Featured Speaker: Sara J. Singer, MBADoctoral FellowHarvard University PhD Program in Health PolicyBoston, Massachusetts

Leveraging Front-line Expertise (LFLE): A research-based intervention to improve patient safety culture

October 25, 2006

Improving Safety Culture and Outcomes in Health Care Research Team & 24 Participating Hospitals

Research support was provided by the Agency for Healthcare Research and Quality and Wharton’s Fishman Davidson Center

Overview

1. Theory behind the intervention2. Brief description of the intervention3. Preliminary results from the

intervention4. Intervention evaluation

Theory

Safety at Work Despite hazardous work environments,

some organizations have High Reliability (consistently error-free) (Roberts 1990)

Key Findings: Senior managers’ support is essential (Alcoa…

Southwest…Aircraft carriers) HROs focus on process reliability rather than

efficiency (Roberts 1990) Employees need sufficient training, motivation,

and staffing (Srivastava 1986)

These factors are considered important elements of “SAFETY CLIMATE”

Prior research

Measuring Safety Climate An important measure is the difference

between perceptions of senior managers’ and frontline employees’ (FLE) Senior managers’ perceptions are consistently

more positive than those of FLE (Singer et al., 2003,2006)

FLE perceptions better predict safety performance (Singer et al., 2006)

Senior managers might fail to allocate necessary resources to improve systems (Auty & Long 1999, MacDuffie 1997)

Improving systems often requires managerial intervention (Tushman 1997, Tucker 2004)

The LFLE Intervention Systematic process to engage senior

managers with the front-lines of care Worksite observations: Seeing the work

environment first-hand, talking with front-line staff in context—all with a patient safety lens

Safety forums: Unit-based, on-site, multi-disciplinary open-communication forums designed to gather patient safety “helps and hinderers” from front-line staff

Debrief meetings: Interdisciplinary/ multi-level teams organize, prioritize, and take responsibility for safety issues identified from worksite observations and safety forums

LFLE process and its purpose

Worksite observationsUnderstand context

Safety town forumsGather wider feedback

Debrief meetingsOrganize information, select items for resolution, assign responsibility

Promote follow-up

Communicate with unitCommunicate outcome of visits and meetings to unit staff

Set expectations, promote understanding

Month Process of Interest

Senior Leader A

Senior Leader B

Senior Leader C

Senior Leader D

1. Nov 05 Teleconference training session

2. Dec 05 Emergency Department: Patient flow

Emergency Department (perspective of nurse)

Perspective of Emergency Physician

Pharmacy (focus on orders from ED)

Laboratory (focus on orders from ED)

3. Jan 05 Safety Forum Emergency Dept 4. Feb 05 Follow up on issues raised from Emergency Dept Communicate results to ED staff 5. Mar 06 OR:

Communication/ teamwork

Operating Room Nurse perspective

OR Surgeon Perspective

PACU Nurse perspective

Transfer of patient to unit

6. Apr 06 Town Meeting OR/ PACU 7. May 06 Follow up on issues raised from OR/ PACU 8. Jun 06 ICU Pharmacy

(focus on ICU orders – delivery)

Maintenance of equipment or Respiratory Therapy

ICU physician ICU Nurse

9. Jul 06 Town Meeting ICU Departments 10. Aug 06 Follow up on issues raised from ICU

Focus on one area for 3-months, through multiple perspectives

Hospital Participation

32 out of the 92 survey hospitals were randomly selected to participate 8 declined to participate 1 dropped out and was replaced

Distributed by size and region, similar to overall hospital sample

Preliminary assessment

Intervention hospitals varied widely Commitment of hospitals based on their

senior managers’ early participation and preparedness for the intervention

Capabilities of hospitals based on their current use of senior managers’ rounds, forms style meetings, and related processes

Assessment suggested most had similar potential for a successful implementation

Preliminary Findings

1,124 hinderers from the 24 hospitals 183 worksite observations 49 safety forums Two-thirds of all observations/forums were

in four units: ER/ED (26%) OR/PACU/Surgery (17%) Med-Surg ward (15%) ICU (10%)

Hinderers by unitDept. # Examples

ER/ED 380 Lengthy triage and registration processArm banding and use of 2 patient IDsVerbal ordersPatients in hallways waiting for roomsSlow response time for labs (imaging, rad)Security on nights and weekends

ICU 212 Information relayed at transfer incompleteInterruptions from external phone calls Access to medications/Pyxis & pharma hours

OR/PACU/Peri/Pre-OP/Surgery

206 Keeping surgical equipment in working order

Bariatric patients (OR table unsafe, equipment not readily available, procedure)

Med-Surg/Inpatient

148 Locating equip/supplies (wheelchairs, pumps)

Unlocked medication carts

Preliminary Analysis of ED Hinderers

Framework adapted from Frankel, A., et al. 2005.

Number/% ED Example

Equipment/ Supplies/Facility

133 (35%)

Ran out of O2 tanks and regulators; these go up with patients and don't come back down

Staff/Policy & Procedures

113 (30%)

Lack of handwashing between patients

Communication/Documentation

75 (20%)

Continued use of “Do Not Use Abbreviations”

Medication/Pharmacy

33 (9%)

Dosages in wrong slots in PYXIS (.2 in .4 slot)

Security 26 (7%)

Focus on nights & weekends

Sample resolution for hinderersIncoming phone traffic overloads the staff– Hospital 105

a) Switchboard supervisor helped solve: calls sorted and sent to correct department on the first transfer. b) Voicemail in triage for non-urgent communications and to pick up calls when triage nurse is busy. c) Charge nurse has cell phone and uses for communicating with EMS, bed placement, and Dr’s offices. A ‘blast fax’ is being sent to inform community physicians.

All in-patients and out-patients’ names appear on the Pyxis screen. According to the two nurses, most of ED’s med errors are wrong patient – Hospital 47

Suggestion: Change program so that only the patients in that dept appear on the Pyxis screen

Wheelchair had no IV pole, staff had no place to hang IV – Hospital 88

Purchasing at least two IV poles for wheelchairs, one each for ER and Inpatient Unit

Benefit of seeing in context

"I don't think the automatic door would have been fixed without the intervention. It was a small issue—although an important one—so it probably would have been overlooked without the intervention. By having senior administrators looking at the problem, there was recognition of the need to fix it.“ -VP of Nursing, Hospital 39.

Data from evaluation interview18/24 evaluations reported

Were Valuable? (1 strongly disagree: 5

strongly agree)

Plan to Continue?

(1 strongly disagree: 5

strongly agree)

Average Number

Worksite observations

4.6 3.8 Range: 2-61 visitsMedian: 9 visits

Safety forums

4.4 3.5 Range: 0-9 mtgs Median: 3 mtgsAttendance: 0-50 Median: 11 people

Debrief meetings

4.2 N/A N/A

Reported follow-up communication

89% of the hospitals reported that staff received or sometimes received follow-up communication to issues raised

56%Unit-wide written67%Unit-wide verbal28%Hospital-wide written22%Hospital-wide verbal

%Form of communication

Obstacles to successful implementation “Competing priorities” was cited as the

primary obstacle to resolving hinderers (72%) and providing follow-up communication (44%)

Other impediments to resolving issues raised by staff included: Financial constraints (56%) Long lead time, requiring budget request (44%) Limited manpower/staff (33%) Not enough time (33%)

Lessons learned Maintain flexibility in substituting people to do the

visits (i.e. if one senior manager has to cancel, the visit continues with another person filling in)

A clinical perspective helped non-clinician senior managers make the most of worksite visits

Benefit of middle managers’ participation & pre-work Brief unit staff in advance Use to focus senior manager attention on key issues Promotes agreement on priorities

Problem resolution and communication required time and attention, but these were difficult to maintain

Next Steps Evaluating the Intervention We hypothesize that the data will show

Improvement in safety culture survey results over time relative to non-intervention hospitals

Greater reduction in difference between responses of front line employees & senior managers

Positive changes towards improving safety Hospital interest in adoption and continuation of

intervention “I think we cared about safety before, but we needed

something to focus us down on what to do to achieve it. That’s what the Stanford intervention did. We’ll continue it. From now on, it will be part of what we do.” CEO

“[The senior managers] were really hesitant to start the town meetings, particularly, but once they got into it they were like this is the greatest thing since sliced bread. They really are into this.” Liaison