Instructional Slide: How To Use This Template Presentatio n

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 2.

with an X or annotated in the notes for the slide. 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 3. Staffing 4. Non-punitive response to error 5. Supervisor expectations and actions promoting safety 7. Feedback and communication about error 8. Frequency of events reported 9. Hospital management support for patient 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 X% X% X% X% X% 2012 X% X% X% X% X% Respondent Demographics

Worked directly with patients Patient Care assistants Registered Nurses Unit Clerks Physicians

Overview of NYSPFP CoS Re-Survey Results

65% 52% X% HOSPITAL’S Response rate (N = X responses) X%

Of hospitals conducted the survey out of 172 participating NYSPFP hospitals Average AHRQ CoS Survey Response Rate

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 X% X% X% X% X% 2012 Grade (All respondents)

X% Excellent X% Very Good X% Acceptable X% Poor 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% 70% 60% 50% 40% 30% 20% 10% 71% 77% 62% 59% 0% Hospital Management Support For Patient Safety Teamwork Across Hospital Units

Composite Hospital Safety Measurements

36% 48% Hospital Handoffs & Transitions

80% 70% 60% 50% 40% 30% 20% 10% 0% 100%

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 90% 56% 95% 66% 50% 50% 96% 69% 74% 58% Overall Perceptions of Safety Teamwork within units Organizational Learning Continuous Improvement Staffing Nonpunitive Response to Error Supervisor Expectations & Actions Promoting Safety Communication Openness Feedback and Communications About Error Frequency of Events Reported

Composite Work Area Safety Measurements

Greatest Increase in Scores by Dimension

% Increase from 2012 X% NYSPFP Percentile

> X th percentile Supervisor expectations and actions promoting safety Overall perception of safety

X%

< X th percentile Hospital management support for patient safety

X%

Between X – X th percentile

Greatest Decrease in Scores by Dimension

Hospital Hand-offs and Transitions

% Decrease from 2012 X% NYSPFP Percentile for 2013

At X th percentile Staffing

X%

Between X th

X

th percentile – Frequency of events reported

X%

< X th percentile

Areas of Strength

Domain

Supervisor expectations and actions promoting safety Teamwork within units

2013 scores compared to 2012

X% Increase/Improvement (also one of the most improved areas) X% Increase Non-punitive response to error X% Increase All dimensions at or above NYSPFP 90 th percentile and national mean

Areas for Improvement

Domain

Frequency of events reported

2013 scores compared to 2012

X% Decrease Overall perception of safety Organizational Learning – continuous improvement X% Improvement Unchanged (X%) All dimensions at or below the NYSPFP 25 th 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