Presentations on understanding results

5 Credit where it s due Based on the work of Katherine Jones, PT, PhD University of Nebraska Medical Center AHRQ Office of Communications and Knowledge Transfer

6 Link to the Action Planning Tool h"ps:// providers/ini9a9ves/safety- culture- services/on- demand- webcasts/

7 How to Become an HRO: Engage in Continuous Improvement Measure Beliefs and Behaviors Ac9on Plan Implement Prac9ces 7

8 HSOPS 42 items categorized in 12 dimensions 2 dimensions measure outcomes at dept/unit level Overall percep9ons of safety Frequency of events reported 7 dimensions measure culture at dept/unit level 3 dimensions measure culture at hospital level 2 addi9onal items measure outcomes at dept/unit level Number of Events Reported Pa9ent Safety Grade 8

9 Safety Culture Element Reporting - Employees feel safe reporting safety concerns. Reporting is valued and used for learning. HSOPS Dimensions or Outcome Measures Frequency of Events Reported Number of Events Reported Just - Errors are not punished. HR policies support justice and accountability. Managers use a consistent approach Non-punitive Response to Error Feedback and Communication about Error Communication Openness Flexible - (Teamwork and Communication) People adapt effectively to changing demands. Those in authority respect the knowledge of frontline staff. Authority patterns relax when safety information is exchanged. Communication is accurate, timely, and verified. Teamwork within Units Teamwork across Units Hospital Handoffs Communication Openness Staffing Learning - Employees learn from experience and participate in continuous improvement. Organization analyzes reported safety events and addresses system issues. Organizational Learning Overall Perceptions of Patient Safety Patient Safety Grade Feedback and Communication about Error Manager Actions Promoting Safety Hospital Management Support

10 Action Planning HSOPS Action Planning tool Anchor plans in mission and strategy Identify practices needed to support safety culture Document your planning process and enhance accountability

11 Action Planning 1. Background Information 1a. Date of most recent HSOPS 1b. Has the HSOPS been conducted previously? 1c. If yes, what were the previous dates? 1d. If yes, what was the previous impact and are action plans and change teams still functional?

12 Action Planning 1.e Describe your organization s overall vision, which may include mission, vision and values. 1f. List your organization s strategic goals 2. Response rate:

13 Action Planning 3. Identify strengths and weaknesses at the hospital level and the work area (unit) level. List the three dimensions with the highest percent positive scores and the three dimensions with the lowest percent positive scores.

14 Action Planning: Dimension Scores by Work Area 4. Identify how the four foundational elements of safety culture vary within your work area, and compared to your hospital and to other work areas: Reporting Just Culture Flexible - Teamwork & Communication Learning

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16 Action Planning: Dimensions by Job Role 5. Identify how the four foundational elements of safety culture vary in your work area by job role. Enter the percent positive score for each survey dimension by job role into the table provided

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18 Action Planning: Practices 6. Rate the extent to which practices that support the four components of safety culture are in place.

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21 Action Planning: Step 1 1. Based on your knowledge of safety culture in your work area (survey scores) and your ratings of the safety culture practices in place, complete the 10 step action plan.

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23 Action Planning: Step 2 2. Create the Change Team Name Role

24 Action Planning: Step 3 3. Define your aims/goals What will be achieved? What departments or people will be involved? When and where will the change occur? How will you know you have met your goal?

25 Example goals and aims 1) We will strengthen our communication skills and make it psychologically safe for all to advocate for patients. We will do this by using SBAR for communication between all who exchange patient information, and teaching all staff to use CUS. We will start with acute care; Nurses and support staff will effectively use SBAR and CUS by March 1, (2) We will improve reporting and learning in the ED by debriefing on a weekly basis, documenting the results and sharing them with all ED staff and management. We will begin by Dec. 1, (3) We will improve our nonpunitive response to error and perception of a just culture by being transparent with all staff about how the decision is made whether or not to hold an individual accountable. We will teach all managers to use the Just Culture Algorithm in an interdisciplinary committee as part of this process.

26 Action Planning: Step 4 4. Design an intervention Unit of focus Which tools or strategies? PDSA Implement

27 Action Planning: Step 5 5. Decide measures for the intervention Observations Counts Outcome measures Repeat HSOPS Patient satisfaction surveys Staff satisfaction surveys Other?

28 Action Planning: Step 6 6. Develop a plan: who does what by when?

29 Action Planning: Step 7 7. Determine how to sustain and spread changes Role modeling Monitoring Integrate into orientation, competency testing Improved feedback

30 Action Planning: Step 8 8. Communication Plan Who needs to provide support? Who needs to be convinced? Elevator speech: We have chosen to focus on. It is important that we improve because puts our patients at risk and impacts our performance. We need you to support our efforts by.

31 Action Planning: Step 9 9. Write your final action plan covering steps 1-8

32 Action Plan: Step Review the plan with all key personnel

33 Summary Get a 60% response rate to be representative of the group Review unit level results by sorted by foundational elements of safety culture Target high and low scoring dimensions Debrief survey, especially high and low dimensions, at the item level, with staff discussion Develop action plans for culture improvement that align with mission, strategy and existing projects

34 For more information Latoshua LeGrant Performance Improvement Specialist Christi Beals Project Manager Laura Maynard Director of Collaborative Learning