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Medical Office Survey on Patient Safety Culture Initiatives MARIAH RAMIREZ MENTOR: KATHY DONOHUE BSN,MBA,CHCQM,CPPS DIRECTOR AMBULATORY QUALITY CEQI

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Page 1: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

MedicalOfficeSurveyonPatientSafetyCultureInitiativesMARIAHRAMIREZMENTOR: KATHY DONOHUEBSN ,MBA ,CHCQM,CPPS D IRECTORAMBULATORY QUAL ITY CEQI

Page 2: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

AgendaI.TheRealityofMedicalErrorsII.Definition:PatientSafetyCultureIII.OverviewofAHRQ2016MedicalOfficeSurveyonPatientSafetyCultureIV:DescriptionofSummerProject◦ Methods◦ Initiatives◦ EvaluationTool

V:MyRole/LearningExperience

Page 3: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

TheRealityofMedicalErrorsinHealthcareSetting

1jet/day

44,000-98,000/year

Source:ToErrisHuman:BuildingaSaferHealthSystem,1999

Page 4: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

Whatis“PatientSafetyCulture”?

“…theproductofindividualandgroupvalues,attitudes,perceptionsandpatternsofbehaviorthatdeterminethecommitmentto,andthestyleandproficiencyof,anorganization’shealthandsafetymanagement.”

Page 5: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

AHRQ2016MedicalOfficeSurveyonPatientSafetyCulture

Administeredtostaffandfacultyofambulatorycarecentersincludes:nurses,physicians,front-deskstaff,medicalassistants,nursepractitioners,etc.

PurposeofAHRQSurvey:◦ Canassessthebaselinestatusofthepatientsafetycultureinamedicaloffice

◦ Canactasaninterventiontoraisestaffawarenessaboutpatientsafetyissues

◦ Canbeamechanismtoevaluatetheimpactofpatientsafetyimprovementinitiatives

◦ Isawaytotrackchangesinpatientsafetycultureovertime

Page 6: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

10DomainsMeasuredStaffTraining

OfficeProcessandStandardization

CommunicationaboutError

CommunicationOpenness

WorkPressureandPace

PatientCareTrackingandFollow-Up

OverallPerceptionsofPatientSafetyandQuality

Teamwork

LeadershipSupportforPatientSafety

OrganizationalLearning

Page 7: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

CharacteristicsofSurveyRespondentsComparativeAHRQDatabase ClinicalPracticesoftheUniversityof

Pennsylvania(CPUP)

25,127medicalofficerespondentsClinicalStaffAdministrativeStaffRegisteredNurses

1,952medicalofficerespondentsPhysiciansAdministrativeorClericalStaffAdvancedpracticenurse

AreasofStrengthTeamworkPatientCareTracking/Follow-Up

AreasofStrengthTeamworkPatientCareTracking/Follow-UpOverallPerceptionsofPatientSafety

AreasofOpportunityWorkPressureandPaceCommunicationaboutError

AreasofOpportunityWorkPressureandPaceCommunication aboutErrorOfficeProcessesandStandardization

Page 8: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

AimofSummerProjectGoal:

ImprovePatientSafetyCultureacrosstheClinicalPracticesofUniversityofPennsylvania

Objectives:

RaiseawarenessaboutcurrentstateofsafetycultureacrossCPUP

Designandimplementinterventionstonarrowgapsinsafetyculture

Maintainimprovementsachievedinpatientsafetyculture

PerceivedCultureofSafetyPatientSafety

Page 9: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

InitiativesImplementedtoAchievetheAim

1– Signage

2- LanguageofSafety

3 – Department-LevelDataPresentations

4 - Penn-SpecificPatientSafetyCultureToolkit

Page 10: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

RaisingStaffAwareness:DataPresentationMeetings

Page 11: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

RaisingStaffAwareness:CultureofSafetyToolkitConstruction

2AreasofFocus

- OfficeProcessandStandardization◦ WorkPressureandPace

- Communication◦ CommunicationOpenness◦ CommunicationaboutError

PatientCareTrackingandFollow-Up

StaffTraining

OverallPerceptionsofPatientSafetyandQuality

OfficeProcessandStandardization

Teamwork

CommunicationaboutError

LeadershipSupportforPatientSafety

CommunicationOpenness

OrganizationalLearning

WorkPressureandPace

Page 12: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers
Page 13: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

SafetyInitiativesbyDepartment

Page 14: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

EvaluationTool:PennMedicineSafetyNet

- Flexible,web-basedeventreportingtool

- TracksmedicalerrorsthroughreportingofincidentsbyallPennMedicineemployees

- SubmissionExamples:- Labelingerrorsontests- Patientfall- “Near-miss”events- Equipmentunavailableorbroken

Page 15: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

EvaluatingtheImpact

Difficultyinmeasuringculture:- CurrentMeasure:

- SafetyNetSubmissionsasaproxyvariable

- FutureMeasure:- Resultsof2018MedicalOfficePatientSafetyCultureSurvey

Page 16: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

MyRoleEvaluatetheimpactofpatientsafetyinitiativesbydepartment◦ DataPresentationMeetingsAttendee◦ Collectedsafetyinitiativesofall19departmentsofCPUP

◦ CreatedanddisseminatedCultureofPatientSafetyToolkitthroughoutCPUP◦ PresentedworkperiodicallytoQualityViceChairsMeetingandDataPresentationMeetingsforfeedback

Page 17: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

MyLearningExperiencePresentationSkills

Interactionwithmedicalstaff

Theimportanceoftakinginitiative

Beingreceptivetoconstructivecriticismandfeedback

PatientSafetyCultureknowledge

Understandingofessentialcomponentswithinahealthsystemthatarecrucialforsuccess

Page 18: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

AcknowledgementsKathyDonohue– Mymentor

DavidHorowitz,MDCPUPChiefMedicalOfficer

BarbaraPriorMSN– CPUPAssociateExecutiveDirector

LaquishaReed– CEQIAdministrativeCoordinator

CEQIOffice

SUMR2017Cohort

JoanneLevy

SafaBrowne

LeonardDavisInstituteforHealthEconomics

Page 19: Medical Office Survey on Patient Safety Culture Initiatives · AHRQ 2016 Medical Office Survey on Patient Safety Culture Administered to staff and faculty of ambulatory care centers

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