# Presentation: 801599

## Patient Safety Culture in West Virginia’s Rural Hospitals

**In the beginning....**
**West Virginia Medical Institute**

## Background

**The IOM Report. *****To Err is Human, ***** focused attention on patient safety and medical errors**
**However, rural West Virginia hospitals did not have systems or infrastructure in place to improve processes as suggested by IOM**
**WVMI saw opportunity to assist and implemented the WV Patient Safety Improvement Program, initially with corporate funds**
** ****We received an AHRQ grant 9/2004 to expand the scope of the original project**

## Objectives

**Improve patient safety and the culture of patient safety in rural West Virginia hospitals**** ****by:**
**Offering a free, confidential event reporting system protected from legal discovery**
**Developing a collaborative network to share information and best practices**

## Barriers to Implementation

**Lack of IT Infrastructure **in rural areas of West Virginia
**Peer Review Statutes- **Hospital legal staff feared data could be discoverable
**Computer Literacy **of hospital staff
- Lack of **trained IT staff**

## Today

**23 hospitals are participating in the AHRQ project to date, 13 of these are CAH **
**Baseline evaluation question:  ****What is the patient safety culture in West Virginia’s critical access hospitals?**

## Critical Access Hospitals

**There are 1013 CAHs across the nation**
**Small rural hospitals differ from larger urban facilities in many different ways that can impact on their ability to implement and sustain patient safety initiatives.**
**Do they differ with respect to the patient safety culture in their facilities?**

## Hospital Survey on Patient Safety Culture: Methodology

**Distributed to staff designated by hospital administration at time of system training.***
**Completed surveys turned in at end of training session.**
**Data scanned into an Excel database and analyzed used SAS.**
**Data collection is ongoing as hospitals are still being recruited.**

## Hospital Survey: Results

**Through April 2005, 860 surveys have been completed representing staff at 16 hospitals**
**10 of the 16 (62.5%) are CAHs**

## Demographic Data about Respondents

**1.  Primary hospital work area, department or clinical area where**
**	**** ****respondents spend most** **of their work time:**
- 	14.9% Many different hospital units / No specific unit 	0.3% Psychiatry / mental health
- 	11.1% Medicine (non-surgical)		3.8% Rehabilitation
- 	1.9% Surgery			2.2% Pharmacy
- 	0.6% Obstetrics			4.8% Laboratory
- 	0.3% Pediatrics			4.4% Radiology
- 	9.5% Emergency department		0.3% Anesthesiology
- 	0.3% Intensive care unit (any type)		45.4% Other
**2.  Staff position in the hospital:**
- 	21.2% Registered nurse			2.6% Dietician
- 	0.3% Physician assistant / Nurse practitioner		8.3% Unit assistant / Clerk / Secretary
- 	6.0% LVN / LPN			0.6% Respiratory therapist
- 	6.1%Patient care assistant / Hospital aide / Care partner	1.3% Physical, occupational, or speech therapist
- 	0.3% Attending / Staff physician		6.1% Technician (e.g., EKG, Lab, Radiology)
- 	0.0%    Resident physician / Physician in training		24.4% Administration / Management
- 	6.1% Pharmacist			20.5%Other

## AHRQ Staff Survey Summary Results

## Demographic Data (continued)

**3.  Time worked**
- 	**--in the hospital****	**8.4% Less than 1 year	33.6% 1 to 5 years	24.9% 6 to 10 years
- 	(years)
- 			8.7% 11 to 15 years	9.9% 16 to 20 years	14.4% 21 years or more
- 	**--in their current****	**** **
**	****hospital work area****	**10.2% Less than 1 year	40.7% 1 to 5 years	23.1% 6 to 10 years** **
**	**(years)
- 	**	**** ****	**9% 11 to 15 years  	7.2% 16 to 20 years	9.9% 21 years or more
- 	**--in their current****	**4.5% Less than 1 year 	24.5% 1 to 5 years 	17.6% 6 to 10 years
**	****specialty** (years)
**	****	****	**16.1% 11 to 15 years 	11.3% 16 to 20 years	 26% 21 years or more
**	****	****	****	****	****	**
**4.  Percentage of respondents with direct interaction or contact with patients:**      73.2%

## Overall Perceptions of Safety

***Overall Perceptions of Safety***

**R**  Indicates reversed-worded items.
- 	NOTE:  The item letter and number in parentheses indicate the item’s survey location.

**Survey Items**_** **_

-  % Strongly Disagree/    % Neither      % Strongly Agree/
-           Disagree		                     Agree

-   1.	Patient safety is never sacrificed to get more
-       work done.  (A15)
-   2.	Our procedures and systems are good at
- 	preventing errors from happening.  (A18)
- R3.	It is just by chance that more serious
- 	mistakes don’t happen around here.  (A10)
- R4.	We have patient safety problems in this
- 	unit.  (A17)

## Frequency of Events Reported

***Frequency of Events Reported***

- 1. When a mistake is made, but is _*caught and corrected before affecting the patient*__,_ how often is this reported?  (D1)
- 2. When a mistake is made, but has _*no potential to harm the patient*__,_ how often is this reported?  (D2)
- 3. When a mistake is made that _*could harm the patient*_, but does not, how often is this reported?  (D3)

- NOTE: The item letter and number in parentheses indicate the item’s survey location.

## Teamwork Within Units

***Teamwork Within Units***

- NOTE: The item letter and number in parentheses indicate the item’s survey location.

**Survey Items**_** **_

-  **% Strongly Disagree/    % Neither      % Strongly Agree/**
**          ****Disagree****	****	****                     Agree**

- 1.	People support one another in this unit.
- 	(A1)
- 2.	When a lot of work needs to be done
- 	quickly, we work together as a team to
- 	get the work done.  (A3)
- 3.	In this unit, people treat each other with
- 	respect. (A4)
- 4.	When one area in this unit gets really
- 	busy, others help out.  (A11)

## Communication Openness

- 1.	 Staff will freely speak up if they see
- 	 something that may negatively affect
- 	 patient care.  (C2)
- 2.	 Staff feel free to question the decisions
- 	 or actions of those with more authority.  (C4)
- R3.  	Staff are afraid to ask questions when
- 	 something does not seem right.  (C6)

- R Indicates reversed-worded items.
- NOTE: The item letter and number in parentheses indicate the item’s survey location.

-             **% Never/           % Sometimes         % Most of the   **
**                ****Rarely                                              time/Always**

**Survey Items**_** **_

## Feedback and Communication About Error

***Feedback and Communication About Error***

- 1.	We are given feedback about changes put
- 	into place based on event reports.  (C1)
- 2.    We are informed about errors that happen
-        in this unit.  (C3)
- 3.	In this unit, we discuss ways to prevent
- 	errors from happening again.  (C5)

- NOTE: The item letter and number in parentheses indicate the item’s survey location.

-             **% Never/           % Sometimes         % Most of the   **
**                ****Rarely                                              time/Always**

**Survey Items**_** **_

## Nonpunitive Response to Error

- R1.	Staff feel like their mistakes are held
- 	against them. (A8)
- R2.   	When an event is reported, it feels like
- 	the person is being written up, not the
- 	problem.  (A12)
- R3.	Staff worry that mistakes they make are
- 	kept in their personnel file.  (A16)

- R Indicates reversed-worded items.
- NOTE: The item letter and number in parentheses indicate the item’s survey location.

**Survey Items**_** **_

-  **% Strongly Disagree/    % Neither      % Strongly Agree/**
**          ****Disagree****	****	****                     Agree**

## Hospital Management Support for Patient Safety

- R Indicates reversed-worded items.
- NOTE: The item letter and number in parentheses indicate the item’s survey location.

**Survey Items**_** **_

-  **% Strongly Disagree/    % Neither      % Strongly Agree/**
**          ****Disagree****	****	****                     Agree**

-  1.	Hospital management provides a work climate that promotes patient safety. (F1)
-  2.	The actions of hospital management show that patient safety is a top priority. (F8)
- R3. 	Hospital management seems interested in patient safety only after an adverse event happens. (F9)

## Teamwork Across Hospital Units

***Teamwork Across Hospital Units***

- R Indicates reversed-worded items.
- NOTE: The item letter and number in parentheses indicate the item’s survey location.

**Survey Items**_** **_

-   1.	There is good cooperation among hospital units that need to work together. (F4)
-   2.	Hospital units work well together to provide the best care for patients. (F10)
- R3.	Hospital unites do not coordinate well with each other. (F2)
- R4.	It is often unpleasant to work with staff from other hospital units. (F6)

## Hospital Handoffs & Transitions

- R Indicates reversed-worded items.
- NOTE: The item letter and number in parentheses indicate the item’s survey location.

**Survey Items**_** **_

- R1.	Things “fall between the cracks” when
- 	transferring patients from one unit to 	another.  (F3)
- R2.	Important patient care information is
- 	often lost during shift changes.  (F5)
- R3.	Problems often occur in the exchange
- 	of information across hospital units.  (F7)
- R4.	Shift changes are problematic for
- 	patients in this hospital.  (F11)

## How Does CAH Pt. Safety Culture Differ from Larger Hospitals in WV?

**At the level of composite scores the differences are minimal, with the exceptions of:**
**Communication Openness, **
**Teamwork Across Hospital Units, and **
**Hospital Handoffs and Transitions.**

**Notes:**
CAH respondents were less likely than non-CAH staff to freely speak up or question decisions.
A greater percentage CAH respondents felt that there was good teamwork in their facilities.
And that handoffs and transitions between units, etc. were cleaner.

## Culture differences continued

- Differences appear in specific questions
- 74% v 57% strongly agree/agree that patient safety is NEVER sacrificed to get more work done.
- 64% v 44% strongly agree/agree that they have enough staff to handle the workload.
- 29% v 44% strongly agree/agree that they work in “crisis mode” trying to do too much, too quickly
- 58% v 42 SA/A there is good cooperation among hospital units that need to work together

## Discussion:  So What?

- Reminder:  Convenience sample, reflecting the opinions of those chosen or choosing to participate in training.
- The patient safety culture in WV rural hospitals of all sizes still have areas needing improvement, e.g., attention to near misses, non-punitive response.
- Some of the ways in which CAH culture may differ, e.g., better teamwork, better transitions could theoretically support the ease with which patient safety interventions could be implemented.

## Time will tell

## Contact Information

**Gail Bellamy, Principal Investigator, **_**[gbellamy@wvmi.org](mailto:gbellamy@wvmi.org)**__**	**_
**Patricia Ruddick, Project Manager, **_**[pruddick@wvmi.org](mailto:pruddick@wvmi.org)**_
**David Lomely, Analyst, **
**	**_**[dlomely@wvmi.org](mailto:dlomely@wvmi.org)**_