Professional Documents
Culture Documents
Patient Safety
Improvement Guide
Prepared for:
TRICARE Management Activity
DoD Patient Safety Program
http://dodpatientsafety.usuhs.mil/
Prepared by:
Westat, Rockville, MD
Contract # 233-02-0087
Task Order # HHSP23300700002T
March 2009
TABLE OF
CONTENTS
Chapter Page
Teamwork........................................................................... 23
1. Cross Training and Use of Universal Protocols....................... 23
2. Implementing a New Way of Doing Rounds .......................... 23
3. Implementing TeamSTEPPS™ ............................................ 24
Chapter Page
3 Staff Engagement/Ownership............................................. 28
1. Establishing Formal Patient Safety Committees..................... 28
2. Spreading Ownership Through a Peer-to-Peer Approach......... 29
3. Recruiting Facility Experts as Patient Safety Champions ......... 29
4. Involving Staff From All Levels ........................................... 30
5. Rewarding Participation in Patient Safety Tasks .................... 31
References.......................................................................... 35
Appendix
The DoD Patient Safety Program developed this Guide to help patient safety leaders
in military treatment facilities (MTFs) strengthen their patient safety programs and
patient safety culture. The Guide includes a brief description of the DoD Tri-Service
Survey on Patient Safety and overall results for the Military Health System (MHS),
advice on how to use the survey results to identify opportunities for improving
patient safety culture, and examples of various initiatives and tools that MHS
hospitals and clinics have implemented in their efforts to improve patient safety
culture and the safety of patient care.
Chapter 1. The examples presented are based on information obtained through telephone
interviews conducted with staff from nine MTFs in January 2009. Those MTFs were
Survey invited to participate in the interviews because of a combination of criteria,
Background including notable improvement from 2005/2006 to 2008 on the DoD Tri-Service
and MHS Survey on Patient Safety, high overall percent positive scores on the 2008 survey,
Results Service branch, and facility characteristics such as type (hospital or clinic) and size
of facility. These top-performing facilities were considered important to interview
because their improved survey scores from 2005/2006 to 2008 suggested they had
engaged in initiatives that strengthened their patient safety culture.
The DoD Tri-Service Survey on Patient Safety Culture, sponsored by TRICARE
Management Activity, is an anonymous patient safety culture survey with 42 items
that assess staff attitudes and beliefs about patient safety, medical error, and event
reporting. A facility’s first administration of the survey provides a baseline for
measuring patient safety culture, and subsequent administrations allow facilities to
track change over time.
After administration of the 2008 survey, MTFs received feedback reports that
included a comparison to their 2005/2006 results. For the overall MHS, the three
highest-scoring survey areas were Teamwork Within Units, Supervisor/Manager
Expectations and Actions Promoting Patient Safety, and Management Support for
Patient Safety. The three lowest-scoring areas were Nonpunitive Response to Error,
Staffing, and Handoffs and Transitions.
Chapter 2. Administering the survey is only a starting point in improving patient safety culture.
Taking action based on a facility’s survey results will make the real difference in
Seven Steps whether a facility succeeds in making gains in patient safety culture. Seven steps of
of Action action planning that will help facilities to realize patient safety culture change are
Planning discussed. These seven steps advise patient safety leaders to:
1. Understand your results by carefully analyzing them
2. Communicate and discuss your results with senior leaders, middle managers,
and staff
3. Develop focused action plans that target a small number of areas of opportunity
for improving patient safety culture
4. Communicate your plans to staff who will be involved or affected, thus
providing them with appropriate information regarding their participation and
making the plans transparent
5. Implement your action plans—arrange for necessary resources and support and
recruit a patient safety champion or leader for the effort
6. Track progress and evaluate the impact of your initiatives to determine if they
were successful or not and should be continued, modified, or discontinued
7. Share what works with other areas within your facility and with other facilities
Chapter 3. Chapter 3 picks up on the last action step—sharing what works with other facilities.
During the interviews, the nine facilities reported on many initiatives and practices
Patient that contributed to their improved patient safety culture between 2005/2006 and
Safety 2008. Their improvement initiatives are grouped into the following categories:
Improvement Event Reporting and Nonpunitive Culture – Two prevalent goals among the
Practices facilities were to increase the number of event reports and to change perceptions that
the reporting process is punitive. The facilities described a wide array of initiatives
that promoted progress toward those goals. Examples include: short surveys on
event reporting and follow-up discussions with staff; Web-based training on event
reporting with individualized feedback; quarterly case study presentations (generally
based on sentinel events); weekly meetings to review event cases for system and
process improvement; improvements in electronic reporting methods and paper
report forms; development of a database to track reported events; leadership focus
on solutions to system and policy problems that contribute to events; award
presentations for reporting events; and feedback to reporters as well as more general
feedback to staff on lessons learned from reported events.
Handoffs and Transitions – For some facilities, a primary goal was improving
handoffs and transitions. Stories shared here focused on the use of handoff
communication tools (e.g., “I PASS THE BATON” and SBAR) and on a clinic’s
successful efforts to identify handoff situations and improve handoff
communications with the use of SBAR.
Teamwork – The facilities described activities that they believe strengthened
teamwork within and across units. One facility reported how it has built a strong
teamwork culture through cross training, use of interdisciplinary teams and universal
protocols, and strong leadership support for a teamwork culture that holds all staff
accountable. Other reported initiatives include changes in round procedures and
implementation of TeamSTEPPS™.
Management Support for Patient Safety – The facilities reported on ways in
which senior leadership is crucial to a strong patient safety culture. They also
stressed the need for a strong patient safety leader who is visibly and actively
promoting patient safety with leaders and staff throughout the facility. They
recommended that patient safety leaders present on patient safety at executive and
departmental meetings, participate in formal or informal walkarounds, participate in
staff training, and demonstrate that the patient safety office is there to help other
leaders resolve patient safety issues in their areas of responsibility—it is not there
solely to “push its own agenda.”
Staff Engagement and Ownership – Patient safety leaders described creative ways
for engaging staff and promoting staff ownership of patient safety. This is essential
they said not only because they cannot do everything themselves but also because
patient safety belongs to everyone in the facility and should be everyone’s business.
Their initiatives included engaging other staff in promoting patient safety as
spokespersons, advisors, and champions; and as members on special patient safety
workgroups and committees, Root Cause Analysis teams, tracer teams, and Failure
Mode and Effects Analysis groups. One facility rewards exceptional service on
patient-safety related tasks by presenting a Patient Safety Coin to recipients and
giving them a paid day off.
Raising Staff Awareness of Patient Safety – Important goals for the facilities
between 2005/2006 and 2008 were to raise overall awareness and knowledge about
patient safety and to promote buy-in for a culture of patient safety. The facilities
described a number of initiatives targeted on those goals: conducting short “pulse”
surveys monthly on patient safety and infection control to assess staff knowledge on
these topics, followed up with on-site training in individual departments; conducting
leadership rounds; training new staff on patient safety issues and goals during
orientation, annual training, and unit-based training; holding special trainings on
patient safety, including “Just-in-Time” training that fits into demanding
work/training schedules; conducting activities during Patient Safety Awareness
Week, including a patient safety scavenger hunt; and promoting patient safety with
pocket cards with reference information and including patient safety goals on staff
ID cards/badges.
Other Improvement Initiatives – Other initiatives that facilities said contributed to
reliable and safe care for patients included various quality improvement initiatives.
For example, one facility conducted group workouts to improve processes, and
another improved quality of care by requiring all area leaders to develop flow charts
of their area processes. One facility created a new nursing care program in which a
primary care nurse manages the care for the patient/family. Another facility had a
DoD Patient Safety Program team provide microsystems training that taught staff
how to identify work processes and systems that need to be fixed.
The DoD Patient Safety Program developed this Guide to help Military Treatment
Facility (MTF) leaders strengthen their patient safety programs and the culture of
patient safety in their facilities. The Guide covers three main topics:
A brief description of the DoD Tri-Service Survey on Patient Safety and survey
results for the overall Military Health System (MHS)
Advice on how to use the survey results to identify areas of opportunity for
improving patient safety culture and develop corresponding action plans
Examples of various activities, tools, and strategies that MTF hospitals and
clinics have implemented in their efforts to improve patient safety culture and
the safety of patient care
Helpful DoD patient safety resources are also provided in an Appendix. The
initiatives highlighted in the Guide are presented as examples of activities the MTFs
believed were helpful in improving patient safety. However, the activities are not an
exhaustive or complete listing.
The Guide is based on information obtained through telephone interviews with staff
from nine top-performing MTFs based on their facility’s results on the DoD Tri-
Service Survey on Patient Safety. The interviews were conducted in early 2009 and
focused on patient safety improvement practices that the facilities had implemented
between the 2005/2006 and 2008 administrations of the safety culture survey.
Facility scores were rank ordered and “top performing” facilities were chosen based
on five criteria:
1. Overall average percent positive score across the survey’s 12 composites in
2008 [Facilities selected had average scores ranging from 61% to 68% positive]
2. Number of composites that increased by 5 percentage points or more from
2005/2006 to 2008 [Facilities selected increased on at least 4 of the 12 patient
safety composites]
3. Average overall change in percent positive scores from 2005/2006 to 2008
[Facilities selected had average overall changes in percent positive scores
ranging from 3 to 14 percentage points]
4. An overall score, which was a statistical combination of the three scores
described above, rank ordered from highest to lowest for hospitals and for
clinics [The six MTF hospitals selected were ranked # 11 or higher on this
overall score among 44 MTF hospitals; the three MTF clinics selected were
ranked # 8 or higher among 96 clinics]
Six hospitals and three clinics among CONUS Army, Navy, and Air Force MTFs
were selected. Other facility characteristics, such as size of the facility, were also
taken into consideration when selecting the sites to be interviewed.
We were limited to interviews at nine facilities and, as noted, we selected nine
facilities that represent top performers on the DoD Tri-Service Survey on Patient
Safety as well as a balance of size, scope, and survey scores. Since a combination of
criteria was used to select the exemplary MTFs, the nine MTFs interviewed were not
necessarily the absolute highest-performing facilities. If your MTF was not selected
to participate in one of the nine interviews, it does not mean that your MTF was not
a top performer.
We wish to thank the nine facilities that participated in the interviews for taking time
from their busy schedules to share information about their patient safety initiatives
and practices. Eight of the participating facilities provided consent to have their
facility listed below:
HOSPITALS:
Air Force
99th Medical Group, Nellis AFB, NV—Las Vegas, NV
Army
Brooke Army Medical Center—San Antonio, TX
Irwin Army Community Hospital—Ft. Riley, KS
Tripler Army Medical Center, Hawaii—Honolulu, HI
Navy
NNMC—Bethesda, MD
CLINICS:
Air Force
95th Medical Group, Edwards AFB, CA—Edwards, CA
Army
Raymond W. Bliss Army Health Center—Fort Huachuca, AZ
Navy
Naval Health Clinic, Quantico—Quantico, VA
Improve the quality of health care services and provide a safer patient care
environment in all MHS settings,
Understand the status of patient safety culture in MHS facilities,
Raise staff awareness about patient safety issues,
Facilitate meeting several Joint Commission Performance Improvement and
Leadership standards,
Use the survey as a tool for forward action planning and program evaluation,
and
Examine patient safety culture change over time.
The DoD Tri-Service Survey on Patient Safety measures 12 patient safety culture
areas and other individual items on patient safety culture (Table 1.1). The survey
consists of 42 items, with 3 to 4 items assessing each patient safety area, plus
additional demographic items. The survey allows for open-ended comments at the
end. A copy of the survey is located in Appendix A.
Table 1.1 Patient Safety Culture Areas
2008 MHS After each administration of the DoD Tri-Service Survey on Patient Safety, MTFs
Results received feedback reports showing their facility’s survey results. In 2008, many
MTFs also received trend data comparing their 2005/2006 and 2008 results to
identify areas where scores increased, stayed the same, or decreased over time.
Survey results were also produced for the overall MHS.
Chart 1.1 shows the composite percent positive scores on the patient safety culture
areas for 2008 and 2005/2006 for the overall MHS. In 2008, patient safety culture
for the overall MHS had a slight improvement of 1 to 3 percentage points in all areas
except communication openness, where the results were the same for 2005/2006 and
2008. The three highest-scoring areas, identified as areas of strength were:
The three lowest-scoring areas that were identified for improvement were:
Chart 1.1 Overall MHS Patient Safety Culture Composite Scores for 2005/2006 and
2008
75%
1. Teamwork Within Units
76%
66%
5. Overall Perceptions of Patient Safety
67%
64%
6. Feedback & Communication About Error
64%
2005/2006
2008
60%
7. Frequency of Events Reported 63%
61%
8. Communication Openness 61%
59%
9. Teamwork Across Units 60%
47%
10. Handoffs & Transitions 49%
45%
11. Staffing 46%
44%
12. Nonpunitive Response to Error 45%
Chart 1.2 Overall MHS Work Area/Unit Patient Safety Grade for 2005/2006 and
2008
100
Percent of Respondents
80
60 2005/2006
46
43
38
40 34 2008
17 15
20
3 3 1 1
0
A B C D E
Excellent Very Good Acceptable Poor Failing
Patient Safety Grade
Chart 1.3 Overall MHS Number of Events Reported in the Past 12 Months for
2005/2006 and 2008
100
Percent of Respondents
80 73 73
60 2005/2006
40 2008
18 17
20
6 6
2 2 1 1 1 1
0
None 1 to 2 3 to 5 6 to 10 11 to 20 21 or
more
Number of Events Reported
Keep in mind that the delivery of survey results is not the end point in the survey
process; it is actually just the beginning.
While administering the DoD Tri-Service Survey on Patient Safety can be considered an
“intervention” to educate staff and build awareness about issues related to patient
safety—this should not be the only goal of conducting the survey. Administering the
survey is not enough. It is often the case that the perceived failure of surveys as a means
for creating lasting change is actually due to faulty or nonexistent action planning or
survey follow-up. Seven steps of action planning are provided to help your facility go
beyond simply conducting a survey to realizing patient safety culture change.1
Figure 2.1 Seven Steps of Action Planning
Step #4:
Step #3:
Communicate
Create Focused
Plans &
Action Plans
Deliverables
Step #6:
Step #5: Step #7:
Track Progress
Implement Share What
& Evaluate
Action Plans Works
Impact
Step # 1: It is important to review your facility’s survey results and interpret them before you
Understand develop action plans. Develop an understanding of your facility’s key strengths and
Your Survey areas for improvement. Examine your facility’s overall percent positive scores on
Results the patient safety culture composites and items:
1 The seven steps of action planning outlined in this chapter are primarily based on the book “Designing and Using
Organizational Surveys: A Seven-Step Process” (Church & Waclawski, 1998).
In addition, compare your facility’s most recent survey results with its previous
results to examine change over time.
Did your facility have an increase in its scores on any of the survey composites
or items?
Did your facility have a decrease in its scores?
When you consider the types of patient safety actions that your facility
implemented between each survey administration, do you notice improvements
in those areas?
After reviewing the survey results carefully, identify two to three areas for
improvement at the facility level. While your facility may want to improve in almost
all areas, it is better to avoid focusing on too many issues at one time.
Step # 2: Common complaints among survey respondents are that they never get any feedback
Communicate about survey results and have no idea whether anything ever happens as a result of a
and Discuss survey. It is therefore important to thank your staff for taking the time to complete
the Survey the survey and let them know that you value their input. Sharing results from the
survey throughout the facility shows your commitment to the survey and
Results
improvement process.
Use survey feedback as an impetus for change. Summaries of the survey results
should be distributed throughout the facility in a top-down manner beginning with
senior management, administrators, medical and senior leaders, and committees,
followed by department managers and then staff. Managers at all levels should be
expected to carefully review the findings. Summarize key findings, but also
encourage discussion about the results throughout the facility. What do others see in
the data and how do they interpret the results?
In some cases, it may not be completely clear why an area of patient safety culture
was particularly low. Keep in mind that surveys are only one way of examining
culture, so strive for a deeper understanding when needed, by conducting follow-up
activities such as focus groups or interviews with staff to find out more about an
issue, why it is problematic, and how it can be improved.
Step # 3: Once areas for patient safety culture improvement have been identified, formal,
Develop written action plans need to be developed to ensure progress toward change.
Focused Facility-wide and department-based action plans can be developed. Major goals can
Action Plans be established as facility-wide action plans. Department-specific goals can be
fostered by encouraging and empowering staff to develop their own action plans at
the department level.
Encourage action plans that are “SMART”:
Specific
Measurable
Achievable
Relevant
Time-bound
When deciding whether a particular action plan or initiative would be a good fit in
your facility, you may find that a guide entitled “Will It Work Here? A
Decisionmaker’s Guide to Adopting Innovations” (Brach, Lenfestey, Roussel,
Amoozegar, & Sorenson, 2008) is a useful resource (available at:
http://www.innovations.ahrq.gov/resources/InnovationAdoptionGuide.pdf). The
Guide helps users answer the four overarching questions:
Step # 4: Once action plans have been developed and approved and resources have been
Communicate cleared, the plans, deliverables, and expected outcomes of the plans need to be
Action Plans communicated. Those directly involved or affected will need to know their roles,
and responsibilities, and the time frame for implementation. Action plans and goals
should also be shared widely so that their transparency encourages further
Deliverables
accountability and demonstrates the facility-wide commitments being made in
response to the survey results.
At this step it is important for senior managers and leaders to understand that they
are the primary owners of the change process and that success depends on their full
commitment and support. Senior-level commitment to taking action must be strong;
without buy-in from the top, including medical leadership, improvement efforts are
likely to fail.
Step # 5: Implementing action plans is one of the hardest steps. Taking action requires the
Implement provision of necessary resources and support. A champion or leader for the effort
Action Plans should be identified to take charge of implementation. It requires tracking
quantitative and qualitative measures of progress and success that were identified in
the planning stage. It requires publicly recognizing those individuals and
departments that take action to drive improvement. And it requires adjustments
along the way.
This step is critical to realizing patient safety culture improvement. While
communicating the survey results is important, taking action makes the real
difference. However, as the Institute for Healthcare Improvement (IHI, 2006)
suggests, actions do not have to be major, permanent changes. In fact, it is
worthwhile to strive to implement easier, smaller changes that are likely to have a
positive impact rather than big changes with unknown probabilities of success.
The “Plan-Do-Study-Act” cycle (Langley et al., 1996) is a pilot-study approach to
change that involves first developing a small-scale plan to test a proposed change
(Plan), carrying out the plan (Do), observing and learning from the consequences
(Study), and determining what modifications should be made to the plan (Act).
Implementation of action plans can occur on a small scale, within a single
department, to examine impact and refine plans before rolling out the changes on a
larger scale to other departments.
Figure 3.2 PDSA Cycle
Act Plan
Study Do
Step # 6: Use quantitative and qualitative measures to review progress and evaluate whether a
Track specific change actually leads to improvement. Ensure that there is timely
Progress and communication of progress toward action plans on a regular basis. If you determine
Evaluate that a change has worked, communicate that success to leadership and staff by
telling them what was changed, and that it was done in response to the safety culture
Impact
survey results. Be sure to make the connection to the survey so that the next time the
survey is administered, staff will know that it will be worthwhile to participate again
because actions were taken based on the prior survey’s results. Alternatively, your
evaluation may discover that a change is not working as expected or has failed to
reach its goals and will need to be modified or replaced by another approach. Before
dropping the effort completely, try to determine why it failed and whether
adjustments might be worth trying.
Keep in mind that lasting culture change will be slow and may take years. Frequent
assessments of culture are likely to find temporary shifts or improvements that may
come back down to baseline levels in the longer term if changes are not sustained.
When planning to reassess culture, it is also very important to obtain high survey
response rates. Otherwise, it will not be clear whether changes in survey results over
time are due to true changes in attitudes, or due to the fact that you may be
surveying different staff each time.
Step # 7: In step six, you tracked measures to be able to identify which changes result in
Share What improvement. Once your facility has found effective ways to address a particular
Works area, the changes can be implemented on a broader scale to other departments within
the facility and to other facilities. Be sure to share your successes with outside
facilities as well.
The comments and experiences of the nine top-performing DoD facilities that
participated in patient safety interviews are shared here. During the interviews, they
described initiatives and practices that contributed to patient safety culture
improvements in their facilities between 2005/2006 and 2008. New patient safety
leaders can use the information in this chapter to help them develop plans for
building effective patient safety programs. More experienced patient safety leaders
can learn about initiatives to consider implementing that are relevant to their own
patient safety goals or actions plans.
The initiatives and practices described during the interviews are grouped into the
following categories:
Event Between the 2005/2006 and 2008 administrations of the DoD Tri-Service Survey on
Reporting Patient Safety, many of the interviewed facilities set goals to:
and Increase the frequency of event reports by all staff
Nonpunitive
Culture Change the perception that the reporting process is punitive
To lay a foundation for meeting those goals, the facilities implemented a broad-
based approach, simultaneously conducting some or all of the following initiatives:
1. Educating staff about medical events and event reporting
2. Maintaining an open door policy about reporting
3. Making event reporting convenient and easy
4. Creating a nonpunitive reporting environment
5. Providing feedback and communicating lessons learned
Improved scores on the DoD 2008 Tri-Service Survey on Patient Safety indicate that
these activities helped many of the nine facilities to create more positive staff
perceptions about reporting. Despite some improvement, most of the facilities,
however, are still striving for increases in the number of events reported during the
past 12 months.
Follow-up: Six months to a year later, the Patient Safety Manager and the
department leaders re-administer the event reporting survey. They compare results
across department areas and track individual departmental progress over time.
Benefits: The short surveys and low-key discussions help staff to recognize what
things should be considered patient safety events. Also, they learn how to file reports
and they realize that the Patient Safety Manger is available to help them fill out
forms and file their reports.
WEB-BASED TRAINING
Patient safety leaders at Nellis AFB reviewed their facility’s results for the DoD Tri-
Service Survey on Patient Safety. The results indicated they needed to help staff
better understand the importance of reporting medical events, even those that do not
result in patient harm. They developed slides on patient safety and event reporting
and presented them on their education website. An email was sent to all staff, under
the Commander’s signature, announcing the new mandatory online training, which
included a posttest. The Patient Safety Manager reviewed all the tests (about 850)
and replied individually to all respondents that had incorrect answers, explaining
why each answer was incorrect. Although this effort was time-consuming, the
manager thought it was necessary to provide individual responses in the initial
stages of staff education about event reporting.
and the Graduate Medical Education Core Competencies (i.e., competency in patient
care, medical knowledge, practice-based learning, interpersonal and communication
skills, professionalism, and systems-based practice).2 Time is then allowed for
discussion of system changes that occurred as a result of the event, whether the changes
were effective, or if there are other recommendations or suggestions for ways to
improve patient safety. Leadership emphasized attendance by house staff, but other
staff were encouraged to attend as well.
Benefits: The presentations facilitated sharing of lessons learned across the
organization. The information motivated staff to think about the process of care. The
presentations were well received.
2 For a description of the Institute of Medicine’s six goals for healthcare, see
http://books.nap.edu/html/quality_chasm/reportbrief.pdf, and for a description of the Graduate Medical Education
Core Competencies, see http://www.acgme.org/acWebsite/RRC_280/280_coreComp.asp
The report goes to the Patient Safety Manager, who forwards it to the appropriate
person (usually the unit supervisor). That person analyzes the report and adds
recommendations and comments.
Resources about “Just Culture” and the “Substitution Test” (highlighted on the next
page) can help facility leaders establish a culture that is nonpunitive when it comes
to system failures that lead to human error, but still holds individuals accountable in
a fair way for intentional and risky violations of rules.
Handoffs “Handoffs occur anytime there is a transfer of responsibility for a patient from
and one caregiver to another. The goal of the handoff is to provide timely, accurate
Transitions information about a patient’s care plan, treatment, current condition, and any
recent or anticipated conditions.”
– The Joint Commission
For more information about “I PASS THE BATON,” see the Tools and
Resources section of this Guide (Appendix B).
Spotlight on SBAR
SBAR is a framework for teams to communicate important patient information
clearly and concisely. It can be recalled through the following mnemonic
device:
S: Situation – summarize the patient’s present situation
B: Background – provide relevant background information
A: Assessment – state the various options available
R: Recommendation – propose what actions should be taken
For more information about SBAR, see Appendix B.
From the behavioral health clinic where a nutritionist thinks a patient needs to
see a primary care provider to the attached primary care clinic,
From the primary clinic to an ambulance if a patient presents with heart attack
symptoms, or
From a clinical staff member who is assessing a patient that begins coding to a
rapid response team.
The department heads and the tracer team identified such situations as handoffs,
with the need for clear, concise, and quick communications to perform the handoff
effectively.
Staff reactions: The Patient Safety Manager worked face to face with staff, assuring
them that help was available in making the change to using SBAR in handoffs.
Nevertheless, staff response to the new program varied. For example, nurses liked the
switch to SBAR and embraced the new program. Staff in some administrative areas,
however, were more resistant to the program. They would say things such as “we’re
logistics, we’re information management, we’re medical records, and we don’t have
anything to do with patients,” to convey their belief that handoffs and transitions were
not issues in their nonclinical work areas. The patient safety program staff response
was to include administrative staff in the training program, but they also provided
specific examples of things that could happen or problems that might begin in
nonclinical areas (e.g., problems with medical equipment). Program staff had good
examples because tracer teams had reviewed both clinical and administrative areas
during their identification of possible patient safety risks in the facility.
Benefits: Staff better understand the meaning of handoffs in their facility and use
more effective communications during transitions.
Teamwork Effective handoffs and transitions are clear examples of strong teamwork within and
across units in health care facilities. Facilities described other activities that
contributed to stronger teamwork in their facilities:
1. Cross Training and Use of Universal Protocols
2. Implementing a New Way of Doing Rounds
3. Implementing TeamSTEPPS™
Benefits: This process ensures that there is open communication among team
members with various levels of experience. The bedside nurse clinician can also use
the process to clarify whether the established care plan is not being followed or to
guide a change to the care plan when the patient’s needs have changed and the care
plan is no longer effective.
3. Implementing TeamSTEPPS™
Two of the interviewed facilities implemented TeamSTEPPS™ between the
2005/2006 and 2008 survey administrations. They briefly described how they
implemented, and adapted, TeamSTEPPS in their facilities.
FACILITY #1
Nellis AFB originally implemented TeamSTEPPS in late 2005. Training was mandated
for all hospital personnel, which created some resistance, especially among nonclinical
staff. Following the 2008 survey, a team from the Service branch spent a week onsite.
The Service team spent 3 days training 25 trainers. During another 2½ days, they
conducted 4-hour sessions training 65 staff in the fundamentals of TeamSTEPPS. Now,
the facility’s own trainers teach smaller classes and personalize the training with a
selection of videos provided by the hospital.
Implementation approach: The facility learned from its 2005 experience by
realizing that TeamSTEPPS is not an “all or none” program, but a valuable
collection of tools with vast applicability in various areas. Leadership gave
priority to high-risk areas and mandated TeamSTEPPS training for the
Emergency Department, Labor and Delivery, and ICU/SDU. Many
departments have implemented the training; the Medical/Surgical Nursing
Units and the Family Practice Clinic are actively involved.
Results: Rather than becoming a burden of mandatory meetings and
voluminous reports, TeamSTEPPS is now a part of the facility culture. Staff
engage regularly in briefs, debriefs, and huddles and use mnemonic devices
for consistent handoffs; conflict resolution techniques enhance
communication. TeamSTEPPS tools are regularly used in response to
reported patient safety events and are found in the formal action plans of
Root Cause Analyses performed in the hospital.
FACILITY #2
Irwin ACH implemented TeamSTEPPS in one of its work areas or units before the
2008 survey administration and subsequently in another unit.
Implementation approach: Units volunteer for TeamSTEPPS; it is not a
top-down mandate. Although the Commander and the Patient Safety
Manager support TeamSTEPPS, they believe the program is better accepted
when unit staff develop the program themselves and have responsibility for
it.
Subsequent training in facility: The nurses that were trained in the first
TeamSTEPPS unit (“stellar leaders who fully embraced it”) are now the
trainers in the second TeamSTEPPS unit.
What Is TeamSTEPPS™?
Team Strategies and Tools to Enhance Performance and Patient Safety
“A teamwork system designed to improve quality, safety, and efficiency of
healthcare; offering a powerful solution to improving patient safety within your
organization.”
For more information about TeamSTEPPS™, see Appendix B.
Management To be effective, patient safety programs require support from leaders throughout the
Support for facility, appropriate staffing for managing patient safety responsibilities, and patient
Patient safety leaders that are highly visible and engaged with staff throughout the facility.
Safety During the interviews, facilities talked about their experiences with the following
elements of management support for patient safety:
1. Ensuring Leadership Support
2. Establishing a Patient Safety Program Manager
Even in the best of patient safety programs, key challenges can arise because of
frequent turnover in senior leadership. On occasion, new senior leaders may have
limited experience with patient safety programs. When that occurs, patient safety
leaders must renew their efforts to educate, win, and sustain senior leadership
support for a strong patient safety program.
Suggestion: One facility stressed that once in place at a facility, new Commanders
have so many responsibilities to fulfill (including military requirements) that it is
difficult to carve out time for leadership training on patient safety and processes
such as Root Cause Analysis. They recommend, instead, that more time be spent on
standardized training on patient safety when Commanders receive their special
training for taking over command. They commented:
“A little more education on it would make the patient safety manager’s
life easier.”
Staff Limited resources usually restrict the size of the patient safety program staff. Thus,
Engagement/ in most of the interview sites, patient safety program staff cannot do everything they
Ownership would like to do. Facilities described creative ways for engaging staff and promoting
staff ownership of patient safety. Patient safety leaders said they need to do this
because they cannot do everything themselves. But they also believe it should be
done because:
“Patient safety is everybody’s business…belongs to everyone.”
“You can’t boil patient safety down to one thing…it has to be
pervasive…there’s nothing we do in this facility that does not impact
patient safety in one way or another. Almost nothing.”
Facilities described many initiatives taken by patient safety leaders for successfully
engaging facility leaders and staff as partners in promoting patient safety:
1. Establishing Formal Patient Safety Committees
2. Spreading Ownership Through a Peer-to-Peer Approach
3. Recruiting Facility Experts as Patient Safety Champions
4. Involving Staff From All Levels
5. Rewarding Participation in Patient Safety Tasks
“Patient safety has many faces, not just the Patient Safety Office.”
The Patient Safety Manager at NNMC Bethesda wanted to increase the number of
expert patient safety advocates in the facility. To do so, she expanded and
reorganized the existing Patient Safety Committee. She added department leaders
from high-risk areas and other major areas, such as radiology, laboratory, information
technology, and pharmacy. She also divided the many responsibilities of the single
quality assurance physician advisor on the committee among more physicians to
enhance the effectiveness of the advisor role.
After identifying five physicians in major disciplines across the facility, she educated
them about their roles and responsibilities and discussed the facility’s mission and
vision regarding the patient safety program, as well as National Patient Safety Goals.
She also reviewed what a Root Cause Analysis is and the categories and
subcategories for events. Each of the new quality assurance physician advisors
conducted a preliminary review of any deaths in their individual discipline areas.
The manager achieved her goal—committee members, especially the quality
assurance physician advisors, are now empowered as patient safety spokespersons
at directorate and department meetings.
Doctor-to-Doctor Communications
It is much more effective to promote patient safety among doctors if a doctor rather
than a nurse says:
“You have to do this universal protocol—it will save lives, this is going to
help you, and I endorse it.”
The Patient Safety Manager persuades physicians to take on this peer leadership role
by providing guidance and assistance to them. She sits down with the physician
team leader and talks about the goals and the elements of performance and how they
will measure it. She also assists the physician in assembling a team.
The team leaders she recruits quickly learn that the activity puts them in front of
their executive councils and their discipline, which enhances their job performance
ratings. That helps in recruiting new team leaders.
“It was important, particularly for the rapid response team, to have the
people who are at the grassroots that were involved in these transfers
to be the leads on these issues.”
The anticoagulation and rapid response team initiatives contributed greatly to the
facility’s improvement in patient safety culture between 2005/2006 and 2008. For
anticoagulation, they have a process in place and a system of resources. For rapid
response teams, they now have a mechanism for staff to call and get help.
The analysis team determines whether they do or do not have a problem in that event
area. The Patient Safety Office presents the findings to the Quality Council,
indicating both where they are performing well and any areas where they need to fix
something. The council members responsible for those areas then take ownership for
follow-up action.
Raising Staff Between 2005/2006 and 2008, a major goal for the facilities interviewed was raising
Awareness of overall awareness and knowledge about patient safety and promoting buy-in for a
Patient culture of patient safety. Facilities described an array of initiatives:
Safety 1. Conducting Short “Pulse” Surveys
2. Conducting Leadership Rounds
3. Orientation and Other Staff Training
Patient safety leaders realize that establishing a strong patient safety culture
takes time:
“When you develop something, it takes a while…and our strategy
here was to get buy-in throughout the entire institution.”
PATIENT-SAFETY-RELATED TRAINING
Communication openness: One clinic dedicated a 2-hour class to patient safety,
focusing on openness and reporting. The trainers emphasized that most events arise
from process errors, not people errors.
Monthly classes: Irwin ACH basically shuts down once every month for 3 hours of
training in the afternoon. Staff can select 3 classes from about 12 that are available.
Class topics vary, but they usually include patient safety issues such as reporting
events and patient safety goals. Staff attendance has been strong.
Just-in-Time training: Leaders at Nellis AFB have responded to the constraint of
competing demands on staff time by packaging their patient safety training so that it
fits into demanding work/training schedules. That is, they do quick and frequent
trainings, such as “Just-in-Time” training activities.
“Passports” for training sessions: The Performance Improvement Manager at
Nellis AFB distributed a “Passport to Joint Commission Success and Patient Safety
Goals” to all staff. Staff were asked to gather voluntarily in one area of the cafeteria
during their lunch time to listen to 10-minute briefings on National Patient Safety
Goals. Ten sessions were conducted over a 2-week period. For example, a physician
delivered a presentation on medication reconciliation about six times during the 2
weeks. Staff who participated in a briefing had their passports stamped for that
training activity. A special drawing was held among staff whose passports were
stamped for all topics covered during the 2 weeks.
Patient safety goals on ID badges: One hospital has included patient safety goals on
staff ID cards/badges. The purpose for doing so was twofold: to remind staff of patient
safety and to serve as a tangible reinforcement for staff while they work.
Other Other initiatives contributed to reliable and safe care for patients between the
Improvement 2005/2006 and 2008 administrations of the DoD Tri-Service Surveys on Patient
Initiatives Safety. For example, facilities engaged in the following quality improvement
processes:
Group workouts: At NNMC Bethesda, staff take a day and stay in the same room
until a process is fixed. This Lean Six Sigma effort brings in a large group of people
who do not usually have input into processes and systems. In the past 6 months, the
facility has completed two workouts.
Flow charts: Under the commander’s direction, all area leaders in one clinic
became knowledgeable about their area processes and prepared flow charts of them.
They have used their compiled data from this Lean Six Sigma initiative to improve
quality of care in their facility.
New nursing care program: In late 2007, Tripler Army Medical Center
implemented a new nursing program—Relationship Based Care. Each patient is
assigned a primary care nurse who manages the care for the patient/family. Staff
have been highly engaged in the new program because it promotes high personal
responsibility.
Microsystems training: A team from the DoD Patient Safety Program came and
briefed commanders in one of the facilities on microsystems training. Initially the
facility started projects in the Intensive Care Unit and the Emergency Department.
The training was valuable because staff learned how to identify what needs to be
fixed. Staff were trained to assess the care a group provides to patients (Is it state of
the art?) and to identify and evaluate all components of a group’s work process—
what they are doing, how they are doing it, and what they need to improve.
Brach C., Lenfestey N., Roussel A., Amoozegar J., and Sorensen A. Will It Work
Here? A Decisionmaker’s Guide to Adopting Innovations. Prepared by
RTI International under Contract No. 233-02-0090. Agency for Healthcare
Research and Quality (AHRQ) Publication No. 08-0051. Rockville, MD:
AHRQ; September 2008.
http://innovations.ahrq.gov/resources/InnovationAdoptionGuide.pdf
Langley, C., Nolan, K., Nolan, T., Norman, C., and Provost, L. The Improvement
Guide: A Practical Approach to Improving Organizational Performance.
San Francisco: Jossey-Bass, 1996.
Military and civilian staff with email access in MHS facilities, including Military Treatment Facilities (MTFs)
and DENTACs (Dental Activities/DTFs), are being asked to complete this survey. It asks for your opinions
about patient safety issues, error, and event reporting in your MHS facility.
It will take about 10 minutes to complete this web-based survey and your individual
responses will be anonymous. Only group-level results will be reported.
Your response to this survey is very important and will help the DOD assess patient safety improvement
efforts in MHS facilities.
For questions about this survey, please email [Name a point-of-contact and provide email] or call [provide phone].
Purpose: This individually anonymous survey asks staff in Military Health System (MHS) facilities
(including MTFs and DTFs) for their opinions about patient safety issues, medical error, and
event reporting in their facilities. The data will help the DOD assess patient safety improvement
efforts in MHS facilities.
Disclosure: Voluntary. Failure to respond will not result in any penalty to the respondent.
However, maximum participation is encouraged so that data will be as complete and
representative as possible.
OMB CLEARANCE
This survey has been approved by the Office of Management and Budget (OMB Number 0720-0034,
Expiration Date 09/30/2008). It is estimated that it takes 10 minutes to complete. If you have comments
about the survey, its length, or any other aspects of this collection of information, send them to: TRICARE
Management Activity, Information Management Control Officer, HPA&E, 5111 Leesburg Pike, Suite 810,
Falls Church, VA 22041.
1. The Military Health System (MHS) facility where you work is in what country and state (if
applicable)?
[NOTE: A drop-down list of by country and state is provided on the web survey. This question is
MANDATORY and must be answered before moving on in the web survey.]
Country:________________________________________________
2. What is the name and DMIS Code of your Military Treatment Facility (MTF) or DENTAC (Dental
Activity/DTF)? [NOTE: A drop-down list of MTF/DENTAC names is provided on the web survey. This
question is MANDATORY and must be answered before moving on in the web survey.]
[NOTE: If a respondent is in an MTF hospital, they will receive this additional question. If their MTF is an
outpatient clinic or dental facility, they WILL NOT receive this additional question. This question will be
MANDATORY for staff in an MTF hospital and must be answered before moving on in the web survey.]
1. Hospital
2. Ambulatory/outpatient clinic
3. Dental clinic
Ai. What is your primary work area/duty area in your MHS facility?
From this point forward, if you do not wish to answer a question, or if a question does not apply to
you, you may leave your answer blank.
Please indicate your agreement or disagreement with the following statements about your work
area.
Strongly Strongly
Disagree Disagree Neither Agree Agree
1. People support one another in this work area .........................
2. We have enough staff to handle the workload.........................
3. When a lot of work needs to be done quickly, we work
together as a team to get the work done .................................
4. In this work area, people treat each other with respect ...........
5. Staff in this work area work longer hours than is best for
patient care ..............................................................................
6. We are actively doing things to improve patient safety ...........
7. We use more agency/temporary staff than is best for
patient care ..............................................................................
8. Staff feel like their mistakes are held against them .................
9. Mistakes have led to positive changes here ............................
10. It is just by chance that more serious mistakes don’t
happen around here.................................................................
11. When one section in this work area gets really busy, others
help out ....................................................................................
12. When an event is reported, it feels like the person is being
written up, not the problem ......................................................
13. After we make changes to improve patient safety, we
evaluate their effectiveness .....................................................
14. We work in "crisis mode" trying to do too much, too quickly ...
15. Patient safety is never sacrificed to get more work done ........
16. Staff worry that mistakes they make are kept in their
personnel file............................................................................
17. We have patient safety problems in this work area .................
18. Our procedures and systems are good at preventing errors
from happening ........................................................................
Please indicate your agreement or disagreement with the following statements about your
immediate supervisor/manager or person to whom you directly report.
Strongly Strongly
Disagree Disagree Neither Agree Agree
1. My supervisor/manager says a good word when he/she
sees a job done according to established patient safety
procedures ..............................................................................
2. My supervisor/manager seriously considers staff
suggestions for improving patient safety ................................
3. Whenever pressure builds up, my supervisor/manager
wants us to work faster, even if it means taking shortcuts .....
4. My supervisor/manager overlooks patient safety problems
that happen over and over ......................................................
SECTION C: Communications
In your work area, when the following mistakes happen, how often are they reported?
Some- Most of
Never Rarely times the time Always
1. When a mistake is made, but is caught and corrected
before affecting the patient, how often is this reported? .........
2. When a mistake is made, but has no potential to harm the
patient, how often is this reported? .........................................
3. When a mistake is made that could harm the patient, but
does not, how often is this reported? ......................................
A B C D E
Excellent Very Good Acceptable Poor Failing
Please indicate your agreement or disagreement with the following statements about your MHS
facility.
Strongly Strongly
Disagree Disagree Neither Agree Agree
1. Management in this facility provides a work climate that
promotes patient safety...........................................................
2. Work areas in this facility do not coordinate well with each
other ........................................................................................
3. Things “fall between the cracks” when transferring patients
from one work area to another................................................
4. There is good cooperation among areas that need to work
together ...................................................................................
5. Important patient care information is often lost during
shift changes ...........................................................................
6. It is often unpleasant to work with staff from other work
areas in this facility..................................................................
7. Problems often occur in the exchange of information
across work areas in this facility .............................................
8. The actions of management in this facility show that patient
safety is a top priority ..............................................................
9. Management in this facility seems interested in patient
safety only after an adverse event happens ...........................
10. Work areas in this facility work well together to provide the
best care for patients ..............................................................
11. Shift changes are problematic for patients in this facility ........
In the past 12 months, how many event reports have you filled out and submitted?
1. How long have you worked in this Military Health System (MHS) facility?
a. Less than 1 year d. 11 to 15 years
b. 1 to 5 years e. 16 to 20 years
c. 6 to 10 years f. 21 years or more
3. Typically, how many hours per week do you work in this MHS facility?
a. Less than 20 hours per week d. 60 to 79 hours per week
b. 20 to 39 hours per week e. 80 to 99 hours per week
c. 40 to 59 hours per week f. 100 hours per week or
more
4. What is your staff position in this MHS facility? Select ONE answer that best describes your staff position.
5. In your staff position, do you typically have direct interaction or contact with patients?
a. YES, I typically have direct interaction or contact with patients.
b. NO, I typically do NOT have direct interaction or contact with patients.
Please feel free to write any comments about patient safety, error, or event reporting in your MHS
facility. Do not write any comments associated with individual patients or event identifiable
information.
NOTE: Verbatim comments will be reviewed at the Service level.
Event Reporting
DoD patient safety data registry (PSR) gathers and standardizes clinically relevant information,
and provides feedback across all three Services about reported instances and categories of actual
events and near misses.
DoD Patient Safety Materials are available only to medical treatment facilities from
the Army, Navy, or Air Force.
DoD Patient Safety Newsletter, published quarterly since 2001, provides information
on MHS patient safety initiatives/activities, upcoming events, training schedules, and
links to articles and websites.
Patient Safety Center Alerts, Summaries, and Advisories are restricted to participants
in the DoD Patient Safety Program. To gain access, please register for an account by
going to: http://dodpatientsafety.usuhs.mil/?name=psaccountsignup
Ongoing Courses:
An Introduction to Patient Safety
Basic Patient Safety Managers Course
Enhanced Patient Safety Managers Course
Basic TapRooT®
Advanced TapRooT®
TapRooT® Software
Failure Mode and Effects Analysis (FMEA)
For questions on DoD Patient Safety programs and resources, ask your Service representative or
contact the program directly at: