Title BlockHSOPS: So You’ve Done the

Survey – Now What?

Dolores Hagan, RN, BSNK-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

• 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.k-hen.com/Portals/16/Documents/KHENKickoff/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/suppl_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