AHRQ Safety Program for Long-term Care: HAIs/CAUTI

Safety Culture Survey Results Forum:

Tips, Tricks and Stories from the Field

Cohort 3

September 2, 2015

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Today’s Presenters

Ann Spenard, RN C, MSNVice President/PrincipalQualidigm

Theresa Famolaro, MPS, MSSenior Study DirectorWestat

Michelle Pandolfi, LMSW, MBA, LNHADirector of Consulting ServicesQualidigm

Upon completion of this webinar, attendees will be able to:

• Recall what safety culture is and its importance to

• Review how to interpret the safety culture survey results

• Identify which results to focus on for improvement

• Describe how to address low scoring areas

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Learning Objectives

• Implement the cultural intervention (along with the CAUTI intervention)

• Assess resident safety culture at baseline and follow-up

• Identify cultural/environmental barriers to success

• Implement new processes and learnings to overcome those barriers

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Program Expectations on Safety Culture

How would your staff define

resident safety culture?

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Defining Safety Culture?

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What is Resident Safety Culture?

“The way we do things around here.”

Exists atmultiplelevels:

System

Organization

Department

Unit

Beliefs, values & norms

Shared by staff

What is:• Rewarded• Supported• Expected

• Talking with your staff about safety culture is important

• How they define safety culture could vary – and be a source of miscommunication! – Safety committee about physical plant issues vs.

patient/resident safety including clinical issues and risk

– Safety culture vs. culture change (person-centered care)

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Your Safety Culture

Overall perceptions of resident safety

Feedback and communication about

incidents

Supervisor/manager expectations and actions promoting patient safety

Organizational learning

Management support for resident safety

Training and skills

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12 Areas of Resident Safety

Compliance with procedures

Teamwork

Handoffs

Communication openness

Non-punitive responseto mistakes

Staffing

Culture Survey Domains Facility X % Positive

Org Lead XAverage % Positive

Cohort X Average % Positive

1. Overall Perceptions of Resident Safety 74 90 872. Feedback & Communication About Incidents 71 88 86

3. Supervisor Expectations & Actions Promoting Resident Safety 62 86 82

4. Organizational Learning 59 80 735. Management Support for Resident Safety

60 80 72

6. Training & Skills 62 82 767. Compliance with Procedures 53 71 668. Teamwork 44 72 689. Handoffs 56 76 7110. Communication Openness 38 61 5611. Nonpunitive Response to Mistakes 34 54 5212. Staffing 35 60 53

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Nursing Home Survey on Patient Safety Culture Sample Baseline Results, by Category

Note: Green = ABOVE the cohort X average % positive Red = BELOW the cohort X average % positive

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Nursing Home Survey on Patient Safety Culture Data Entry and Analysis Tool

Have you heard of the AHRQ Nursing Home

Comparative Database?

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AHRQ Nursing HomeComparative Database?

Purpose:

• To gather data from the AHRQ Nursing Home Survey on Patient Safety Culture into a central place to be able to compare safety culture across facilities

• AHRQ Nursing Home Comparative Database compares data across nursing home facilities that provide data

• To help facilities identify strengths and opportunities for improvement in their resident safety culture

• To track changes in resident safety culture over time

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AHRQ Nursing Home Comparative Database

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• Your facility will receive an individual feedback report comparing their results to the comparative database

• A free Comparative Database Report

• Report provides aggregate nursing home-level statistics.

• Compare your results to other nursing homes like yours

• Access the 2014 Nursing Home Survey on Patient Safety Culture Comparative Database on the AHRQ website

Benefits of ParticipationNursing Home Comparative Database

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Nursing Home Survey on Patient Safety Culture Sample Individual Feedback Results from the Comparative Database

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Participation is easy!

• HRET can submit your AHRQ Survey on Patient Safety Culture data to the Comparative Database

• Sign the AHRQ Data Use Agreement (DUA)– Nursing home systems/chains can submit one DUA for all

nursing homes; must list each nursing home

• Receive your free individual Nursing Home feedback report

Nursing Home Database Participation

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Next data submission is in April 2016 (Opens April 1, 2016)

To join, contact DatabasesOnSafetyCulture@westat.com or

contact A.J. Rolle at ajrolle@aha.org

Call Westat for more information: 1-888-324-9790

Nursing Home Database Registration

Step #2: Communicate & Discuss Results

Step #4:Communicate

Plans & Deliverables

Step #6 and 7:Track Progress,

Evaluate Impact and Share

Step #1:Understand Your Results

Step #3:Create Focused

Action Plans

Step #5: Implement Action Plans

Action Planning for Improvement

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Identify strengths & positive change• Determine a cutoff for what is considered a “strength”

Identify areas for improvement • Determine a cutoff for what is considered an “area 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

Understanding Your Results

Review your results with an open mind

– Did any areas seem to relate or have cross over?

– Was there a common theme that emerged?

– Example – Your facility scored lowest in these four areas…

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Identifying Areas for Improvement

What is the common theme? COMMUNICATION!

Step #1:Understand

Your Results

• Discuss results with your leadership teams

– Were there any surprises?

– Have you already begun to address issues?

– If you tried anything in the past – what worked? What didn’t work?

• Agree on 2-3 areas of resident safety on which to focus

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Taking Action! Talk About It!Step #2: Communicate &

Discuss Results

• Share your survey results with your staff at meetings and post it–hold “town hall” meetings

• Discuss findings and areas for improvement with staff– Use learning circles to encourage open dialogue and the sharing of

ideas from all levels of staff

• Incorporate staff ideas into your action plan

• Invite staff to serve on area focus teams and to meetings about the areas of focus

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Taking Action! Tell About It! Step #2: Communicate &

Discuss Results

Taking Action! Do Something About It!

Assign a “champion” for each area of focus

• Champions are to help guide and facilitate the work of the team for their area

• Champions should be organized and able to collaborate with each other

• Example: If communication is the common theme – your champions should ideally be someone the staff listens to!

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Step #3:Create Focused Action Plans

Taking Action! Do Something About It!

Determine your next steps and timeline for addressing each area

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Step #3:Create Focused Action Plans

Time frame Interventions

Staff education

Milestones and goals

Tracking and measurements

• Post your improvement plans for everyone to see

– All shifts, all departments

– Consider it a QAPI project

– Include residents and families in your action plans

• Provide updates on changes and progress often – at least quarterly

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Taking Action! Tell Everyone Your Plan! Step #4:Communicate Plans & Deliverables

START! Don’t delay. Just begin implementing your plan.

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Taking Action! Start and Track Your Work!

Step #6 and 7:Track Progress,

Evaluate Impact and Share

Step #5: Implement

Action Plans

Review your plan and track your progress during meetings, and against your stated objectives/goals from the beginning.

• What needs to be changed? What works? Doesn’t work?

Provide updates to staff, residents and families on changes and progress often–at least quarterly.

• Review and discuss survey findings

• Narrow your focus by identifying your top concerns

– Don’t forget to celebrate your successes!

• Engage and listen to staff ideas

• Try different interventions to address your areas of focus

– Review the following ideas, categorized by dimension:

Improving Patient Safety in Nursing Homes: A Resource List for Users of the AHRQ Nursing Home Survey on Patient Safety Culture

• Check-in with staff often and tweak your action plan as needed

Check out TeamSTEPPS for Long-Term Care26

To Be Successful…Summary

WHY THE SAFETY CULTURE SURVEYIS IMPORTANT: EXAMPLES

Real-life Stories from LTC Facilities

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Remember Miami Jewish Health SystemsA Story from the Field

WHY• Invested in safety• Resident safety is everyone's job

HOW • Had laptops in each unit on each shift• Allowed for paper completion as

needed

ANALYZING THE RESULTS• Broke down results, e.g., by job title,

direct care providers• Created a video with employees

presenting the results• Decided not to compare with others;

wanted to treat each opportunity for improvement as important

USING THE RESULTS TO IMPROVE• Worked on quick wins/low-hanging fruit

first to demonstrate commitment to improvement

• Disseminated results in open dialogue in town hall meetings

• Presented video at each unit/department

• Convened focus groups to address OFIs requiring more study to create solutions

Staff, resident and family perceptions=

their reality

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LTC Facility: Not-for-profit SNF in Connecticut

Continuum of Care• Independent Living• Assisted Living• Memory Care• Home Care• Hospice Care• Long-term Care• Outpatient Rehab• Post-Acute Care• Day Program• Meals on Wheels 29

Why the Safety Culture Survey is ImportantA Story from SNF in Connecticut

Annually serves patients, residents and families in over 12 different services and programs

They support the Nursing Home Culture Survey because…

• They are committed to continuous improvement and resident and

staff safety

• Resident safety is everyone's job– Everyone’s opinion is important– Everyone is part of the solution

Staff, resident and family perceptions =

Their level of quality care30

Why We Promote the Safety Culture SurveyA Story from SNF in Connecticut

How We Did It and How We Are Using the ResultsA Story from SNF in Connecticut

HOW • Allowed for paper completion

• Encouraged all nurse managers to hand out survey on their neighborhoods

• Involved all departments, service lines

ANALYZING THE RESULTS• Broke down results (e.g., by job title,

direct care providers)

• Presented PowerPoint presentation to leadership team and board of directors, staff

• Decided not to compare with others; wanted to treat each opportunity for improvement as important

USING THE RESULTS TO IMPROVE• Chose four areas needing most

improvement for focused attention

• Disseminated results in open dialogue in town hall meetings

• Asked staff for feedback on action plan and areas of focus

• Brainstormed ideas for better communication

• Implemented TeamSTEPPS

• Repeating survey one year later

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