inova leadership institute quality update and safety culture results february 2015 1

Inova Leadership Institute

Quality Update and Safety Culture Results

February 2015

1

2

Core Measures

2014 Overall Perfect Care = 96%

80% of Value Based Purchasing Core Measures at CMS Threshold Level

Higher is better

3

Mortality

Overall 2014 Mortality O:E = 0.71, meeting 2014 Goal

Lower is better

4

PSI-90

2014 All Medicare Patients PSI-90 is below CMS benchmark, meeting goal.

Lower is better

5

Readmissions

2014 Inova Overall is meeting Readmission Goals for AMI (heart attacks) and COPD (chronic lung disease)

Lower is better

6

Readmissions

2014 Inova Overall is not meeting, but very close, to Readmission Goals for heart failure & pneumonia

2014 Inova Overall is not meeting Readmission Goal for joint replacement

7

Hospital Acquired Infections

2014 Central Line Associated Blood Stream Infections (CLABSI) have decreased.

2014 Catheter Associated Urinary Tract Infections have mostly

decreased. Opportunity for Improvement in IFH Adult ICUs.

Lower is better

8

Multi-Drug Resistant Infections

2014 C.diff infections are mostly trending down. Some opportunity for improvement remains at IAH and IFH.

Some spikes in 2014 MRSA infections, but remains at goal.

Lower is better

Patient Safety CultureILI 35

Patient Safety Culture Review

“Virtually no one clearly defines what they mean by “culture,” and when they do they usually get it wrong.”

-John Kotter

10

Safety Culture

11

Informed

Reporting

Just

Flexible

Learning

Safety

Culture

Safety Culture Journey

12

2011 2012 2013 2014

Measure & Analyze

Partial Administration

Baseline Administration & Debrief

1st Comparative Administration & Debrief

2nd Comparative Administration & Debrief

Focus • Reporting and Just Culture

• Reporting and Just Culture

• Reporting and Just Culture

• Teamwork• Staffing

Act • Set Targets for Improvement

• Planned for full administration

• Engagement of leaders

• Prep for improvements

• Safety Always Implementation

• Safety Always Implementation

• TeamSTEPPS®

Improve ↑ 0.3% ↑ 1.6%

Conclusions

• Overall, patient safety culture scores have improved slightly over 2013

• Engagement of staff in the survey increased drastically in 2014

13

• Nonpunitive Response to Error (+5.7%) and Hospital Handoffs and Transitions (+3.7%) had the greatest increase since 2012

Conclusions

• Since 2012, only Staffing has decreased consistently

• Hospital Management Support suffered a steep decline in 2013, improved in 2014, but not fully to the 2012 baseline

• The custom questions show a large increase in confidence around our new Safety Always event reporting system

14

Fairfax Alexandria Mt. Vernon Loudoun Fair Oaks0%

10%

20%

30%

40%

50%

60%

70%

80%

42.7%39.0%

41.6%44.0%

51.3%

62.6% 63.5% 63.5%68.1%

75.5%

2013 2014

Ove

rall

Perc

ent P

ositi

ve R

espo

nse

Response Rate by Facility

National Average (54%)

90th Percentile 75th Percentile

Average*

25th Percentile 10th Percentile or Less

Non-Punitive Response to

Error

Handoffs and Transitions

Staffing

Teamwork in Unit

Manager expectations

around PSManagement support for

Patient Safety

Communication Openness Event Reporting Teamwork Across

Units

Perceptions of Patient Safety

Organizational Learning

Feedback about Error

N = 7,305

Inova 2014 HSOPS Results*Benchmarked against 2014 AHRQ Database (All Hospitals)

Inova HSOPS See-Saws Over Time

2012

2013

2014

National Percentiles

HSOPS Dimension2014 % Positive

Difference to Next

Percentile10th 25th 50th 75th 90th

Overall perceptions of safety 62% 4% 56% 61% 66% 71% 77%Frequency of events reported 68% 3% 57% 61% 65% 71% 76%

Supervisor/manager expectations & actions promoting safety

76% 4% 68% 71% 76% 80% 84%

Organizational learning - Continuous improvement

73% 5% 64% 68% 73% 78% 82%

Teamwork within units 81% 4% 73% 78% 81% 85% 88%Communication openness 66% 5% 54% 58% 62% 66% 71%

Feedback & communication about error 73% 5% 57% 61% 66% 72% 78%Nonpunitive response to error 47% 3% 34% 38% 43% 50% 56%

Staffing 45% 4% 44% 49% 55% 61% 68%Hospital management support for patient

safety67% 5% 61% 67% 72% 79% 84%

Teamwork across hospital units 57% 2% 49% 53% 59% 67% 75%Hospital handoffs & transitions 46% 7% 35% 40% 46% 53% 63%

Operating Unit Results

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Overall Percent Positive Response

20

Alexandria Fair Oaks Fairfax Mt. Vernon Loudoun0%

10%

20%

30%

40%

50%

60%

70%

80%66

.0%

67.4

%

55.3

% 64.6

%

66.9

%

62.6

%

67.4

%

57.1

%

65.0

%

68.7

%

63.7

%

67.0

%

58.8

%

66.2

%

72.0

%

61.8%64.8%

60.8% 62.2%64.8%

2012 2013 2014 Benchmark

Ove

rall

Perc

ent P

ositi

ve

The overall percent positive response for the 75 th percentile is 69.4%.

300 – 399 Beds 100 – 199 Beds500+ Beds 200 – 299 Beds

100 – 199 Beds

*Benchmarked against 2014 AHRQ Database (All Hospitals)

Fairfax 2014 HSOPS Results

90th Percentile75th Percentile

Average*


or Less


Error


Staffing

Teamwork in Unit


around PS

Management support for

Patient Safety

Communication Openness

Event Reporting

Teamwork Across Units




N = 3,413

90th Percentile 75th Percentile

Average*


or Less


Error


Staffing

Teamwork in Unit



Patient Safety


Event Reporting






Alexandria 2014 HSOPS Results

N = 1165


Average*


or Less


Error


Staffing

Teamwork in Unit


around PS


Patient Safety

Communication Openness Event Reporting






Mt. Vernon 2014 HSOPS Results

N = 687


Average*


or Less


Error


Staffing

Teamwork in Unit



Patient Safety


Event Reporting






Fair Oaks 2014 HSOPS Results

N = 1074


Average*

25th Percentile

10th Percentile or Less


Error


Staffing

Teamwork in Unit


around PS


Patient Safety


Event Reporting






Loudoun 2014 HSOPS Results

N = 966

Difference from AHRQ Benchmark (50th percentile) by Composite

26

Hospital Loudoun Fair Oaks Mt. Vernon Alexandria Fairfax

Benchmark 100 - 199 Beds 100 - 199 Beds 200 - 299 Beds 300 - 399 Beds 500+ Beds

Staffing

Teamwork within units

Overall perceptions of safety

Hospital management support for patient safety

Teamwork across hospital units

Organizational learning - Continuous improvement

Hospital handoffs & transitions

Supervisor/manager expectations & actions promoting safety

Frequency of events reported

Communication openness

Nonpunitive response to error

Feedback & communication about error

-40% -30% -20% -10% 0% 10% 20% 30% 40% 50%

Alexandria Fair Oaks Fairfax Mt. Vernon Loudoun

Difference from Benchmark

Composite score exceeds respective benchmark.Composite score below respective benchmark.

Safety Always

Difference from 2013 by OU

27

Fair Oaks

Mt. Vernon

Alexandria

Fairfax

Loudoun

-20% -10% 0% 10% 20% 30% 40% 50%

Overall perceptions of safety Frequency of events reportedSupervisor/manager expectations & actions promoting safety Organizational learning - Continuous improvementTeamwork within units Communication opennessFeedback & communication about error Nonpunitive response to errorStaffing Hospital management support for patient safetyTeamwork across hospital units Hospital handoffs & transitions

Difference from 2013

2014 Composite score exceeds 2013 score2014 Composite score below 2013 score

Composite Two Year Trends

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Color CriteriaGreen Above the 75th Percentile or a 5% increase from 2012Yellow At least a 1% increase from 2012 (National Average rate of improvement)Red Less than a 1% increase from 2012

2012 to 2014 DifferenceComposite Alexandria Fair Oaks Mt. Vernon Fairfax LoudounNonpunitive response to error 0% 4% 1% 7% 11%Hospital handoffs & transitions -1% 0% 7% 5% 8%Frequency of events reported -1% 3% 7% 1% 5%Feedback & communication about error 0% 1% 0% 5% 6%Teamwork across hospital units -3% 0% 3% 4% 6%Organizational learning - Continuous improvement -1% 1% 1% 6% 4%Teamwork within units 1% -1% 1% 5% 3%Communication openness -3% 0% 1% 5% 4%

Supervisor/manager expectations & actions promoting safety -1% 0% 1% 3% 2%

Overall perceptions of safety -4% -2% 1% 2% 5%Hospital management support for patient safety -5% -2% -1% -1% 5%Staffing -9% -7% -3% 1% 2%

Staffing Perceptions

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Staffing Questions

40%

31%

18%

34%

21%

27%

24%

24%

38%

42%

58%

42%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

We have enough staff to handle the workload. (A2)

Staff in this unit work longer hours than is best for patientcare. (A5R)

We use more agency/temporary staff than is best forpatient care. (A7R)

We work in "crisis mode" trying to do too much, too quickly.(A14R)

Staffing

% Negative % Neutral % Positive

Question 2014 % Positive Response Difference from 2013

We have enough staff to handle the workload. (A2) 38% 0%

Staff in this unit work longer hours than is best for patient care. (A5R) 42% -1%

We use more agency/temporary staff than is best for patient care. (A7R) 58% -3%

We work in "crisis mode" trying to do too much, too quickly. (A14R) 42% 0%

Common Barrier to Improvement

Staffing

Quality

Engagement

Patient Satisfaction

Safety Culture

What Is Staffing

Staffing

Right Number

Leadership

Teamwork Individual

Competencies

Leadership vs. Frontline

33

Differences in Perception

34

2014 Front Line Perceptions

2014 Leadership Perceptions

Average gap between leaders and frontline has been 11% on all three surveys (2012, 2013, 2014)

Domain Breakout (System)

-80% -60% -40% -20% 0% 20% 40% 60% 80%

Obstetrics

Intensive Care Unit (any type)

Pharmacy

Rehabilitation

Medicine (non-surgical)

Surgery

Anesthesiology

Radiology

Psychiatry/Mental Health

Laboratory

Emergency Department

Pediatrics

Staffing Hospital management support for patient safetyOverall perceptions of safety Teamwork across hospital unitsHospital handoffs & transitions Teamwork within unitsOrganizational learning - Continuous improvement Supervisor/manager expectations & actions promoting safetyFrequency of events reported Nonpunitive response to error

Domain Breakouts

Many different hospital units/No

specific unit

Medicine (non-surgical)

Surgery Obstetrics PediatricsEmergency

Department

Intensive Care Unit (any type)

Psychiatry/Mental Health

Rehabilitation Pharmacy Laboratory Radiology AnesthesiologyOther Units

Respondents 372 1003 1213 543 131 676 663 153 350 221 389 462 64 1065

Role Breakouts

37

System Wide Role Based Analysis

Overall p

erceptions o

f safe

ty

Frequen

cy of e

vents

reporte

d

Superv

isor/m

anag

er ex

pectati

ons & ac

tions pro

moting safe

ty

Organiza

tional learn

ing - Continuous im

prove

ment

Teamwork

within units

Communication opennes

s

Feedback

& co

mmunication ab

out erro

r

Nonpunitive re

sponse

to er

ror

Staffing

Hospita

l manag

ement s

upport fo

r pati

ent safe

ty

Teamwork

acro

ss hosp

ital u

nits

Hospita

l han

doffs & tr

ansiti

ons30%

40%

50%

60%

70%

80%

90%

100%

Technician/Technologist Nurses Doctors Leadership

Perc

ent P

ositi

ve R

espo

nse

1172 2854 546 546

Safety Always Project

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• Issues with event reporting identified in safety culture survey (2012)

• Technology, process, and cultural factors identified as barriers to learning from error (2013)

• New technology vendor selected (Datix) with implementation partner (Synensis)– Rollout included:

• Assessment, System Configuration, ILI Training, Frontline Communications, and Reassessment

Summary

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Focused HSOPS Questions

41

0%

20%

40%

60%

80%

39% 41% 44%

71% 70%54%

2013 2014

Switched event reporting systems from Quantros (2013) to Safety Always (2014).

Safety Always Goals

42* HSOPS dimensions include: “Frequency of Events Reported”, “Non-punitive Response to Error”, “Feedback and Communication about Error”, and “Management Support for Patient Safety”

Goal Progress (as of Dec 2014)

Increase reporting by 30% 37.1% increase

Reduce unclassified events from 25% to 15% 17% of total are unclassified

Decrease event entry time from 15-20 minutes to 5 minutes Average entry time = 4 min

Decrease anonymous reports from 12% to 6% 11% of total are anonymous

Track medical staff entering events into the system 2.1% of total are Medical Staff

Positive Changes

• Safety Always is perceived significantly better than Quantros– Quicker data entry– More feedback to frontline

• “Great Catch” program continues to add positivity to reporting– Causes perceptions of the system to be “less punitive”

• Many units and departments are spending more time learning from individual events and near misses

• Internal communications have started to shift perceptions of reporting and have been a key to the success of the roll-out

• Leadership has increased transparency and learning by sharing more information regarding errors that occur and follow-up actions taken

43

Challenges & Opportunities

• Large opportunity to learn from events within Safety Always– System is used primarily for documentation– Middle management unsure how to use data and dashboards

• Workflow can continue to improve– Interdepartmental events are still difficult to complete and close– Reporters receive feedback inconsistently

• Anonymous reporting remains higher than expected– Partially attributed to speed of data entry– Reporters often feel uncomfortable reporting colleagues

• Further engage physicians– Increase utilization– Increase staff’s comfort with feedback

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Closing Thoughts & Next Steps

45

• Patient safety culture is improving, but slower than desired

• Successful roll-out of Safety Always has increased our ability to capture and learn from error– Improved behaviors need to be hardwired

• Focused action improves results

Closing Thoughts

46

Patient Safety Culture• Begin system-wide and OU-level action planning

Safety Always• Celebrate successes across the system• Optimization of tool and our processes

• Continued work to clarify and improve manager workflow• Increased utilization of reports and dashboards to learn from error• Ongoing focus on actions to address root causes of events and

great catches

Next Steps – Starting in February

inova leadership institute quality update and safety culture results february 2015 1

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