Title: J' Bryan Sexton, Ph'D'
1Culture Eats Strategy for Lunch Safety Culture
Assessing Improving
J. Bryan Sexton, Ph.D. Johns Hopkins
University Quality and Safety Research
Group Anesthesiology and Critical Care
Medicine (School of Medicine), Health Policy and
Management (School of Public Health)
2Disclosure
- Lotus Forum has licensed the rights to the SAQ
described in this presentation. Dr. Sexton is the
inventor of the SAQ and a paid consultant to
Lotus Form. The terms of this arrangement are
being managed by the Johns Hopkins University in
accordance with its conflict of interest
policies.
3What of MI OR frontliners agree?
- OR Nurses I know the first and last names of all
the personnel I worked with during my last shift - Surgeons I know the first and last names of all
the personnel I worked with during my last shift - Anesthesiologists I know the first and last
names of all the personnel I worked with during
my last shift - CRNAs I know the first and last names of all the
personnel I worked with during my last shift
86 37 29 32
4Familiarity with others is a critical component
of effective teamwork
- 74 of all commercial aviation accidents happen
on the first day of a crew flying together - Familiarity trumps fatigue (simulator studies)
- Highlights the importance of predictable patterns
of behavior - Many teamwork tools, e.g., briefings are a proxy
for familiarity
5My suggestions about safety would be acted upon
if I expressed them to management.
of respondents that agree
n657 Clinical Areas from MI 2007
6- Tell me and I forget,
- Show me and I remember,
- Involve me and I understand.
- -Chinese Proverb
7Central Mandate
Scientifically Sound
Feasible
Local Wisdom
Measurement Culture balance
8Annual US Health
Research Funding
Millions of Dollars Spent
Sources ACP-ASIM Observer, 2001,
http//www.acponline.org/journals/news/feb01/clinr
esearch.htm Federal Funding and
Priorities for Health Services Research,
AcademyHealth, March 10, 2003.
9We are just beginning to understand the context
and delivery of care
10Safety Culture Primer
- The way we do things around here
- Measure of frontline caregiver consensus
- Predicts clinical and operational outcomes
- New field, evolving rapidly
- Assessing culture improvement is two-pronged
- Did the unit improve climate by 10 points or
more? - Did the unit maintain a good culture of 60 points
or more?
11Comparing Culture Surveys
SAQ 22 out of 23 characteristics
Qual. Saf. Health Care 200514364-366
12Respecting the Wisdomof Frontline Caregivers
The way we do things around here
Frontline caregiver assessments of safety culture
are measurable using the Safety Attitudes
Questionnaire, which is the most widely used and
thoroughly validated instrument in healthcare.
SAQ results are reliable, responsive to
interventions, and predictive of clinical and
operational outcomes. Most research has involved
teamwork and safety climate domains, which have
been linked to
- Decubitus Ulcers in Med/Surg Units
- Delays in OR and ICU
- Bloodstream Infections in the ICU
- VAP in the ICU
- Wrong Site Surgeries
- Post-Op Sepsis
- Post-Op Infections
- PE/DVT per 1000 surgical discharges
- RN Turnover
- Absenteeism
- Incident Reporting Rates/Reporting Harm
- Burnout
- Spirituality
- Unit Size
13SAQ Background
- The SAQ collects input from front-line
personnel to determine the strengths and
weaknesses of work settings. - Used in medical, aviation, maritime, rail
military settings - Administered in over 2000 hospitals (USA, United
Kingdom, Switzerland, Germany, Norway, Sweden,
Spain, Portugal, Italy, Turkey, New Zealand, and
Taiwan) - SAQ is a reliable tool and formally validated
- Sexton J.B., Thomas E, Pronovost P Context of
care and the patient care team The Safety
Attitudes Questionnaire. National Academies of
Science Report on Engineering in Healthcare.
Washington, DC The National Academies Press,
2005. - Sexton J.B., Helmreich RL, Neilands TB, Rowan K,
Vella K, Boyden J, Roberts PR, Thomas EJ. The
Safety Attitudes Questionnaire Psychometric
properties, benchmarking data, and emerging
research. BMC Health Services Research. 2006 Apr
36(1)44. - Sexton J.B., Makary MA, Tersigni AR, Pryor D,
Hendrich A, Thomas EJ, Holzmueller CG, Knight AP,
Wu Y, and Pronovost PJ. Teamwork in the Operating
Room Frontline Perspectives among Hospitals and
Operating Room Personnel. Anesthesiology. 2006
in press. - Sexton J.B., Holzmueller CG, Pronovost PJ, Thomas
EJ, McFerran S, Nunes J, Thompson DA, Knight AP,
Penning DH, Fox HE. Variation in Caregiver
Perceptions of Teamwork Climate in Labor and
Delivery Units. J Perinat.2006 in press. - Pronovost PJ and Sexton J.B., Assessing safety
culture guidelines and recommendations. Qual Saf
Health Care. 2005 14231-233
14SAQ items are grouped into 6 factors
15Teamwork Climate is the consensus of frontline
assessments of collaboration between caregivers
The Teamwork Climate Scale Items
- It is easy for personnel here to ask questions
when there is something that they do not
understand - I have the support I need from other personnel to
care for patients - Nurse input is well received in this clinical
area - In this clinical area, it is difficult to speak
up if I perceive a problem with patient care - Disagreements in this clinical area are resolved
appropriately (i.e. not who is right, but what is
best for the patient) - The physicians and nurses here work together as a
well-coordinated team
16SAQ Teamwork Climate Validity
- Sexton JB, Makary MA, et al. (2006) Teamwork in
the Operating Room Frontline Perspectives among
Hospitals and Operating Room Personnel.
Anesthesiology - Sexton JB, Holzmueller CG, et al. (2006)
Variation in Caregiver Perceptions of Teamwork
Climate in Labor and Delivery Units. Perinatology - Sexton JB, Helmreich RL, et al. (2006) The Safety
Attitudes Questionnaire Psychometric properties,
benchmarking data, and emerging research. BMC
Health Services Research
17Hospital Wide Culture
- Interesting
- Not the best unit of analysis masks variability
between work units
18The Clinical Area is the Locus of Safety
Results using the Safety Attitude
Questionnaire Variance decompositions conducted
using nearly 15,000 responses from more than 700
clinical areas of approximately 50 hospitals
19Teamwork Climate by MI Hospital
respondents reporting good teamwork climate
20Teamwork Climate across 535 Units
respondents reporting good teamwork climate
21JHH Culture SurveySafety Attitudes Questionnaire
- Participation is improving
- First robust signs of widespread improvement
- Average Response rates
- 2004 (75) 123 clinical areas 4965
- 2006 (77) 150 clinical areas 4497
- 2007 (75) 163 clinical areas 4798
- 98 clinical areas were linked from 2004 to 2007
(same unit, good response rate)
22Teamwork Climate across 100 Hospitals
of respondents reporting positive teamwork
climate
232007 Teamwork Climate Across Clinical Areas
NOTE Teamwork climate is negatively correlated
with annual nurse turnover rates, absenteeism,
BSI, PE/DVT, delays, and burnout
NOTE Teamwork climate is negatively correlated
with annual nurse turnover rates, absenteeism,
BSI, PE/DVT, delays, and burnout
Goal 80
of respondents reporting good teamwork climate
Needs improvement lt 60
24Teamwork Climate Across Michigan ICUs
The strongest predictor of clinical excellence
caregivers feel comfortable speaking up if they
perceive a problem with patient care
of respondents within an ICU reporting good
teamwork climate
25MI OR Teamwork Climate by Hospital
respondents reporting good teamwork
N69 sites from MI 2007
26MI Operating Room Physician and RN Collaboration
of respondents reporting above adequate teamwork
OR RN/Surg CRNA/Anesth
27Labor and Delivery Collaboration Map
Table 1 Labor Delivery Respondent
Demographics
28 Reporting Good Collaboration
Makary MA, Sexton JB, Freischlag JA, et al.JACS.
2006 May202(5)746-52.
w/ each other 96
70
Anesthesiologists
84
87
89
88
48
75
92
58
63
76
68
29Teamwork Climate Annual Nurse Turnover
reporting positive teamwork climate
30Communication Breakdowns are frequently the root
cause of undesirable outcomes
31Teamwork Disconnect
- RN Good teamwork means I am asked for my input
- MD Good teamwork means the nurse does what I say
32May 2006 2135 OR respondents 60 hospitals 77
response rate
33OR Teamwork Climate and Postoperative Sepsis
(per 1000 discharges)
May 2006 2135 OR respondents 60 hospitals 77
response rate
34Safety Climate Across ORs
of respondents within an OR reporting good
safety climate
35May 2006 2135 OR respondents 60 hospitals 77
response rate
36Teamwork Climate Across Clinical Areas
NOTE Teamwork climate is negatively correlated
with annual nurse turnover rates, absenteeism,
BSI, PE/DVT, delays, and burnout (see slide 62,
refs 9, 10, 14, 15, 16, 18)
Goal 80
of respondents reporting good teamwork climate
Needs improvement lt 60
37Disagreements In This Clinical Area Are Resolved
Appropriately (i.e. not who is right, but what is
best for the patient).
NOTE this item is typically negatively
correlated with annual nurse turnover rates
of respondents that agree
N69 sites from MI 2007
38Conflict Resolution Tools and Techniques
39Conflict Resolution in the OR
- Conflict was observed in 10 of flights and 10
of surgeries
- Resolved in 80 of instances in cockpit
- Resolved in 20 of instances in operating room
40(No Transcript)
41(No Transcript)
42Communication ratings in the O.R.
Communication was rated as poor in one out of
five procedures but what does it mean to get
ratings of poor?
- failed communication of skin incision
- failure to communicate removal of the aortic
cross-clamp - implementation of trendelenburg position without
notifying the surgeon - failure to communicate insufficient regional
anesthesia prior to incision.
43Behavioral Markers by Phase Related to Pt Harm
Induction BM Briefing Inquiry Assertion
Intraop BM Vigilance Info Sharing
Handoff BM Contingency Management
Regression of these BMs onto Pt Outcome score
captures 20 of the variability R.445, plt.001
44The Physicians And Nurses Here Work Together As
A Well-Coordinated Team.
NOTE this item is typically negatively
correlated with annual nurse turnover rates
of respondents that agree
N69 sites from MI 2007
45Shared Mental Models
46Communication breakdowns that lead to delays in
delivery of care are common.
of respondents that agree
N69 sites from MI 2007
47Next Steps
- Harness the wisdom of frontline caregivers
- Provide them the tools and opportunities to take
ownership of their local work environment - Integrate culture, tools, and next steps into
existing QI infrastructure, e.g. quality council,
patient safety committee, executive walkrounds,
etc.
48Safety Culture Debriefing Action Tool
- Safety Culture Debriefing Action
-
- OBJECTIVE Use the Debriefing Guide to
- conduct a 30-60min structured discussion
- produce a specific data-driven next step to
- improve the local environment in this unit.
-
- Debriefing Guide
- Review SAQ results with particular attention to
items with less than 60 agreement. - Which item(s) seem most relevant (items/why)?
- Which item is of particular concern to this unit
right now due to recent events or activities
(item/score/why)? - Share examples of how this item reflects your
events or experiences in this unit? - Envision an ideal unit what would it look like
if 100 of the caregivers in this unit agreed
strongly with the SAQ item (provide specific
behaviors, processes, norms, policies)? - Agree on one actionable step toward the ideal
unit (agree on the task the person responsible
the follow-up date the external committee or
leader to whom this plan is disclosed)?
Adapted from Sexton, Paine, et al. A Checkup for
Safety Culture in My Patient Care Area, Jt Comm
J Qual Patient Saf. 2007 Nov33(11)
49MI OR Teamwork Climate by Hospital
respondents reporting good teamwork
N69 sites from MI 2007
50OR Teamwork Climate by Hospital
respondents reporting good teamwork
Sexton JB, Makary MA, et al. Anesthesiology.
2006 Nov105(5)877-84.
51Setting the Stage Good Movie/Bad Movie
- The tone for communication and teamwork gets set
in literally seconds - Positive input is welcome, it feels safe, we all
know what is going to happen - Negative the plan is unclear, its hard to speak
up, lots of hierarchy, doesnt feel safe
52Improving OR Teamwork Through Briefings
- OR Briefing Guide
- Do we know names and roles of team members (is
there role clarity does each have experience w/
this procedure)? - Is the correct patient/procedure confirmed
(TIME-OUT)? - Were ABX given (if appropriate)?
- What are the critical steps of the procedure?
- What are the potential problems for this case
(Nursing, Anesth, Surg)? -
-
-
-vs.-
Evidence Based Briefing Fast Facts Purpose
Provide a simple structure in which the surgeon
can set expectations and make the surgical
procedure more predictable for everyone, while
improving the quality of information flow. Less
than 2 minutes, usually 90 seconds. Initiated by
Surgeon, but the circulating nurse can prompt if
surgeon forgets. Briefing comment examples If
something were to go wrong, what would it likely
be from your view? If anything doesnt look
right, let me know, and I will do the same for
you
53OR Teamwork Climate by Hospital
respondents reporting good teamwork
54Culture Nuggets
- Size of unit matters units with fewer than 40
caregivers often have a stronger consensus,
better culture, and better implementation of
innovations than units with over 80 caregivers - Improvement is harder in teaching hospitals than
faith based or community hospitals - Losing a particularly ineffective or unpopular
manager is a shock to many units transition is
associated with a drop in safety climate which is
the opposite of the expected improvement after
what is often a long awaited departure - Changes in geographic location, unit merging, and
changes in managers each negatively impact
teamwork and safety climate - Introducing new technology to a unit is often
associated with lower teamwork and safety climate
scores - E.g., POE, ORMIS, e-Mar, PAPR's and negative
pressure rms, PYXIS supply - This association appears to fade after 1 year
- What is going on in the low safety climate units?
- Changes in MD or RN leadership (not executive)
- had a facility redesign within existing unit
- Low safety climate units rely more on agency
nurses
55Take Home
- Improving Quality You should know your culture
to be effective stewards of limited quality
resources - Rigorous cultural assessment harnesses the wisdom
of the front line workers - Culture is related to clinical and operational
outcomes - Specifically teamwork climate and safety climate
- Culture is local work unit culture trumps
hospital culture - Beware of tagalong projects that piggyback on
successful quality and safety efforts - A little structure goes a long way to improve
communication daily goals, briefing, SBAR - Barriers to sustainability changes in
management, structure, staffing, leadership
attention span - Extraordinary consensus about culture within
units inter-rater reliability of over 80! - Patient safety and quality with methodological
rigor is a pioneering effort the science of
safety is racing to keep pace - Be ready to answer the question
- Are We Safer?
56References for Culture, Teamwork, and Patient
Safety Tools and Resources
- Pronovost P, Berenholtz S, Dorman T, Lipsett PA,
Simmonds T, Haraden C. Improving communication
in the ICU using daily goals. J Crit Care. 2003
18(2)71-75. - Pronovost PJ, Weast B, Bishop K, Paine L,
Griffith R, Rosenstein BJ, Kidwell RP, Haller KB,
Davis R. Patient Safety, - Senior Executive
Adopt-a-Work Unit A Model for Safety
Improvement. Jt Comm J Qual Saf. 2004
Feb30(2)59-68. - Thompson D, Holzmueller C, Hunt D, Cafeo C,
Sexton B, Pronovost P. A morning briefing
setting the stage for a clinically and
operationally good day. Jt Comm J Qual Patient
Saf. 2005 Aug31(8)476-479. - Sexton JB, Thomas E, Pronovost P. Context of care
and the patient care team The Safety Attitudes
Questionnaire. National Academies of Science
Report on Engineering in Healthcare. Edited by
Reid P, Compton W, Grossman J, Fanjiang G.
Washington,DC, The National Academies Press,
2005, pp 119-23. - Pronovost PJ, Weast B, Rubin H, Rosenstein B,
Sexton JB, Holzmueller C, Paine L, Davis R, Rubin
H. Implementing and validating a comprehensive
unit-based safety program. Journal of Patient
Safety. 2005 1(1)33-40. - Pronovost PJ, Sexton JB. Assessing safety
culture guidelines and recommendations. Qual Saf
Health Care 2005 14231-233. - Thomas EJ, Sexton JB, Neilands TB, Frankel A,
Helmreich RL. The effect of executive walk rounds
on nurse safety climate attitudes A randomized
trial of clinical units. BMC Health Serv Res.
2005 Jun 85(1)4. - Pronovost PJ, Holzmueller CG, Martinez E, Cafeo
CL, Hunt D, Dickson C, Awad M, Makary,MA. A
Practical Tool to Learn From Defects in Patient
Care. Joint Commission Journal on Quality and
Patient Safety, 2006 Feb 32 (2)102-108(7) - Sexton JB, Helmreich RL, Neilands TB, Rowan K,
Vella K, Boyden J, Roberts PR, Thomas EJ. The
Safety Attitudes Questionnaire Psychometric
properties, benchmarking data, and emerging
research. BMC Health Services Research. 2006 Apr
3644. - Makary MA, Sexton JB, Freischlag JA, Holzmueller
CG, Millman EA, Rowen L, Pronovost PJOperating
room teamwork among physicians and nurses
teamwork in the eye of the beholder. Journal of
the American College of Surgeons. 2006
May202(5)746-52. - Makary MA, Holzmueller CG, Sexton JB, Thompson
DA, Martinez E, Freischlag JA, Ulatowski JA,
Heitmiller ES, Rowen L, Pronovost PJ. Operating
Room Debriefings. Jt Comm J Qual Patient Saf.
2006 Jul32(7)407-10, 357. - Pronovost P, Holzmueller CG, Needham DM, Sexton
JB, Miller M, Berenholtz S, Wu AW, Perl TM, Davis
R, Baker D, Winner L, Morlock L. How will we know
patients are safer? An organization-wide approach
to measuring and improving safety. Crit Care Med.
2006 Jul34(7) 1988-95. - Rose JS, Thomas C, Tersigni A, Sexton J.B., Pryor
D. A leadership framework for culture change in
healthcare. Jt Comm J Qual Patient Saf. August
200632(8)433-42. - Pronovost PJ, Berenholtz SM, Goeschel CA, Needham
DM, Sexton JB, Thompson DA, Lubomski LA,
Marsteller JA, Makary MA, Hunt E. Creating high
reliability in health care organizations. HSR.
2006 Aug41(4Pt 2)1599-617. - Sexton JB, Holzmueller CG, Pronovost PJ, Thomas
EJ, McFerran S, Nunes J, Thompson DA, Knight AP,
Penning DH, Fox HE. Variation in caregiver
perceptions of teamwork climate in labor and
delivery units. J Perinatol. 2006
Aug26(8)463-70. - Sexton J.B., Makary MA, Tersigni AR, Pryor D,
Hendrich A, Thomas EJ, Holzmueller CG, Knight AP,
Wu Y, and Pronovost PJ. Teamwork in the operating
room frontline perspectives among hospitals and
operating room personnel. Anesthesiology. 2006
Nov105(5)877-84. - Makary MA, Mukherjee A, Sexton JB, Syin D,
Goodrich E, Hartmann E, Rowan L, Behrens DC,
Marohn M, Pronovost PJ. Operating room briefings
and wrong-site surgery. JACS. 2007
Feb204(2)236-43. - Thomas EJ, Taggart B, Crandell S, Lasky RE,
Williams AL, Love LJ, Sexton JB, Tyson JE,
Helmreich RL. Teaching teamwork during the
Neonatal Resuscitation Program a randomized
trial. J Perinatol. 2007 Jul27(7)409-414. - Pronovost PJ, Needham D, Berenholtz SM, Sinopli
D, Chu H, Cosgrove S, Sexton JB, Hyzy R, Welsh R,
Roth G, Bander J, Diovine B, Kepros J, Goeschel
C. A Multi-Faceted Intervention to Reduce
Catheter-Related Blood Stream Infections in
Michigan Intensive Care Units. NEJM 2006, in
press.
57End Slide