Featured Speaker:

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• Featured Speaker
• Sara J. Singer, MBA
• Doctoral Fellow
• Harvard University PhD Program in Health Policy
• Boston, Massachusetts

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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 Whartons
  Fishman Davidson Center

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Overview

• Theory behind the intervention
• Brief description of the intervention
• Preliminary results from the intervention
• Intervention evaluation

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TheorySafety at Work

• Despite hazardous work environments, some
  organizations have High Reliability (consistently
  error-free) (Roberts 1990)
• Key Findings
• Senior managers support is essential
  (AlcoaSouthwestAircraft 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

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Prior researchMeasuring 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)

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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 contextall 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

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LFLE process and its purpose
Worksite observations Understand context
Safety town forums Gather wider feedback
Debrief meetings Organize information, select
items for resolution, assign responsibility Promot
e follow-up
Communicate with unit Communicate outcome of
visits and meetings to unit staff Set
expectations, promote understanding
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Focus on one area for 3-months, through multiple
perspectives
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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

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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

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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)

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Hinderers by unit
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Preliminary Analysis of ED Hinderers
Framework adapted from Frankel, A., et al. 2005.
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Sample resolution for hinderers
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Benefit of seeing in context

• "I don't think the automatic door would have been
  fixed without the intervention. It was a small
  issuealthough an important oneso 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.

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Data from evaluation interview18/24 evaluations
reported
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Reported follow-up communication

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

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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)

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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

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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. Thats what the Stanford
  intervention did. Well 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