november 10 th , 2009 learning from pse study dissemination day

What kind of PSE learning behaviours are Ontario hospitals engaging in?

November 10th, 2009Learning from PSE Study Dissemination Day

Outline

1. Can we only learn from Catastrophe?

2. Is there variation in learning from PSEs across Ontario hospitals?

3. What learning behaviors do we engage in most often…least often?

4. The case of hospital size

5. Using (and misusing) these data

Learning Behaviours / Responses to PLEs

• Identification & Reporting

• Analysis of Causes

• Change Implementation

• Dissemination / communication

3.383.033.07

2.58

1

2

3

4

Minor Moderate Major NM Major

4-Always

3-Usually

2-Sometim

1-Never

Event learning

n=54

Event learning Event learning Event learning

1.Can we only learn from Catastrophe?Learning Responses to 4 types of PSEs

3.61

2.88

Analysis

Dissem

Matryoshka Dolls Learning from patient safety events takes place in only a very small subset of events

A

1. Safety incidents

2. Recognized safety incidents

3. Recognized and discussed incidents

5. Recognized, and locally investigated

B

C

4. Recognized, discussed and reported:A – in the chartB – to a paper or on-line IR systemC – to person / team with mandate & resources to investigate and make change

2. Is there variation in learning from PSEs across

Ontario hospitals?

Minor event learning scores for 54 Ontario hospitals

Moderate event learning scores for 54 Ontario hospitals

Major NM learning scores for 54 Ontario hospitals

Major event Analysis learning scores for 54 Ontario hospitals

Major event Dissemination learning scores for 54 Ontario hospitals

3. What learning behaviors do we engage in most

often…least often?

% engaging in learning response “always/almost always” OR “usually”

Learning Response Item Minorevent

Modevent

MajorNM

Majorevent

Discussion around these events focuses mainly on system-related factors, rather than focusing on the individual(s) most responsible for the event

87.0 94.4 96.3

Individuals involved in the event contribute to the understanding and analysis of the event

66.7 79.6 85.2 88.9

A multidisciplinary review team in our hospital helps units with the analysis of these kinds of events

83.0 94.4

A formal process for disclosure of events to patients/families is followed and this process includes support mechanisms for patients, family, and care/service providers.

88.5

% engaging in learning response “always/almost always” OR “usually”

Learning Response Item Minorevent

Modevent

MajorNM

Majorevent

We have dedicated “patient safety rounds” where these events are discussed 13.5 28.0

Information about these events is shared with staff informally within the unit (e.g., through personal communica, email, commun books, bulletin boards).

46.3 64.2

Things that are learned from these events are communicated to staff using more than one method (e.g. communication book, in-services, unit rounds, emails) and / or at several times so all staff hear about it

47.2 65.4 62.3

The patient and fam are invited to be directly involved in the processes that follow major events (analyzing what occurred & making necessary changes)

33.3

4. Do PS leadership and hospital size explain variance

in learning from PSEs?

Organizational Leadership for PS and Learning from PSEs

2

2.5

3

3.5

4

2.43 4.93Organizational leadership for patient safety

Learning scores

Major eventanalysis (no effect)

Major eventdissemination

Moderate events

Minor events

Major near misses

Moderate event learning in small and large hospitals under conditions of strong and weak PS leadership

1

1.5

2

2.5

3

3.5

4

low high

Formal organizational leadership for safety

Lear

ning

from

mod

erat

e ev

ents

Small hospital

Large hospital

weak strong

Major event communication in small and large hospitals under conditions of strong and weak PS leadership

1

1.5

2

2.5

3

3.5

4

low high

Formal organizational leadership for safety

Maj

or e

vent

di

ssem

inati

on/c

omm

unic

ation

Small hospital

Large hospital

weak strong

5. Using (and misusing) these data

Challenges of KT– Different purposes/uses for data – Different data for research and QI– Ethics– Timelines

• Grant to results• Staff change: 50% PSO, 46% CEO

… Using (and misusing) these data

• Comparison with peers• Comparison over time• Starting conversations

– Do the PSE learning instrument with the right people: assess current practice

– Take the results (and process?) up and down the organization: goal setting

• Getting CEOs involved through an in-depth PSE case study (Conway, 2008)

• PSE Learning instrument concrete tool to reduce the knowing-doing gap (Pfeffer & Sutton, 2000): action reduces this gap

“In our experience, most boards and leaders overestimate the frontline staff’s ability to improve. In such cases, even with sufficient will and great ideas…execution stalls” (Conway, 2008)

Single-loop learning – quick fixes

Double-loop learning – correcting the underlying causes of a problem