Welcome to the Leadership for Safety Webinar
Safety Attitude Questionnaire:
Unit-Level Results on Teamwork and Non-Punitive
Response to Error
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Agenda for Today’s Webinar
•
Unit-level COS results from San Francisco General
Hospital, and UT Tyler
•
Unit by unit COS data, resilience, and readiness for change
•
Run chart “poster session”
•
Next month’s focus: Just Culture – How to know whether
to hold an individual to account for a safety mishap.
Who is on Today’s Call?
Jim Reinertsen, MD
Bart Hill, MD, MPA
Sue Currin, MS, RN
St. Luke’s Treasure Valley
St. Luke’s Regional Medical Center
St. Luke’s Meridian Medical Center
Alfred Connors, MD
Cook County Health & Hospitals System
John H. Stroger, Jr. Hospital
Provident Hospital
San Francisco General Hospital and Trauma Center
Contra Costa Regional Med. Center
Alameda County Medical Center
Santa Clara Valley Health and Hospital System
Truman Medical Centers
TMC- Hospital Hill
TMC- Lakewood
San Mateo Medical Center
Jill Steinbruegge, MD, PhD
MetroHealth
Bianca Perez, PhD
Regional Medical Center at Memphis
Los Angeles County Department
of Health Services
Harbor-UCLA Med Center
LAC+USC Healthcare Network
Rancho Los Amigos National
Rehab. Center
Kimberly Horton, DHA,
MSN, FNP, RN, FACHE
Maricopa Medical Center
UT-Health Science Center at Tyler
Univ. Medical Center of El Paso
Harris County Health System
Ben Taub General
LBJ Hospital
Quentin Mease
LSU-HCSD
Interim
Bogalusa
Arielle Gorstein
Leadership Summit staff
Thomas Holton, MS, RN
Guest speakers on today’s call
David Coultas, MD, FACP
University of Texas – Tyler
Comparative Results By Unit
Teamwork Across Units
1. Hospital units do not coordinate well
with each other.
2. There is good cooperation among
hospital units that need to work together.
3. It is often unpleasant to work with staff
from other hospital units.
4. Hospital units work well together to
provide the best care for patients.
Database
Your
Hospital
Unit 1 2012
Unit 1 2010
36
36
33
45
48
46
33
55
50
49
58
45
58
56
58
64
Difference
-12
Your
Hospital
Database
Your
Hospital
Database
Your
Hospital
Unit 1 2012
Unit 1 2010
Database
84
84
Your
Hospital
92
73
86
86
85
73
Database
2. When a lot of work needs to be done
quickly, we work together as a team to get
the work done.
3. In this unit, people treat each other with
respect.
4. When one area in this unit gets really
busy, others help out.
-22
13
2. When an event is reported, it feels like
the person is being written up, not the
problem.
3. Staff worry that mistakes they make are
kept in their personnel file.
43
39
33
55
57
53
56
64
63
62
75
73
66
63
Difference
-22
Unit 3 2012
Unit 3 2010
44
43
35
14
58
56
50
43
61
60
47
53
66
65
Difference
21
Unit 4 2012
Unit 4 2010
48
46
100
60
63
60
80
80
64
64
80
80
71
69
Difference
40
Unit 5 2012
Unit 5 2010
41
39
75
65
55
54
75
52
56
55
92
71
65
63
Difference
10
Your
Hospital
Database
74
74
Your
Hospital
77
50
Database
67
67
Your
Hospital
69
36
-8
2
7
-6
0
0
23
21
-6
63
36
27
57
47
10
100
100
0
92
62
30
Difference
Unit 2
2012
Unit 2
2010
Difference
Unit 3 2012
Unit 3 2010
Difference
Unit 4 2012
Unit 4 2010
Difference
Unit 5 2012
Unit 5 2010
Difference
89
89
85
84
92
92
83
83
100
100
82
81
100
100
100
78
90
90
81
81
90
89
86
86
100
100
85
75
100
100
100
87
80
80
77
76
88
87
73
73
100
100
85
75
100
100
100
74
77
77
64
62
77
75
65
65
19
12
27
0
0
0
1
10
10
0
0
0
22
13
26
33
67
67
0
52
56
-4
100
100
0
100
52
48
Difference
Unit 2
2012
Unit 2
2010
Difference
Unit 3 2012
Unit 3 2010
Difference
Unit 4 2012
Unit 4 2010
Difference
Unit 5 2012
Unit 5 2010
Difference
46
46
46
46
64
64
48
49
Nonpunitive Response to Error
1. Staff feel like their mistakes are held
against them.
Unit 2
2010
Database
Teamwork Within Units
1. People support one another in this unit.
Unit 2
2012
Unit 1 2012
Unit 1 2010
43
43
58
38
36
38
22
33
43
45
41
-12
38
44
25
42
13
80
62
100
61
-20
50
46
39
46
11
62
28
36
27
26
33
31
27
30
6
45
32
6
31
39
40
52
60
50
-20
50
35
43
34
7
Database
Your
Hospital
31
36
-5
25
18
7
15
6
9
80
20
60
42
48
-6
Database
Your
Hospital
Database
Your
Hospital
Unit by Unit COS data, Resilience,
and Readiness for Change
7
From Bryan Sexton
9
Key Domain One: Teamwork
Driven by Answers to Six Questions
1.
Nurse input is well received in this clinical area.
2.
In this clinical area, it is difficult to speak up if I perceive a problem with
patient care.
3.
Disagreements in this clinical area are resolved appropriately (i.e., not
who is right, but what is best for the patient).
4.
I have the support I need from other personnel to care for patients.
5.
It is easy for personnel here to ask questions when there is something
that they do not understand.
6.
The physicians and nurses here work together as a well-coordinated
team.
10
A poor teamwork score (less than 60%
reporting positive teamwork)…
• Results from persistent interpersonal dysfunction on the unit
• Predicts operational outcomes e.g. staff turnover, delays, etc.
Needs a specific leadership response: If teamwork
score is low, find out which of the questions is
dragging the score down and address that issue
specifically
Key Domain Two: Safety Climate
Determined by scores on seven questions:
1. I would feel safe being treated here as a patient.
2. Medical errors are handled appropriately in this clinical area.
3. I know the proper channels to direct questions regarding patient safety
in this clinical area.
4. I receive appropriate feedback about my performance.
5. In this clinical area, it is difficult to discuss errors.
6. I am encouraged by my colleagues to report any patient safety concerns
I may have.
7. The culture in this clinical area makes it easy to learn from the errors of
others.
Poor safety climate scores (<60%)…
• Predict poor clinical outcomes, and high staff injury
rates
• Result from perceived lack of commitment to safety by
leadership
• Leadership response: demonstrate eagerness to learn
about safety problems, and willingness to do something
about them
Key Support Domain: Resilience (Burnout)
Determined by scores on four questions:
1.
2.
3.
4.
I feel fatigued when I get up in the morning and a have to face
another day on the job
I feel burned out from my work
I feel frustrated by my job
I feel I am working too hard on my job
Leadership Response:
For units with HIGH resilience, you can go ahead with a new initiative even if
safety or teamwork scores are low (but you will need to address the specifics
of why these scores are low)
For units with low resilience AND low teamwork/safety climate scores, you
must first deal with the burnout issues before you can hope to accomplish
ANY change initiative.
The MetroHealth System
Run charts for 2010, 2011, 2012 for
VAP, CLBSI, and CAUTI
Catheter Related Bloodstream Infections (CLBSI),
2010 to 2012
60
2.91*
2.58*
*infections per 1000 catheter days
Number of infections
50
40
1.86*
30
20
10
0
ICU
Non-ICU
2010
2011
2012
14
40
23
28
10
25
16
Ja
n
Fe -10
b
M -10
ar
Ap -10
M r-10
ay
Ju 10
n1
Ju 0
l-1
Au 0
g
Se -10
p
Oc -10
t
No -10
v
De -10
cJa 10
n
Fe -11
b
M -11
ar
Ap -11
M r-11
ay
Ju 11
n1
Ju 1
l
Au -11
g
Se -11
p
Oc -11
t
No -11
v
De -11
cJa 11
n
Fe -12
b
M -12
ar
Ap -12
M r-12
ay
Ju 12
n1
Ju 2
l-1
Au 2
g
Se -12
p
Oc -12
t
No -12
v
De -12
c12
Total Hospital Acquired Catheter Related Bloodstream Infections
(ICU and non-ICU, 2010 to 2012)
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
14
9
8
4
4
4
4
1
8
8
7
6
5
2
1
5
3
3
2
2
6
5
4
4
3
4
3
3
2
2
1
1
1
1
0
17
Ventilator Associated Pneumonia (VAP)
2010 to 2012
60
4.81*
4.69*
*pneumonias per 1000 ventilator days
Number of infections
50
40
4.14*
30
20
10
0
VAP
2010
2011
2012
51
51
35
18
Ja
n
Fe -10
M b-1
a 0
Apr-10
M r-1
ay 0
Ju -10
n
Ju -10
Au l-10
g
Se -10
p
Oc -10
No t-10
Dev-10
c
Ja -10
n
Fe -11
M b-1
a 1
Apr-11
M r-1
ay 1
Ju -11
n
Ju -11
Au l-11
g
Se -11
p
Oc -11
No t-11
Dev-11
c
Ja -11
n
Fe -12
M b-1
a 2
Apr-12
M r-1
ay 2
Ju -12
n
Ju -12
Au l-12
g
Se -12
p
Oc -12
No t-12
Dev-12
c12
Infections/Month
Ventilator Associated Pneumonia
2011 to 2012
8
7
4
1
0
7
5
5
4
3
2
1
5
7
7
7
5
4
3
2
7
6
6
5
5
6
5
5
4
4
3
3
2
1
3
3
1
4
3
4
3
2
1
0
19
Catheter Associated Urinary Tract Infection (CAUTI)
2010 to 2012
180
8.71*
160
Number of Infections
140
4.12*
*infections per 1000 catheter days
120
100
3.11*
80
60
40
20
0
CAUTI
2010
2011
2012
167
119
76
20
Ja
n
Fe -10
b
M -10
ar
Ap -10
M r-10
ay
Ju -10
nJu 10
Au l-10
g
Se -10
p
Oc -10
t
No -10
v
De -10
c
Ja -10
n
Fe -11
b
M -11
ar
Ap -11
M r-11
ay
Ju -11
nJu 11
Au l-11
g
Se -11
p
Oc -11
t
No -11
v
De -11
c
Ja -11
n
Fe -12
b
M -12
ar
Ap -12
M r-12
ay
Ju -12
nJu 12
Au l-12
g
Se -12
p
Oc -12
t
No -12
v
De -12
c12
Infections/Month
40
20
5
Catheter Associated Urinary Tract Infections (CAUTI)
(ICU and non-ICU)
35
36
Change in CAUTI definition
33
30
31 31
29
27
25
23
20
28
26
24
23
19
15
16
10
11
7
16
13
10
10
8
6
7
4
10
7
6
7
8
3
4
9
5
3
4
0
21
Total BSI, VAP, UTI
2011 to 2012
250
200
51
34% reduction
2011 to 2012
150
51
35
100
50
35
118
75
0
2011
2012
CAUTI
CLBSI
VAP
Total BSI, VAP and CAUTI
2011 to 2012
40
35
34
30
30
25
26
25
23
22
22
20
18
16
15
18
17
16
15
13
13
17
16
14
12
12
10
13
9
7
5
Total VAP, CLBSI, & CAUTI
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Mar-11
Feb-11
Jan-11
0
Linear (Total VAP, CLBSI, & CAUTI)
23
Next Month:
Tuesday February 12th 8am PT/9am MT/10am CT/ 11am ET
Just Culture
1. Have a brief conversation with the chief nurse, or the head of HR,
and ask the following questions:
 Did we initiate disciplinary action against any staff member (nurse, pharmacist,
physician, nursing assistant…) because of a safety mishap in the last year?
 If yes…by what method did we decide that this was a problem with the
individual? What is our method for determining individual culpability for safety
mishaps?
2. Be prepared to discuss what you’ve learned about your
organization and how it decides when to hold people to account for
their safety behaviors.

Just Culture Algorithm, HR protocols, or other document
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