The #1 topic they didn’t teach you in Paramedic School: Culture

I have been working with the Center for Patient Safety (CPS) for about four months, and I’m learning something new every day.  As a Paramedic, patient safety has always been a high priority, but I didn’t know how an organization’s culture could impact the delivery of care.

Much of what we do at CPS is to educate, inform and help others make the connection between culture and safety.  While that might sound simple, it’s a rather complicated task.  Also, it’s about finding leaders and providers that are willing to listen and learn about these concepts that aren’t taught in Paramedic school.

Culture is comprised of many things including the collective beliefs, attitudes, perceptions, and values of the employees and the entire organization. How would you describe your organization’s culture? Did you know that you can measure it?

The EMS Safety Culture Assessment provided by CPS offers an organization the tools to understand their strengths and opportunities when it comes to their safety culture.  Many use it as a tool before implementation of just culture or as a baseline measurement of the values within their organization and then come back a year later and re-measure to see how their work has improved the safety culture.

The Safety Culture Assessment can also help with local or regional quality improvement projects and initiatives as it measures areas such as patient handoffs and communications between healthcare providers. These are just a few reasons why measuring your culture should be something that is not only accepted by EMS but expected in EMS just as it is in other healthcare settings.

Years ago I worked as a flight Paramedic and the safety culture in an air-based service seemed to be more advanced since it was linked to aviation. It was acceptable to turn down a flight and have a safe time-out due to severe exhaustion or if something didn’t seem right. As a ground paramedic, a safety time-out didn’t exist and many had never heard of it. Today, many years later, safety precautions like time-outs, are more common and practiced within a growing number of ground organizations.

One of the interesting things I get to do in my new position is listen to how leaders and providers describe their safety culture.  However, just like the safety time-out, many have never thought about it or can’t describe it.

One agency recently completed the EMS Safety Culture Assessment and learned of staff concerns regarding a change from 24-hour shifts to 48-hour shifts and how that change could impact patient and provider safety. As a result, the ground service implemented a time-out policy that addresses exhaustion, a pro-active approach to building a safe culture.

Do you have a safe organization where employees come to you with concerns about an unsafe situation or when a mistake occurs? Alternatively, are you the Chief that believes near misses and mistakes do not happen within your organization? How do you truly know the thoughts and feelings of the employees within your organization if you haven’t assessed the culture or given them the opportunity to speak up without the fear of repercussions from their colleagues and administration?

Our mission at the Center for Patient Safety is: Reducing preventable harm, but what does that mean and how do you accomplish that? The EMS Safety Culture Assessment is the first step in recognizing and learning about the culture component of your organization.

The EMS Safety Culture Assessment provided by CPS gives employees a voice that is trusted and de-identified so they can speak up without fear of retribution from colleagues or punishment from administration. The assessment also helps administration recognize the need to fulfill a safe practice and utilize the results to make positive changes within their organization.

Shouldn’t all first responders feel safe within the environment they call their second home?

Please contact me so we can start your EMS safety journey today! Your employees and your community are counting on you!

Shelby Cox

AHRQ Posts Medical Office Toolkit for Tests

Some of the best-known safety speedbumps for physician practices lie in the patient testing area.  Orders have to be developed and communicated, results communicated from the lab to the office and then to the patient or other providers.  The provider who ordered the test has to see the results and react appropriately.  Documentation of this process needs to be complete and accurate.   AHRQ has developed a toolkit to address this issues in collaboration with the University of Colorado.  It is available here.  [link:  https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/ambulatory-care/labtesting-toolkit.html?utm_source=ahrq&utm_medium=en&utm_term=&utm_content=1&utm_campaign=ahrq_iltp_2018]  And remember that in support of that work, the Center for Patient Safety offers the AHRQ Safety Culture Survey for Medical Offices, along with follow-up support to improve the culture behind the work.

 

CPS Safety Culture Assessment

“I am very impressed with the reports. I know my leadership team will be thrilled to have the individual reports by their division. This
has been a very positive experience for me.”

“We love the Center’s patient safety culture survey feedback reports. The department level reports give a level of granularity we
were lacking with previous surveys.”

The Center focuses heavily on culture to support patient safety improvement. A punitive environment discourages open communication of events and near misses, creating a barrier to learning about the mistakes that are occurring.

The Center has been administering the AHRQ Surveys on Patient Safety (SOPS) since 2011. Since then, we have administered hundreds of thousands of surveys and provided survey support, feedback reports, and consultation to hundreds of organizations.

A select group of 42 hospitals were selected from the 2016 database. These organizations were selected based on their activity level and extended use of the Center’s resources and services for PSO participation, webinar attendance, resource usage, and consulting. An analysis of their patient safety culture scores are compared to the national compare database from AHRQ. More than 14,000 surveys were analyzed.

  • 7 dimensions were equal to or higher than the 50th AHRQ Percentile
  • “Nonpunitive Response to Error” ranked in the 75th AHRQ Percentile
  • 23 questions were equal to or higher than the 50th AHRQ Percentile
  • “We are actively doing things to improve patient safety” ranked in the 90th AHRQ Percentile

The top strengths for these organizations align with the top strengths from the 2016 AHRQ Hospital Compare Database:

However, the areas with potential for improvement, or the lowest scoring dimensions, indicate variation in two of the composite scores:

The Center has had a long history with a focus on creating a nonpunitive environment. The dimension includes the question “Staff worry that mistakes they make are kept in their personnel file.” The higher score for the composite “Nonpunitive Response to Error” is statistically significant (>5%). Compared to the national average, the organizations in our select group are in the 75th percentile nationally.  While most of the respondent emographics for the hospitals included in the Center’s summary align with the AHRQ Compare Database, it is worth noting:

  • 15% of staff indicated they report 11-20 event reports per year; 29% indicated they report 3-5 events per year (statistically significant variation from AHRQ National Compare Database)
  • Higher numbers of reports suggest an environment that supports open communication without a fear of retribution or punishment.

Additional notes:

  • 85% of respondents had direct patient care
  • 41% of staff worked 1-5 years in the current work area
  • 36% of staff worked 1-5 years in the current hospital; 13% worked 21 years or more in the current hospital
  • 44% of staff indicated they were a Registered Nurse

Click here to download the full data report.

Interested in receiving reports like this for your organization’s departments or locations? Request a no obligation price estimate with a summary of the Center’s survey administration services.

The Joint Commission released Sentinel Event Alert #57

The Joint Commission released Sentinel Event Alert #57 this week:  The Essential Role of Leadership in Establishing a Patient Safety Culture.

The Center for Patient Safety supports the 11 patient safety tenets and provides services and supports to help health care providers across the continuum improve patient safety.  For additional information contact us.

It’s Patient Safety Awareness Week – #PSAW2017

The Center for Patient Safety encourages providers to use the week as a great way to remind the staff and community of their commitment to safety.
It should be a time of celebration of successes, but also a time of reflection.

In recognition of the week, and the efforts that continue every day throughout the year, the Center for Patient Safety is offering a 20% discount on the already affordable safety culture survey services. Download a proposal with sample feedback reports and an online sample survey link. We encourage the use of the survey as a diagnostic tool to assess your culture. Get started today and take advantage of the offering!

Several available toolkits can support your improvement efforts. It’s easy to start with tools that have already been developed and proven successful:  10 Patient Safety Tips for Hospitals

We also want to remind you that consumer involvement is important to ensure a successful patient safety program. The Agency for Healthcare Research and Quality provides several flyers and videos that can complement your events and programs during Patient Safety Awareness Week:

Patient Safety Awareness Week Approaches, March 12-18th

The Center for Patient Safety (CPS) encourages all healthcare organizations to use Patient Safety Awareness Week, March 12-18th, as a way to remind staff and community of your commitment to safety. It should be a time of celebration of successes, but also a time of reflection.

Free Toolkit for Patient Safety Awareness Week 2017

CPS reminds you to plan in advance for Patient Safety Awareness Week. Plans don’t have to be time consuming or extravagant, but a little planning can go a long way. We recommend hosting an event or several events to recognize patient safety efforts at your organization.

For example:

  • Recognize staff and committees that work every day to provide safe care
  • Launch a patient safety culture assessment during the week (mention this blog and receive 10% off your survey services through CPS!)
  • Have leadership, patient safety/risk/quality department and/or safety committees host events in the cafeteria with snacks or dessert or something special to celebrate safety at their organization
  • Ask departments to develop poster presentations of their successful safety efforts. Display in hallways.
  • Hang a safety awareness week poster in the foyer of the organization with signatures from all staff
  • Hold safety-focused training during Patient Safety Awareness Week
  • Publish safety-focused articles for the organization’s internal newsletter, professional newsletters, local newspapers, local consumer groups
  • Contact a local radio station to host a spokesperson to share patient safety tips and highlights
  • Launch a new safety awareness effort – a “good catch” program, implement a new “CUSP Team”, announce an upcoming “Safety Culture Survey”, etc.

Several available toolkits can support improvement efforts. It’s easy to start with tools that have already been developed and proven successful:  10 Patient Safety Tips for Hospitals

We also suggest you consider consumer involvement to ensure a successful week. The Agency for Healthcare Research and Quality provides several flyers and videos that can complement events and programs during Patient Safety Awareness Week:

Visit www.unitedforpatientsafety.org for more information and resources about #PSAW2017.

FREE WEBINAR – Safety Culture Assessment for LTC

Culture impacts everything we do. And it’s no different in health care organizations. The strongest cultures support employee engagement, promote open communication and the sharing of mistakes to foster improvement.

Learn about how the Center’s administrative survey can save you time and money and why measuring your culture is so important to improve patient safety.

Webinar – Tue, Nov 1, 2016 1:00 PM – 2:00 PM CDT

Register Here!

Free Webinar For Hospitals on Survey on Patient Safety

Culture impacts everything we do.  And it’s no different in health care organizations.  The strongest cultures support employee engagement, promote open communication and the sharing of mistakes to foster improvement.

Learn about how the Center’s survey administrative survey can save you time and money and why measuring your culture is so important to improve patient safety.

Friday, September 9th from 12-1pm (Central) – REGISTER

The Center for Patient Safety is hosting a webinar to share information and answer questions on how taking the Survey on Patient Safety can help you improve patient safety:

Benefits of CPS Safety Culture Survey Services:

  • Deepest feedback reports in the industry!
  • Comprehensive reports at the organization and department-level!

SAVE TIME & MONEY! Save 30+ hours of administrative time.  You’ll need about 2 hours for the entire process and we’ll take care of the rest!

  • ACCESSIBLE – online, anonymous survey with access via computer, smart-phone, tablet, etc
  • DATA ANALYSIS – data is analyzed for you
  • SUPPORT – we’ll talk with you about your results and guide you to your next steps

Learn More about SOPS

Cultural Transformation

A study completed at The Ohio State University, and published in the American Journal of Medical Quality, shows a patient safety cultural transformation after implementation of Crew Resource Management.  AHRQ’s Survey of Patient Safety (SOPS) tool was used to measure progress of the culture improvement.  The Center for Patient Safety offers low-cost, high-value administration and department-level analysis of the AHRQ safety surveys.  Contact us!

 

CPS Newsletter, Summer Edition Released!

NewsImageThe latest newsletter from the Center for Patient Safety has been released. You won’t want to miss the best practices and patient safety resources in this issue!

View this newsletter

A NEED FOR SPEED
Improving Event Investigation through the Development of SPRINT: Serious Patient Safety Event Rapid Investigation Teams. 4

THE ORANGE DOOR
Facing use of street drugs and alcohol, and decreased availability of medical care and facilities for individuals suffering mental or behavioral illnesses, Liberty Hospital has been able to stem the tide using a multi-disciplinary approach to helping create a safer care environment for staff and patients alike. 6

A UNITED FRONT TO IMPROVE CARE
What the AHRQ guidance means for providers and their patients. 11

PSO LEGAL UPDATE:
Cases involving the Patient Safety and Quality Improvement Act continue to work their way through state and federal courts. 15

EMS UPDATE:
New CPS report seeks to raise awareness of safety concerns in the EMS community. 16

ALSO IN THIS ISSUE:

  • Call to Action: Change the Statistic
  • Safety Insider
  • Watch Your Step, a Falls Analysis
  • New CPS Report Seeks to Raise EMS Awareness: EMSForward
  • CPS Unveils New Website
  • Put the Focus on Safer Care in EMS Community
  • PSO Update: For PSO Participants

BLOG:

PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

Read More

RESOURCES:

The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.