Transcript HSOPS: So You’ve Done the Survey – Now What?

HSOPS: So You’ve Done the
Title Block
Survey – Now What?
Dolores Hagan, RN, BSN
K-HEN Education/Data Manager
Objectives
Upon completion of this session, the
participant will be able to:
• Interpret HSOPS survey results
• Identify areas for targeted interventions
• Determine appropriate interventions
based on survey results
“The biggest challenge to moving toward
a safer health system is changing the
culture from one of blaming individuals for
errors to one in which errors are treated
not as personal failures but as
opportunities to improve the system and
prevent harm”¹
¹Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century.
Washington, DC: National Academy Press, 2001
Why Survey?
• Diagnose safety culture to identify areas
for improvement and raise awareness
about patient safety
• Evaluate patient safety interventions or
programs and track changes over time
• Conduct internal and external
benchmarking
• Fulfill directives or regulatory requirements
Survey Success
• Key senior leadership support
• Determine who will be surveyed
• Monitor and encourage respondent
participation
• Review result reports
• Implement action planning and change
initiation
The Tool
Agency for Healthcare Research an Quality (AHRQ)
Hospital Survey Of Patient Safety (HSOPS)
• Survey Goals
– Improve patient safety
– Encourage error reporting and analysis to promote
learning and prevention
– Staff empowerment
• Survey Purpose
– Examines patient safety culture from a staff
perspective
– Identify areas of strengths and opportunities for
improvement
What It Measures
• Seven unit-level aspects of safety culture
– Supervisor/Management expectations and
actions promoting safety
– Organizational Learning – Continuous
Improvement
– Teamwork within units
– Communication openness
– Feedback and communication about errors
– Nonpunitive response to error
– Staffing
What It Measures
• Three hospital-level
aspects of safety
culture
– Hospital management
support for patient
safety
– Teamwork across units
– Hospital handoffs and
transitions
• Four outcome
variables
– Overall perceptions of
safety
– Frequency of event
reporting
– Patient safety grade
– Number of events
reported
Results Report
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Demographics
Composite scores
Item Level scores
Patient Safety Grade
Frequency of event reporting
National database comparison
– By unit
– By staff type
Results Analysis
• Begin by looking at Composite scores
– Identify strengths – any section scored > 75
– Identify opportunities – any section scored < 50
• Drill down to the Item Level
• Review national database comparison for
breakdown by unit and staff type
Sharing Survey Results
• Results sharing
– Who will present the results
– To whom they will presented to (sequencing)
– When and how results are presented
• Plan your approach
– Prepare for defensiveness and negativism
– Provide specialized training to department
leaders on patient safety culture
Results Sharing
• Staff who participated need to hear the
results
• Feedback and action planning may be
combined for greater impact
• Clinical staff, department leaders and
supervisors must be involved in feedback
discussions
Seizing Opportunity
• Common areas of opportunity
– Reporting ‘near misses’
– Staff feel free to question decisions of those with
more authority or ask questions when something
doesn’t seem right
– Person feels ‘blamed’, fears retaliation
– Staffing
• Not enough
• Work in crisis mode too often
– Feedback about errors reported
– Teamwork across units
– Handoff communication
Technical Assistance
• Resources available through K-HEN
– One on one analysis of HSOPS results
– TeamSTEPPS training
– Comprehensive Unit Based Safety Program
(CUSP)
– Learning from Defects analysis
Improvement Tools
• TeamSTEPPS(http://teamstepps.ahrq.gov/)
• Failure Mode Effects Analysis (FMEA)
• Learning from Defects Analysis
(http://www.khen.com/Portals/16/Documents/KHENKick
off/Learning_from_Defects_Tool.pdf)
• Huddles (http://www.k-hen.com/Pivot.aspx Falls November 2012 Coaching Call)
References/Resources
• http://qualitysafety.bmj.com/content/12/su
ppl_2/ii17.full
• Institute of Medicine. Crossing the
quality chasm: a new health system for
the 21st century. Washington, DC:
National Academy Press, 2001
• http://www.patientsafety.gov/SafetyTopics
/HFMEA/FMEA2.pdf