I1q12009

Issue 1: Quarter 1 February, 2009

Newsletter Total Benchmark Solution, LLC’s (TBS) mission is to provide a solution to analyze and benchmark Quality Practices and Performance that executives, nurses, physicians, and care professions can understand and act upon in order to improve quality of care. We now provide a solution to automate your AHRQ Hospital Survey on Patient Safety Culture needs. We strongly encourage healthcare organizations to make a commitment to measuring and benchmarking their quality and patient safety performance. This is not a one time organizational event but an ongoing commitment to providing the best possible care for the patients an organization serves. We encourage organizations to purchase a subscription to our solution and implement an organizational process to use our solution to improve patient safety and quality of care.

Contact Us: For more information or a demo on our Survey Solutions contact us by phone at: (800) 940-0424 or online at:

Hospital SOP’s: Tips for Increasing Success:           

Benchmark Internally and Externally Evaluate change and track progress over time Identify differences within units/departments Recognize potential for low response rate and survey “fatigue” given competing surveys, busy clinical environment; undertake strategies to maximize response rates Use Graphs as reasons for actions. Where you score lower than your peers, action needs to be taken. Use this within departments and units too. Use a postcard that users can send in when they take the survey. That way you can still know who took the survey, but will still be anonymous, and non-respondents can be reminded to participate. Use team training meetings as a “The biggest challenge to moving toward a safer time to have team members health system is changing the culture from one of complete the survey blaming individuals for errors to one in which errors Hold department managers are treated not as personal failures, but as opportuniaccountable ties to improve the system and prevent harm.” Use a Key Point of Contact IOM (2001). Crossing the Quality Chasm: A New Health Set the stage ahead of time System for the 21st Century, P. 79 Raise staff awareness

Tips from Trending Hospitals: 



Hospitals witnessed response rates increase: One health system saw their response rate increase 13% between 2 survey implementations; they thought the reason for the increase was competition among hospitals and departments as well as overall communication of the survey and why it was being administered. Another health system saw their response rate increase 20% the second time then another 25% the next time. They used incentives for departments that had 100% completion rate. One health system does formal on-site visits every 2 years focused on Patient Safety to both increase awareness, and promote the next round of surveys. They felt this was the main reason as to why their response rates increased from one year to the next

Additional Information:    

The AHRQ Hospital Survey on Patient Safety Culture meets the new Joint Commission leadership standard, effective January 2009 2009 AHRQ Benchmark Data will be available in February 2009, and will include 623 participating hospitals AHRQ is considering a potential Version 2.0 of HSOPS with that will have N/A question choices, better wording of some items, and expanding work areas and staff positions Next User Group Meeting will be held in February of 2010

AHRQ@TOTALBENCHMARKS OLUTION.COM

WWW.TOTALBENCHMARKSOLUTION.COM

Page 1

Actions Taken by Trending Hospitals: "The quality, safety and value of care can be no better than the structures and processes used by providers in direct contact with the patient. Culture is a lens through which organizations support providers at the point of care." Katherine Jones. PT, PhD University of Nebraska Medical Center

For more information on the presentations from the conference, please go to: http://ugm.tbsahrq.com

Four general themes explaining increases in scores over time: —Adapted from the Interviews Conducted by Westat:

1) Hospitals improved their communication between management & staff on patient safety   

Senior leaders’ engaged with staff during walkabouts Continually focused staff meetings on the importance of patient safety Staff invited to participate in biweekly “huddles” to discuss patient safety issues, and other topics

2) Hospitals focused on improving error reporting systems and applying non-punitive/”Just Culture” principles  Educated hospital leaders on making error reporting anonymous, easy, and convenient  Implemented electronic reporting system  Set up a hotline for reporting errors and developed anonymous reporting forms for medical errors  Trained staff to use the new reporting systems  Provided training on “Just Culture” 3) Hospitals engaged staff in identifying solutions to patient safety problems  Allocated resources for safety needs identified by staff – for example, buying safer beds  Directly involved staff in designing successful solutions to handoff problems  Started an employee engagement committee that included senior leaders  Instituted nursing peer review to promote open communication  Assigned staff to a scheduling team to accommodate staff preferences

“Our systems are too complex to expect merely extraordinary people to perform perfectly 100% of the time. We as leaders have a responsibility to put in place systems to support safe practice.” James Conway

4) Hospitals developed, implemented, and monitored action plans  Charged department managers with developing and implementing an annual action plan & held them accountable 5) Other explanations  Implemented SBAR communication tool for unit-to-unit transfers  Hired a consultant group to work with department directors on specific patient safety problems  Addressed staffing requirements – filled nursing vacancies and improved patient/staff ratios Page 2

WWW.TOTALBENCHMARKSOLUTION.COM CONFIDENTIAL AND PROPRIETARY TO TOTAL BENCHMARK SOLUTION, LLC COPYRIGHT © 2009 TOTAL BENCHMARK SOLUTION, LLC. ALL RIGHTS RESERVED