National Implementation of TeamSTEPPS Webinar 4

American Institutes for Research

Moderator: Alexander Alonso
September 17, 2008
12:00 pm CT

Operator: Ladies and gentlemen, thank you for standing by. Welcome to Using the AHRQ Hospital Survey on Patient Safety Culture conference call.

During the presentation, all participants will be in a listen only mode. Afterwards, we will conduct a question and answer session. If you’re using Live Meeting, please proceed to ask a question there. Then we will conduct an audio question and answer session. To ask a question, please press the 1 followed by the 4 on your telephone. If by anytime during the conference you need to reach an operator, please press star 0.

As a reminder, this conference is being recorded today Wednesday, September 17, 2008.

I would now like to turn the conference over to Dr. Alexander Alonso. Please go ahead sir.

Alexander Alonso: Thank you. Good morning and welcome to the fourth Webinar in the series provided by the TeamSTEPPS National Implementation Program. I want to welcome everyone and I say good morning to those of us who are not necessarily on the Eastern Standard Time zone. So, those of you who are, I’d like to say good afternoon.

As many of you know, this Webinar’s topic is the Hospital Survey on Patient Safety Culture and for this Webinar we’ve brought in a very special guest by the name of Dr. Katherine Jones. Katherine is an assistant professor in physical therapy education at University of Nebraska Medical Center. She is also a primary investigator for AHRQ funded partnership in implementing patient safety grant.

This grant was entitled "Implementing a Program of Safety in Small Rural Hospitals”. The project created a Medication Safety Tool Kit for small rural hospitals and identified the impact of systematic medication error reporting on safety culture. Her team developed a rural adapted version of the AHRQ survey on Patient Safety Culture to accurately categorize employees in small hospitals.

She is also funded by the Nebraska Department of Health and Human Services to evaluate the effect of TeamSTEPPS training on the culture of safety in 25 Nebraska Critical Access Hospitals. She has conducted the TeamSTEPPS master training and train the trainer course for 40 Critical Access Hospitals as part AHRQ’s efforts to disseminate AHRQ tools. She has also completed an assessment of the readiness of Nebraska Hospitals to treat acute stroke and is the evaluator of the Nebraska Geriatric Education Center.

Before we begin and get into the nuts and bolts of the actual AHRQ Hospital Survey on Patient Safety Culture. I’d like to remind everyone that you considerate of others while participating in this Webinar, that you mute your phone to reduce background noise, and that you do no put your phone on hold if you have a hold music or advertisements as part of your hold for your organization.

The agenda for today consists of six pieces. First, we’re going to go ahead and describe who we are then we’re going to describe the national implementation of TeamSTEPPS program, provide an overview of the HSOPS, and then provide a case study with data. Following that, we’ll take questions and then we’ll give you information on resources as well as how to contact us.

We represent -- and by "we" I mean myself and several other presenters -- represent the American Institutes for Research, which is a prime contractor on the National Implementation of TeamSTEPPS program. We are a not for profit non-partisan research organization based in Washington with 11 U.S. offices and 12 International offices with researchers focusing on health services research, education and work force research.

We have health services researchers, nurses, physicians on staff, as well as social and behavior scientists. Our mission as an organization is to better society through our research.

The National Implementation project is an AHRQ sponsored project that is also funded by the DOD as well. The emphasis or the objective of this project is to create a national infrastructure to support the adoption of TeamSTEPPS using resources and potential master trainers from the quality improvement organization, from the Patient Safety Improvement Corps as well as early adopters like the high reliability organizations, action partners and academic medical centers.

The goal of this is the diffusion of TeamSTEPPS or to spread TeamSTEPPS nationwide. Ultimately, we’d like to create 1,200 new master trainers, many of whom are attending here today. This project or this program is run as part of a larger scale project and it consists of four primary team resource centers where master training is made available.

The first of these is Minnesota, or the University of Minnesota, we also have a master training site at Creighton University where Katherine helps provide the training. We have one at Duke University and one at Carilion Clinic in Roanoke. We also are supported by two quality improvement organizations, one known as Lumetra and the other the one known as Delmarva Foundation here in D.C.

Also we have groups in New York known as the Group for Organizational Effectiveness who's helping us with the development of measures and a group helping us conduct evaluation and development of systems for learning (unintelligible), Booz Allen Hamilton.

As mentioned earlier, the sponsors for this national implementation program are the Department of Health and Human Services and specifically the Agency for Healthcare Research and Quality, and the Department of Defense and specifically the TRICARE Management Activity. The AIR project team consists of Dr. David Baker, who has a dual appointment with Carilion Clinic as well as serving as the overall project rector for TeamSTEPPS efforts at AIR.

Myself, I am the Deputy Project Director for Research, Debbie Milne who is the Deputy Project Director for Outreach User Support and much more and Cori White and Rachel Greenberg who serve as our administrative leaders.

To get a hold of us, you can reach us at any one of our email addresses, which are listed up here, or our telephone numbers. We will provide this further or this information is also provided in our handouts, which can be found up here in this section and it is the little tab at the top right above the actual slide or presentation that has three sheets. You’ll notice that our handouts are available there.

So, now we want to get into the actual nuts and bolts of the Hospital Survey on Patient Safety Culture and the primary reason that we want to discuss is we want to talk about the importance of patient safety culture as it relates to TeamSTEPPS and then also as it relates the organizational outcomes and organizational practice.

Culture is literally a manifestation or organization culture is a manifestation of the values, prophecies, and systems of an organization. It is clear that to provide quality healthcare, patient safety culture is a crucial area. It is important to assess the crucial area in quality healthcare, it is important to measure patient safety culture to identify the organizational conditions that can lead to adverse events as well as what might lead to patient harm.

Measuring patient safety culture is also an important part of evaluating interventions to improve patient safety.

[Minor discussion of technical difficulty] I apologize for that. Okay, so what is the Hospital Survey on Patient Safety Culture? It is a free and easy to use reliable and valid instrument to assess patient safety culture sponsored by AHRQ, this was developed by Westat, an organization much like AIR that was responsible for creating this measurement tool.

It is a comprehensive instrument that assesses staff perceptions of patient safety culture hospital wide to a specific work area or unit and specific staff positions. It is comprised of 51 items and 12 composites for dimensions.

How can hospitals really use the HSOPS? Hospitals can use this to raise awareness about patient safety issues. They can also use this to assess their patient safety culture. One can also track changes in patient safety culture over time. One example that we’ll talk about here today is how patient safety culture has changed over time across several hospitals or Critical Access Hospitals.

It can also be used to conduct internal and external benchmarking and one of the things that we’ll talk about at the end of this is the comparative database or the National Comparative Database produced by AHRQ. Finally, and this is one that is most relevant to folks who’ve been trained as TeamSTEPPS master trainers, it can be used to evaluate the impact of patient safety interventions, such as the TeamSTEPPS initiatives.

So, where does the HSOPS fit in to the TeamSTEPPS process per say? Well as you can see on your computer screens right now, we’re talking about the three phase system for the implementing the TeamSTEPPS initiative or for carrying out the TeamSTEPPS initiative.

The first phase starts with assessment and setting the stage. And you can see the culture survey is a large part of conducting your pre-training assessment. It also helps you determine whether or not you’re facility or organization is ready or your specific unit is ready for the specific teamwork intervention like TeamSTEPPS.

The measure consists of 12 areas of patient safety and two key overall items. There are unit level safety areas that include topics such as overall perceptions and safety, frequency of events reported, teamwork within units, teamwork across units, non punitive response to error and staffing. There’s also hospital wide safety areas that include the teamwork across hospital units, hospital handoffs and transitions, and hospital management support for patient safety.

Then there are also two overall items that really assess the grade or what would be given as far as patient safety for the overall area or unit and the total number of events that the respondent has reported in the last 12 months and by events we’re referring to patient safety events.

One question that arrives commonly is can hospitals customize the survey. AHRQ recommends that hospitals or units only make changes that are necessary or absolutely necessary. The reason for this is the modifications can really endanger the level of benchmarking that your unit can do specifically with external benchmarking.

If modifications aren’t necessary, AHRQ advises that you follow guidance provided in the survey users guide. Some of this guidance includes not shortening the instrument by deleting single questions instead delete all items within a dimension that are of low priority.

Another thing that is reported is to make sure that you add new questions at the end of the survey rather than throughout the survey because it can change the psychometric properties of the survey or specifically the internal dimensions that we are interested in measuring as part of the survey.

So, what are some of the key data collection procedures and things that you should look out for when considering the AHRQ culture survey or the HSOPS? Primarily you want to think about sampling and the goals for survey respondents to be as representative of all staff or specific sub sets as possible. For example, you want to make sure that you get as many folks that represent the overall distribution of disciplines within a specific unit if you’re doing the HSOPS survey in a specific area like the ED or like Labor and Delivery.

You also want to consider the length of time that is required for key data collection. The survey typically takes approximately 10 minutes to complete. Data collection modes, you want to consider the fact that the data collection is paper and pencil based or recommended that it be paper and pencil based because it ensures a stronger response rate.

And specifically it ensures a stronger likelihood of the entire survey being completed as opposed to a Web based collection, which can lend itself to partial responses. Finally, when analyzing and reporting you want to use the tool kit that is provided by AHRQ.

At this point, I’d like to go ahead and turn it over to Katherine, who is going to give us some insight into a specific application of the Hospital Survey on Patient Safety culture as well as talk about how that related to the TeamSTEPPS initiative within her state.

Katherine Jones: Thank you, Alex. I’m here to share the experience of one particular hospital in Nebraska, Dundy County Hospital in Benkelman Nebraska and even though Dundy County as you can see is pretty small hospital, it’s down in the southwest corner of the state and I have given you a picture there of Dundy County and some of the scenery around it.

Even though it’s a small hospital, the same principals of becoming a learning organization and how we use the safety culture survey apply in their small organizations just as well as they apply in a 500-bed hospital. The advantage is that in a small organization, learning and change can take place quickly when we have the proper mix of leadership and willingness in place.

For those of you who aren’t familiar with Critical Access Hospitals, Critical Access Hospitals are a category of limited service hospitals that were created in 1997 as part of the Balanced Budget Act. Critical Access Hospitals maintain access to care in rural areas by providing cost-based reimbursement. These hospitals actually get reimbursed what it cost them to provide the care, plus 1% for all of their Medicare patients.

As you can imagine when you have a 14-bed hospital like Dundy County it’s pretty hard to come out ahead of the game when you’re using diagnoses related groups that require a volume to break even. So, Critical Access Hospitals are all limited to 25 inpatient beds for acute care and an average length of stay of 96 hours. And all those dots on the map represent locations of Critical Access Hospitals and you can see that they are concentrated in the plains states where we have large geographic areas and low population density.

So, I like to think of Critical Access Hospitals as really little laboratories for change for some of the patient safety interventions that we’re implementing through TeamSTEPPS and to other patient safety activities. Critical access hospitals do account for 1/4 of the general community hospitals in the country.

So, for my portion of the Webinar today, I wanted you to think about the specific objectives. One of the problems that we encounter is that too often people are pretty fuzzy about what it means when we say safety culture. So, I hope that at the end of the presentation we have working definition of safety culture.

I hope you’re able to identify safety culture strengths and weaknesses from the AHRQ, HSOPS results. And this includes looking at aggregate results across an organization and results within work areas and staff positions because you don’t have one culture in your organization, you have multiple cultures, which is dedicated by how leaders within work areas and staff positions, how their leaders use information.

I want you to be able to use the Safety Culture Survey results to identify gaps between belief and behaviors within specific dimensions of the survey. I hope you’re able to identify and describe key practices that you can use to address weaknesses and safety culture.

And I want you to value the key effect of key multiple practices across the four components of culture that contribute to organizational learning, it isn’t just one practice in isolation, but it’s the key to the effect of multiple practices across the four key components of culture that enable organizational learning.

So, what is that definition of safety culture that should just roll off the tip of your tongue? Safety culture is the enduring, shared belief, and behavior that reflect your organization willingness to learn from errors.

And the IOM report taught us that there are three beliefs that’s present in a safe informed culture and that those beliefs are that our processes are designed to present failure. We believe that we are committed to detect and learn from error and we believe that we have a just culture that disciplines based on risk taking, not based on outcome.

Now these three beliefs are reflected in a Hospital Survey on Patient Safety Culture and I want you to keep in mind this whole idea that a safe culture is an informed culture. And I’m sure most of you are familiar with the term high reliability organization and a high relate ability organization is one that is informed and it’s safe because it is informed about those risks it has inherent in its system.

So, High Reliability Organizations are those organizations like the airline industry, aircraft carriers, nuclear power, they are preoccupied with failure. People come to work thinking every day, how can a system failure harm an employee or our case harm an employee or a patient.

They’re sensitive to how each member of team is going to affect the process. They allow those people who are most knowledgeable about the processes to make decisions. Now, think about that in terms of healthcare, do we allow those people at the front line who are most knowledgeable about processes to be at the table when we implement change or a new system.

And finally, High Reliability organizations are those organizations that are able to resist the easy way out and blame an individual for errors within complex processes. You know, as Alex explained, our partnerships in implementing patient safety grant focused on medication errors.

And whenever I saw on an error report that a supervisor discussed the error with an individual or retrained an individual when we know that 90% of medication errors have system causes, you know, that’s the easy way out when you look at speaking to an individual when most of those errors have system causes.

So, as I mentioned, the hospital survey on patient safety culture reflects the four components of a safe informed culture. And this interpretation is based on James Reason's work and James Reason is an organizational psychologist and the volume that this work is taken from is Managing the Risks of Organizational Accidents”. And what James Reason says is that there are four components to safety culture: reporting, adjust, flexible, and learning.

And when we think about it an informed culture is founded on a culture that is able to report. A safety information system is this because the frontline workers are ready to participate in reporting; the people in direct contact with hazards are able to report their errors and near misses because there’s fundamentally a just culture and atmosphere of trust where people are encouraged and even rewards for providing information about essential safety related processes.

Now, people are not going to report if you don’t have a just culture and they are not going to report if the culture isn’t flexible enough to act on that information and change and a flexible culture can take a number of forms.

But, in many cases it involves the ability for the culture to shift so that the higher archetypal patterns that exist in terms of RN to LPN, LPN to Nurse Aid, DON to RN, supervisor to frontline worker, physician to nurse, physician to therapist. Those higher archetypal patterns will relax when people are talking about safety information because the knowledge of the frontline worker is valued.

And when I think about a flexible component of culture, that where TeamSTEPPS exist. TeamSTEPPS lives in that flexible part of culture, but the practices that we learn in TeamSTEPPS can support all of the other components of culture. TeamSTEPPS tools support the notion of a just culture, they support reporting, and they obviously support being a learning culture.

And at that goal of being a learning where we have the willingness and the component to draw the right conclusions from our three key information systems that we’re all seeking. But we cannot have a learning culture if our culture is not flexible through teamwork, if we don’t have a just culture that only punishes people for knowingly increasing the risk to patients in an (unintelligible). And we cannot have a learning culture if, first and foremost, we don’t have information about our systems and processes.

So, let's take a minute and look at how we use four components of culture to crosswalk to the different dimensions or outcomes measures of the HSOPS.

Oh, that’s funny how the bullets end up showing as a number 10. Is that how it works on other peoples' slides?

Cori White: That’s how it looks to me.

Katherine Jones: Well, that’s funny, that’s supposed to be a bullet.

So, a recording culture, we can look to two outcome measures, frequency of events reported and number of events reported. For a just culture, we cross walk that like to the non-punitive response to errors dimension and we called it the different dimensions of the safety culture are either outcome measures, they’re measured at the level of the unit or department or they’re measured at the level of the hospital as a whole.

So, a just culture is actually looking at the unit or the department as a whole and that’s makes sense because people can’t judge whether the culture of the hospital as a whole is just, they can only judge whether the culture within their own department or work areas is just.

In terms of flexible culture, we have a number of HSOPS dimensions and outcome measures. Teamwork within departments, staffing, and communication openness will get teamwork and flexibility of the culture within a unit and teamwork across departments and hospital. Handouts and transitions of course looks at teamwork across the hospital as a whole.

Learning cultures, there are a number of outcome measures and unit and hospital wide department measures that we can cross walk to learning culture specifically whether the hospital management supports learning culture and then whether the unit level managers support learning culture. Then we look at feedback and communication about error and organizational learning at the unit level. Of course we cannot have learning if we don’t have feedback and communication.

I’d like to pause here now and ask if anybody has any questions.

Cori White: It looks like we don’t have any through the electronic Q&A system, but I just want to remind people that if you do have a question, we prefer that you use the Q&A tab at the top of your screen to enter it so that we can manage them.

Katherine Jones: One thing I’m interested in is whether people find this idea that we can boil safety culture down to four components. Fundamentally, what I like to do is take complex concepts and make them workable, make them actionable for people at the frontline. And by looking at safety culture really adds either reporting practices, the a just culture practices, your teamwork practices, and your learning practices, that gives us a way to improve.

And for me, this was just so intuitive as physical therapist, I’m used to looking at somebody’s gait, how they walk and then I look at, well do they have the strength to support normal gait, do they have the range of motion to support normal gait, do they have the balance and sensory perceptions to support normal gait. So, to me looking at safety culture and looking at the four components was just the same as if I was trying to look at how an individual walks. There were similar skills to me.

If anybody else has any comments about that, that’d be interesting to hear. So, let’s take questions.

Alexander Alonso: I think we do Katherine. Cori, do you want to go ahead and tackle those?

Cori White: The first one that I just answered to everyone, and actually it looks like a second person’s just popped up, is where we can access slides and the handouts. And the answer to that question is at the top right of your screen, there should be a small icon that looks like a bundle of three pieces of paper and if you click on that it should take you to the download handout manager so that you can download the slides that we have.

And we have them available in PDF format both as single slides and as three slides with a place for notes and if that doesn’t work for you, you can also email TeamSTEPPSwebinars@air.org and we’ll be sending out an email to people who request them after the Webinar with a copy of the slide set.

Let’s see what else we have in here. We have a comment that says that the person would suggest that a just culture should be on the ground for pyramid rather than a reporting culture.

Katherine Jones: I’ll tackle that one, if you look at the pyramid, you’ll see that there are two way errors between each component and I would happily flip flop those around, but of course if you don’t have any reporting, you don’t have anything to be just about. You know, if you start from the standpoint that there’s information then there’s no opportunity to punish anybody and then you start with well there’s no opportunity if you’re not just, there’s no information.

So, it’s really a chicken and egg thing and that’s why I screwed around that by putting the interacting error between them because really what happens the idea is that a just culture and reporting culture interact to create an atmosphere of trust.

So, if we could take this combined a just culture and reporting culture and replace that with trust, that’s really what we’re seeking and I’ll ask Randy to think about that and maybe respond to that later on that a just culture and reporting culture combined to create trust in your organization.

Are there any others?

Cori White: Someone has their hand raised, but I just want to let you know that if you do have a question we ask that you type in to the electronic manager. If you - sometimes we just get a little icon that says you’re hand is raised and at that point because of the way that our audio is set up, we don’t know what you’re question is.

So, if you have a question, please type it in and we’ll address it as soon as we’re able. Other than that I think we have them covered for now.

Katherine Jones: Okay, so we’ll take Randy's comment and we’ll say that a just culture and reporting culture work together simultaneously to create trust in the organization and I thank Randy for that comment.

[Loud noise] Oh, no. We just had a huge system error here in my office. I just moved offices and they put a power strip under my desk and I moved my foot and it cut my power off. So, that was a bit of a scare.

Moving along, what I have here is one of the tools that we use to present the HSOPS results to our hospitals. As Alex said, we conducted the hospital survey on patient safety culture as part of our grant. So, we have 24 hospitals that were involved in this learning how to use a medication error reporting program to identify system causes of medication errors and we wanted to evaluate the impact of this reporting program on their safety culture.

And once we started looking at safety culture that’s where we found out that not only do we need a systematic reporting system, we need a just culture, we need teamwork, we need learning practices. So we educated our hospitals about some of those other practices as well, but our primary intervention was teaching our small Critical Access Hospitals to use Med Mark, the national medication error-reporting database.

So, when we gave the safety culture back to our hospitals, we gave them back - one of the tools was the benchmark graph and when you look at the graph, what you see on the bottom of the x-axis are the dimensions of the safety culture survey.

These first two dimensions here are outcome measures, overall perceptions of safety and frequency of events reported. Then next seven dimensions are unit level or department level dimensions from manager actions promoting safety all the way to staffing. Those are the seven unit or department levels dimensions. And then, finally on the right-hand side, hospital management support for patient safety, teamwork across hospital departments and handoff in transitions, these are the three hospital level dimensions.

Now the black line at the top of the graph is not a hospital. It is the single most positive response for a given dimension from any of the 24 hospitals in our tier group. Similarly, the orange line is the least positive response from any of the 24 hospitals. So, if you’re Dundy County Hospitals, and that’s whose hospital results I have, and these were their results, their baseline results in October 2005 when we started our reporting project.

The purple line is Dundy County. So if you are Dundy County, you can quickly see where you’re strengths are and where you’re weaknesses are in comparison to the range across the tier group. So, obviously they have strength and hospital management support for patient safety, they’re setting the top range in that dimension, they have a strength overall as in teamwork within departments.

A particular weakness they had obviously was non-punitive response to error, which you can see that all of the hospitals non-punitive response to error was the least positive dimensions perceived across all of the hospitals. And also, we’ve got some concerns here about communication openness and feedback and communication about error where only 60% of people overall were positive about those dimensions.

So, you take a complex tool like the hospital survey on patient safety culture and you give it back to people in a way that they can use - quickly communicate the results to their stake holders, such as their board of directors, their medical staff.

And to all their employees because one of the important things when you use the hospital survey on patient safety culture, you’ve asked people their opinion, their perceptions about safety culture across the hospital and within their department, you have got to report back to them what you found and what you’re going to do with the results.

But, remember that when you aggregate information together, when you aggregate date, you lose specific information at the level of the department and staff positions. And, I’m going to go on to the next slide and I’m going to show you an example of this.

The purple line is still Dundy County Hospital’s aggregate results what we’ve done now is split that out into what the nurses think, which is the blue line, and what non nurses, everybody who’s not a nurse thinks. So, when you look at the information presented this way, you get a little bit different idea of what’s going on for nurses within the hospital.

And this works for all departments and all staff positions, you need to drill down into the results and look at them by work area either by department or unit and by staff positions because you have multiple micro cultures.

You have a crazy quilt of culture within your organization and our small hospitals tend to be more similar across the hospitals than what many large hospitals are. And one of things that we found from looking at - I looked at results from over 50 hospitals and almost always lab and surgery are more positive safety cultures than what the nursing unit are.

And if you think about it, lab and surgery have more structured ways of looking at the safety of their processes than what the frontline staff do that work the floor.

So, anybody have any comments about the differences that you see when you split the nurses out from the hospital as a whole?

(Cory White): If you have comments, they can also be addressed through the question and answer tab at the top of your screen.

While we’re waiting for people to do their comments, we do have another questions. Katherine, we have a question that asks how long have you been working on this? What was your first safety culture survey and how many have you done since that time?

Katherine Jones: Actually, I started working with these hospitals back in 2002, but the first time that we assessed safety culture was in October of 2005 and we implemented our reporting intervention at that time, then we reassessed safety culture in March of 2007 and I’ll show you those results. You know, there’s a lot of discussion about how often you should assess safety culture and culture takes time to change because we don’t change people’s belief’s, we change what they do, their behaviors, their practices and then the beliefs follow.

You know, Nike knows what they’re doing when they say, “just do it”. That’s what we do here, we implement new practices and we enable people to change what they do and their belief follows, so all that takes time to accumulate within the culture.

So the short answer is I think you should only reassess with the safety culture survey every 18 months or every two years, 18 months is the minimum amount of time that you should take to reassess safety culture. And I think two years is probably even closer to perhaps being able to tell some changes. And we’re going to re-do safety culture again in March, 2009.

So, we’re going to move on now and look at another example of how safety culture varies by staff position. And with this graph, you’ve the same, you’ve got your dimensions of culture along the bottom and across the top what I’ve got results for providers across all of our hospitals. So, that’s 80 physicians, physician assistants or nurse practitioners, the triangle is management, anybody who identifies themselves as a manager, and then nurses, nurses are the squares.

So, you can quickly see that management has a more positive perspective of safety cultures than anybody else and I’d like to challenge you to think about did they have a more positive perception about safety culture because they have more or less information about what’s going on at the front line. And most people typically say it’s because they have less information.

Do we want to take more questions at this time or should we go on a little bit and take questions a little bit later.

Alexander Alonso: Katherine, let’s go ahead and take some questions because we actually have quite a few now that are relevant to the slides.

Katherine Jones: Okay.

Cori White: Okay, the first one we have is what percent of nurses and non-nurses responded to the survey at this facility?

Katherine Jones: I meant to look that up, but I know their response rate was in the upper 80%. One of the things that we pride ourselves on in this project is that we use the (Gillman)'s method.

The safety culture survey goes out in the facility as a paper survey, where the respondents fill out and mailed back to us here at UNMC so they’re assured of confidentiality and anonymity within their organization because of course in a small facility, everybody knows your handwriting. So, our responses are generally quite good and in Dundy County they were in the upper 80’s.

Cori White: Okay, the next one is have you looked at associations between responses from different groups, nurses versus MD’s etc. and other markers of safety. Other studies have shown that MD’s report higher perceptions of safety in teamwork and nurses and evidence suggest that the nurses have more accurate view when correlated with patient outcomes.

Katherine Jones: If you look at the graph here, what you can see is sometimes the providers track with the nurses and sometimes they track with the management. Now, in small rural hospitals, I think the physicians have a greater idea of what’s actually going on in terms of systems and processes because the facility is so small, so if you look at overall perceptions and safety, the nurses and providers are pretty much right and managers are a little bit above them.

If you look at something say like non-punitive response to errors, look at how they’re split apart there. Of course physicians have a much more punitive experience in our healthcare system, who’s the one that’s most likely to be the target of litigation is the physicians and we’ve got a lot of more work to do in terms of bringing providers into the community of just cultures.

That’s an excellent question and I hope with additional funding and more resources that we’re going to be able to work more at how physicians and managers and nurses all differ on the various dimensions of safety culture. And I think it’s going to require some qualitative research where we actually getting in there and talk to people and find out what they’re actual experience more so than a quantitative approach.

Another question.

Cori White: The next one is what were there many differences identified between non-nurses and nurses for the finding of manager actions promoting patient safety.

Katherine Jones: The main difference was remember this was a very small hospital and the main difference was our project gave tools to our frontline manager that took those tools and ran with them and she was a real leader for the nurses. And so the main difference was we had a champion, a nurse champion - well she was actually the quality improvement coordinator and you guys will meet her a little bit later on in the presentation.

Cori White: And it looks like the last thing we had is someone who commented that they think it’s interesting that nurses rank the outcome so different from non-nurses.

And again I’d like to just point out that we have a few people who appear to have questions. I’m not going to point you out by name. But if you do have a question and you’re part of the live meeting, we do need you to actually type the question in rather than just using the hand raising option because otherwise we’re not able to address it.

Katherine Jones: Okay, as we move on to the next slide, what I’m going to show you now are actually the results from the nurses at Dundy County from 2005 and 2007. And I’m showing you the results this way for two reasons. Number one, because we saw that the perceptions of nurses were different from the perceptions of non nurses and number two because our medication error reporting intervention and all of our safety culture interventions were aimed primarily at the nurses in our hospital.

So, when you look at the - and this slide is the actual way the results look on the excel reporting template that you get back if you use the excel tools to analyze your results. So, in 2005 only 25 percent of the nurses at Dundy County believed that when a mistake is made but is caught and corrected before affecting the patient that it’s reported frequently.

And you can see that by 2007, that had increased to 65%. Well, what were the practices that we implemented that resulted in that change? We implemented a systematic reporting system and a successful reporting system has to be non punitive, confidential, independent, has expert analysis associated with it, it’s timely, it’s systems oriented that looks at the systems and it’s response meaning that when people report they are told what the results of the reporting were and what was done with that information.

And, as I told our hospitals all learned how to use Med Mark, the National Medication Error Reporting Database. And Med Mark did a number of things for these hospitals and we’ll talk about that on the next slide. But, before I do that I want to point out that reporting within a safe culture takes multiple formats. You can use a reporting form and database like Med Mark, but you can also use a long sheet that just track mere misses, just a quick log sheet.

And you can use a telephone hotline, chart audits, secret shoppers, safety briefing, leadership (unintelligible), a bulletin board where you post safety concerns or a suggestion box. All of those are ways that an organization can collect some information, so all of those are the reporting practices.

But, what Med Mark did and this critical, with Med Mark gave our hospitals a language to talk about error that reflected this system. And that language consisted of talking about the severity of the error as a category A, a category B, a category C. I don’t know how many of you are familiar with that. It’s the NCC MERP, National Coordinating Council for Medication Error Reporting and Prevention.

The NCC MERP when A is a potential error, a B is a near miss, a C is a error that reached the patient but did not cause any harm and so on all the way up to category I with the error caused death.

So, now these hospitals have a language to talk about near misses versus errors that reach the patient. They could talk about did the error originate in the ordering stage where the physician used an inappropriate abbreviation like q.d. and q.i.d. or did it originate in the documenting phase, did it originate in dispensing, administering, they could talk about the type of the error. Was it a wrong time, a wrong medication and inaccurate dose, they talk about the cause and so on.

But, we have to have a language to talk about events that reflects the system, if we don’t have that language all you’re left with is who did what and when did they do it. So, you can see that using a systematic error reporting system provides language that also supports a just culture.

Now let’s take a look then at changes in a just culture from 2005 to 2007 and you can see that I like the one. Number two, when an event is recorded it feels like the person is being written up, not the problem. When you look at the safety culture survey, there are some items that are reverse worded and they have an R in front of them and a reverse worded item is one that is to be positively interpreted, you have to disagree with the statement.

So, when an event is reported it feels like the person is being written up, not the problem. And you can see that in 2005, a third of the nurses disagreed with that statement and in 2007 (unintelligible) improved to 50% and you can similarly see that we had improvements in a just culture, non-punitive response to error in the other two items as well.

They did not feel like their mistakes we’re held against them as much. And boy this idea that we put mistakes in people’s personnel files is hard to shake because that was one of the chief things that we emphasized in our project that mistakes are not kept in people’s personnel files. And there’s still about a little over half of the nurses there that weren’t quite sure about that.

So, if we look at a just culture what were the practices that Dundy County used as part of our project to change perceptions of a just culture? We did some education about the nature of human error, understanding the difference between the active error and the (unintelligible) error.

We did some education about dated markers concepts that we look at conduct in terms of human error negligence, reckless behavior and intentional rule violations and we really focused on disciplinary decision-making that people have the power to make the decisions when an event lands on a manager’s desk, that manager needs to make a decision. Is this event (unintelligible) I’m going to hold an individual accountable for or is this an event that has its beginnings in the system.

So, you need to really focus on risk taking and not the outcomes. And one of the tools that we use is the Unsafe Acts Algorithm. And I just want to briefly mention here the whole emphasis on disruptive behavior. I think it’s going to find its roots in our concept of just culture. The joint commission issued a Sentinel Event Alert about disruptive behavior.

So, the Unsafe Acts Algorithm if you expect to implement or have a just culture in your organization, how do you operationalize that? And as I said, it ultimately comes down to an event lands on a managers desk and he or she needs to make a decision about how to handle that.

And that event either goes the way of disciplinary action and human resources handles it or it goes to route that we have to investigate this event in terms of becoming a learning organization in terms of learning from our experience. And this algorithm, this is something that I’ve adapted again from James Reason.

And this tool, this decision tree enables a manager to make that decision about which way this event goes. You start at the top left-hand side and ask yourself were the actions as intended? So, let’s take a well known example of the recent numerous times that premature infants in the NICU have received adult doses of heparin when they were intended to just have their lines flushed out.

So, in that instance were the actions as intended? Absolutely not. Was there any evidence of illness or substance abuse if we go to the next box? Well we’re going to assume that there wasn’t. Go to the next box. Did somebody knowingly violate a safety procedure? And what people typically tell is that yes, they probably violated checking the five rights. Did they hold heparin in their hand and compare it to the (MAR) and say, "Have I got the right drug for the right patient? Is this the right kind? Is it the right dose?"

But, what we know is that when you’re flushing the lines in the NICU, how many times do you typically do that a day? Quite a few. Do you have the (MAR) when you pull that flush out of the Pyxis? Probably not. So we go to the next item and say were the procedures available, workable, correct, intelligible, and in routine use and what we know is that - somebody’s drawing on the screen. I’m not sure who it is.

What we know is that what often happens is policies and procedures are implemented in an organization, but we don’t pay any attention within an organization as to how well - as to whether they are intelligible, correct, and routinely used. So what we know is that checking the five rights when you do a heparin flush is not typically done in a busy NICU.

So, we go there to know, well was it a system-induced violation and in order to determine that what we look at is the substitution test. So could someone else have done the same thing and at least in the first instance of the - the first publicized instance of the error with the heparin flush, we know that at least six babies received the adult dose of heparin.

So, obviously the substitution test was passed because at least six nurses also used the adult dose of heparin rather than the flush and what we now know is that a pharmacy (tech) loaded the adult dose of heparin into the Pyxis in the NICU by mistake.

So, what you can see as you work through the rest of the algorithms is that, yes the substitution test was passed. We ask ourselves, do these nurses have a history of unsafe acts, that’s probably the answer to that question is no and you end up with blameless error. Even if you say yes, they have a history of unsafe acts. It doesn’t make any difference in this instance because it was still a system source of the error.

But, what I challenge people to do is to make this algorithm transparent across your organization. You tell people, this is how we’re going to decide whether you have knowingly increased risk or whether this is a system source of the error and we need to look to the system for the cause of this error.

But, when you talk about a just culture, you have to ask yourself how are we operationalizing it, how do we make it transparent to the front line workers that there is a clear decision process as to when people are going to be held accountable for an event.

So, I’ll take time again for questions.

Alexander Alonso: I think we have one question Katherine. I’m going to go ahead and read it. It is with a true team orientation, what are strategies to reduce obstructive managers or groups from bullying individuals with blame in the team. I’ve seen too many instances of organizations adopting a new concept such as teamwork in name, but not in practice with old practices continuing under the new banner.

Katherine Jones: I think the answer to that question is leadership; that you have people who are willing to hold those people who are disruptive and bullying accountable for their behavior and it has to be - and I think that’s the key to disruptive behavior is that the same standards of behavior apply to everybody.

If I have an encounter with a co-worker or somebody who’s above me in the pecking order and I go away and ruminate about that encounter and worry about it all day long, I’m not focusing on my patient. And that in and of itself is disruptive behavior.

So, the key is at the top and from the bottom up, people are held to the same standards of behavior and they’re enforced. That’s a very simple answer, but the execution of it is difficult. I can’t remember who the quote is from, but I would much rather have a mediocre - oh I think it’s from Einstein - I’d much rather have a mediocre idea excellent and execution than an excellent idea and mediocre execution.

So, a just culture is an excellent idea, but we have to execute with specific tools to manage disruptive behavior and using algorithms to hold people accountable. It’s the execution.

Alexander Alonso: Okay Katherine, I think we have no other questions at this time.

Katherine Jones: Okay, let’s go along and let’s take a look at the survey results for flexible culture and this is where we’re starting to get into TeamSTEPPS and it’s applicability as an intervention that you would use in response to your HSOPS safety culture survey results.

So, this slide gives me an opportunity to focus on that gap between beliefs and behavior. Remember, your culture is made up of beliefs and behaviors. So, this first item, staff will freely speak up if they see something that may negatively affect patients care. Of course, the majority of people believe that they’re going to speak up if something will negatively affect patient care.

But when we get to a specific behavior like speaking up to those with more authority, what you see and you always see in a safety culture survey result that if we ask people to speak up to somebody with more authority then the percent that will do that drops considerably. And you can see the drop as 60% here from speaking up that they believe that they’ll speak up if something will negatively affect patient care to speaking up to those with more authority.

And look how nurses improved from 2005 to 2007. We had introduced the idea of the two challenges rule. I’m concerned. I’m uncomfortable. We introduced the idea of advocacy (unintelligible), but we hadn’t really implemented TeamSTEPPS yet. But, we still got a nice jump in communication openness from 2005 to 2007.

Looking at our reporting system intervention and they had started using (unintelligible) a little bit by the time we had reassessed in March 2007. But what you ask yourself when you see this gap between beliefs and behaviors is I think that’s your staff crying out for a specific tool to use and the tool we have are the structured communications tools that are part of TeamSTEPPS can bridge that gap between belief and behaviors and communication openness.

So, CUS, two challenges rule, SBAR, those are all ways that structure our communication and psychologically safe to speak up to those with more authority.

Let’s take another look at a dimension that crosswalks the flexible culture and this dimension is teamwork within units. Now you take a look at these results from 2005 and you think, wow they don’t have any problems at all. But, I want to draw your attention to another gap between beliefs and behaviors. So, if we look at the belief’s that people support one another, 88% of those nurses vow that we’re in this foxhole, we support one another.

But, look at the behavior, when one area in this unit gets really busy, others help out. Look at the drop off, a 25% gap between the belief that we support one another and the behavior that we help each other out when it gets busy.

And as you can see there wasn’t much change between 2005 and 2007, and that is why we have embraced TeamSTEPPS whole-heartedly across our project hospitals here in Nebraska, because our reporting interventions gave us a foundation of reporting in a just culture. But we saw that we needed tools to really implement TeamSTEPPS to really implement the team skills in communication.

So we’re hoping that when we reassess with the safety culture survey in March 2009, that we’ll see a better change of some 63% and 67%, we hope to close that gap even more. We have 25 Critical Access Hospitals here in Nebraska that have been trained in TeamSTEPPS as of April of this year. And we’re supporting them in how they implement that.

Let’s take a look at one more. This item is hospital handoffs and transitions. So, this is looking at teamwork across the hospital as a whole and you can see that we’ve some room for improvement there, particularly in looking at problems that often are in the exchange of information across hospital units. Only 44% responded positively in 2005 and we got a little bit of an improvement in 2007. But, of course if you’re looking at transferring information across hospital units we can look at SBAR and (unintelligible) specific tool.

So, obviously as I said, the tool that we’re implementing to respond to the safety culture survey results in terms of the flexible culture components is TeamSTEPPS. And I’m not going to go into depth about TeamSTEPPS because all of you are involved in national implementation and you know all about the four skills and how those are embedded in the team’s structure. And TeamSTEPPS is really the answer to the flexible culture component of the HSOPS.

And I always like to emphasize that idea when you’re talking to clinician’s that clinicians have to simultaneously look at their clinical outcomes and their team outcomes and that we’re interested in that transition from looking at outcomes individually to looking at that paradigm of shifting to the team focus, the dual focus on clinical and team skills.

And, I think if you challenge clinicians that way - let’s be just as interested in our outcomes and teamwork as we are in our clinical outcomes because our teamwork are going to improve our clinical outcomes. Of course, there are teamwork outcomes by the Safety Culture Survey Results. So, what we’re really interested in is whether we’re a learning culture because if we’re a learning culture we’re going to be a safe culture.

So, if we take a look at some of their results the nurses from 2005 to 2007 remembering that our focus in our project initially was giving them specific information about their medication errors. And part of that we map they’re process of medication use which they had never done process mapping before and we gave them information about best practices, we helped them rearrange their pharmacies so that it was rearranged in a way that supported safety so we don’t have look alike sound alike drugs next each other.

So, we’ve got higher root drugs segregates, we taught them how to use a formulary. Most of these hospitals don’t have onsite pharmacists. So, those are some of the things that we did in the context of our reporting intervention. But, a learning culture is really about closing the loop with people, they report something, you look at that report in terms of the system who make process changes, then you let people know what you did in response to that information.

So, we are given feedback about changes put into place based on event reports. 44% responded positively in 2005 that improved to 72% in 2007. And just that idea that you have people at the frontline discussing error in the context of their daily work improved from 50% to 83%.

One of the things that I want to you to walk away from this presentation with is the idea that the gold standard in whether you are a learning organization is that you should be able to walk up to anybody in your organization and ask them how have mistakes led to positive changes. And Dundy County has room for improvement in that as you can see, we’re pretty ecstatic from 63% to 65%.

They know they’re actively doing things to improve patient safety and they know that after they make changes to improve patient safety they evaluate the effectiveness. But drawing that line directly from mistakes to positive changes requires communications from management back to front line workers about things like the outcomes of a root cause analysis so that people clearly know this mistake happens and this is the positive change that came from it. That is the hallmark of being a learning organization.

Now, remember I told you one of the questions was looking at what happened within the nurses that drove those changes. And if you look here at supervisor manager expectations and actions promoting patient safety, I told you that we had a champion, it was the quality improvement coordinator at Dundy County that stepped up to the plate with all these tools, took ownership, and really drove all of the implementation of the reporting system and the best culture practices.

So, let’s just take an example, my supervisor, managers, seriously considers staff suggestions for improving patient safety that improved from 44% to 89% so that staff knew that when they went to this QI coordinator and had a report or something, they introduced leadership WalkRounds.

And leadership WalkRounds is a way for managers to ask the front line staff what’s the next thing that’s going to harm a patient in this area and you write that down in your notebook, you solve the issue, put together a team that solves the issue and then you report back to people what you did.

So, you can see that - what a huge difference that champion, that front line manager can make when they actually are seen as the leader who can drive those changes home.

This is a slide that really summarizes for you that being a learning culture is built on the interactive practices of reporting just and flexible cultures. And specific tools and practices that Dundy County use included (unintelligible) analysis kind of seem alike if you will just by comparing their process maps to evidence based best practices, they did some (unintelligible) effective analysis and they embraced RCA as a tool wholeheartedly.

I personally helped train them on how to conduct individual RCA and aggregate RCA and now they do quarterly aggregate RCAs on medication errors and falls. And they look at falls across their organization whether it’s an employee who fell in the parking lot or if it’s a patient who is on the unit. So, they did - those are the three main learning practices that they did to improve their scores on the safety culture survey in terms of learning organization.

And, this is Kathy Broz. She is the RN, QI coordinator at Dundy County Hospital and what she has there is one of the tools that she used. It’s called close encounters of the safety kind and anybody in the organization (unintelligible) is in a public hallway, so anybody a patient, a family member, an employee can post a safety concern on the bulletin board. Management is responsible for taking that safety concern, resolving it, and putting it back up there with how it was handled.

So, you can see right away how this practice captures all four components of the safe culture. People are able to report anonymously, this is just because of course it’s anonymous, nobody’s going to be punished for anonymously reporting a safety concern. The organization is flexible as a team, we will take these concerns, and they act on them, and they post them and report back to people how the organization has handled this concern.

So, this one simple practice encapsulates all four components of a safe culture and it exemplifies how this one person, this manager of QI champion all of those interactions.

So, this slide summarizes for you the journey that Dundy County hospital made from 2005 to 2007. The dotted line is their results from 2005 and that solid line is their results from 2007. So, you can see how manager actions promoting patient safety improves from about 72% to about 87%, you can see how we didn’t change much in team work within departments, which is why we’re implementing TeamSTEPPS.

We can see that we still have some work to do in a just culture and non-punitive response to error, but look at the huge jump from 2005 to 2007 in feedback and communication about errors, communication openness. You cannot have improvements in organizational learning without improvements in feedback and communication about error and communication openness.

And of course we did not have much change in teamwork across the hospital as a whole. Again, this will be a target for improvement in our 2009 results. But, when I give this graph back to our hospitals, what a great communication tool this is to their board, their medical staff, their employees, this is how their involvement in our patient safety projects has been translated into changes in their culture.

So, I’d like to pause now for more questions.

Cori White: We have a few questions. The first one we have is about item R2, which is information lost during shift changes and the question is just, the asker wonders what you would attribute that 20% decrease to, what maybe caused that?

Katherine Jones: Let’s go back to that slide. The 20% information lost during shift changes. Important patient care information is often lost during shift changes. This brings up an excellent point, I’m glad somebody picked up on that and one thing that the safety culture survey, the first time you conduct it as it educates people about things that they hadn’t known about before. So, one of the things that people have figured out is, oh wow we could do a better job at translating information during shift changes.

They’re starting to look at their communication patterns, they’re starting to look at how they hand off information and they’re learning about what a safe culture should be. So, that’s one of the things you find with the safety culture survey is that people are going to hold you to a higher standard the second time around because just acts of conducting the survey has educated them.

And in this organization as a whole, they’ve also found out that they we’re not doing things the way they could be doing them, so they’re holding you to a higher standard. So, they’ve got higher perceptions of what safety culture could be, so that’s one of the things that people need to take into consideration.

If you were to compare hospital results on the safety cultures survey to some external criterion like the patient safety indicators, you’ve got to remember that a 90% or 60% on an item may not mean the same thing in each organization and the tool is really best suited for tracking change within an organization over time.

And my contention is that it’s going to not hold up so well if we want to differentiate between hospitals based on this instrument. Because of this effect of each organization, it’s going to change, and their education level is going to change, and as people become better educated about the tools for patient safety, they are going to continually hold you to a higher standard.

So, that’s the answer to that question.

Cori White: The next question we have did you have any physician champions in any of the facilities? Did you have key gaps in physician provider perceptions that stood out as opportunities for improvement?

Katherine Jones: The answer to that question is categorically, no. We did not have any physician champions and one of the problems that we’ve run into in our hospitals is that none of our physicians are employees of the hospital. They’re all family practice physicians that work in a community. They are typically, you know, not very many physicians in the community. These are small rural communities Dundy is about 2,000 people and our physicians - we’ve have a hard time integrating them into a lot of the patient safety interventions.

Now that is changing with TeamSTEPPS, we’ve actually got a couple of communities, we’ve got physicians attending the TeamSTEPPS training. We’ve had to go through the backdoor and the best way I’ve found in these small communities is to include a physician in an RCA because one of the problems is that too often physicians do not appreciate all of the systems that they essentially put into motion when a patient is admitted to a hospital.

And when they write orders, they don’t see all of the systems and processes behind those orders and we have to find a way to educate them about those processes and make them part of the team.

But, it’s really difficult in this small world and the physicians, you know, it’s hard to work with the chief of staff when you only have four physicians in a group practice and that’s it in the community. It’s very difficult to engage them and I hope to have a better answer to that question if I get a chance to speak to you again and year or two from now.

(Cori White): Okay. The next question we have is what message do you use to share the organizational learning from harmful errors that don’t expose organizations to risk of discovery and liability?

Katherine Jones: Here in Nebraska we’re very fortunate that we have state statutes that protect all information collected as part of quality improvement from discovery and that’s held up very well and our hospitals have embraced. And we have been very active in Nebraska in sharing information without that threat because of our state statues.

Cori White: Okay, and then the last question we have right now in this bunch is what do you know about the hospital or hospitals that has or have the highest rating on non punitive response to error, how do they achieve those results?

Katherine Jones: The highest scores on non-punitive response to error occur when you have a true synergistic response across all four components of culture. So, you have an effective systematic reporting system, you have a way to clearly delineate between acceptable and unacceptable behavior like transparent use of the Unsafe Acts Algorithm.

You have some basic structured communication skills such as the two challenges rule and CUS and SBAR. And you have basic learning organization tools like you have effective use of root cause analysis and effective use of process mapping to compare current processes to best evidence.

The answer is you will have the best just culture non-punitive response to error responses when you have basic practices in all four components of culture. Just culture does not exist in isolation from reporting, teamwork, learning practices.

Cori White: Okay, that’s the last question we have at the moment if you want to continue.

Katherine Jones: Okay, let’s get caught up to where we were. These are great questions.

Oh, the last bit of the presentation deals with the way we adapted the safety culture survey to set the work environment. Basically we collapse work areas and job titles so that we could correctly categorize people because you can’t drill down into your safety culture survey results and identify those micro cultures within work areas and staff positions if you’ve high percentages of people choosing other, you know, you’ve got to have people correctly categorized.

So, I won’t dwell on that much more other than to brag about the fact that in the national database, 1/3 of people are choosing other for work area or staff position. And in our work with rural hospitals we are able to correctly categorize 88% of people by work area and 92% by job title and we allow people to sort by work area or job title if there are five or more people in a work area or job title rather than 11.

And that’s the way the original Excel template was set up. So, that’s how we’ve adapted the survey, we have not changed any of the items at all.

I want to go back to that slide as we close in on our time to be finished that Alex showed that when you look at your readiness for TeamSTEPPS, I want you to think about the triangle with the four components of culture. And it’s my contention that you have basic practices in place in terms systematic error reporting.

And just culture and learning practices such as an effective use of RCA, your TeamSTEPPS implementation is not going to be as effective as it could be if you can’t embed it within effective practices that support the other three components of culture.

So, this slide gives you - Alex did you want to pick up here or do you want me to finish?

Alexander Alonso: No, I’ll go ahead and pick up here Katherine, thank you very much.

Katherine Jones: Go ahead.

Alexander Alonso: So, this slide gives you information about where you can go ahead and the get the hospital survey of patient safety culture and you’ll notice first that there is an AHRQ Web site, which is www.ahrq.gov/qual/hospculture and you would click on hospital survey tool kits.

There’s also a rural adapted version for Critical Access Hospitals with 25 or fewer beds from the University of Nebraska Medical Center Web site and this Web site is www.unmc.edu/rural/patient-safety. Here you will be able to click on hospital survey on patient safety culture resources.

Should you have any questions regarding some of the information that was provided here today or the hospital survey of patient safety culture, please don’t hesitate to contact Katherine herself directly. Her email is kjonesj@unmc.edu.

For support regarding the actual hospital survey of patient safety culture including survey forms, survey user guide, survey feedback template, summaries and so on, benchmarking data and the comparative database, you would go to the AHRQ Web site that we’ve discussed before.

As far as an action plan tool kit by the four components, you can go back to the UNMC Web site to identify that’s a rural access hospital or Critical Access Hospital. Should you have questions about the survey for the support contractor you can reach them at safetyculturesurvey@westat.com.

At this time, I also want to go ahead and remind you that we contact information available here for the national implementation program team and we can also be reached at teamsteppswebinars@air.org should you have any questions.

Cori, I’m going to go ahead and turn it over to you so that you can conduct some of the polls. We do have questions for you and we will continue to answer questions following the polls.

Katherine Jones: Alex, this is Katherine, I would just like to say that the tool kit that’s on our Web site was created as part of our PIPS grant and it isn’t just for Critical Access Hospitals - any hospital can use that tool and they will find information about practices that supports the four components of culture, so thank you.

Alexander Alonso: Okay, thank you Katherine.

Cori White: Okay, we have just two quick questions for all of you. The first question is about how useful you found this Webinar today. This helps us understand for future Webinars and how to make them better and I’ll just give you a minute to do that and then we’ll do the second question.

And in the meantime, it looks like we do have another question. And the question is about whether the Webinar will be repeated or if it will be made available on a Web site. The Webinar will not be repeated or we don’t have plans to at this point, but there will be a transcript made available on the TeamSTEPPS Web site under our page with the Webinars. If you don’t have that Web site address, you’re welcome to email anyone of us and we can point you in the right direction.

And then again if you weren’t able to download the handouts or slides, you can contact us at teamsteppswebinars@air.org and we’ll make sure you get a copy when they’re sent out.

Alexander Alonso: Let’s go ahead and close that first poll Cori.

Cori White: Okay. And I’m going to open this second question was just asked whether or not you would tell your friends. So, we want to know if you would recommend these Webinars to other people.

Alexander Alonso: Okay, Cori let’s go ahead and close that poll.

Cori White: Okay.

Alexander Alonso: And you want to go ahead and the make the polls public or have they been...

Cori White: Sure, if you guys want to see the results, we can do that. This is the second question and it sounds like a lot of you would recommend this series of Webinars to other people. And then on the first one, it looks like overall you found it pretty useful.

Alexander Alonso: Okay. At this time, I want to go ahead and open up the floor for further questions. As you know that we have received Kudos from some of the participants and I want to thank you for that. And I want to thank Katherine for having provided such useful information.

Katherine Jones: It’s my pleasure Alex. The Hospital Survey on Patient Safety Culture I think is just an essential tool to identify for a hospital what their basic fitness level is to engage in quality improvement and patient safety. There is just that infrastructure of patient safety practices that we have to have that the culture say they get that.

Alexander Alonso: Okay.

Cori White: I’m going to go ahead and put our contact information back up just so if anyone has questions they’re able to have it.

Alexander Alonso: Katherine, we have a few questions here, one is whether or not you will be a speaker at the HSOPS user group meeting in Arizona in December.

Katherine Jones: Yes, as a matter of fact I will and I am so thrilled. Scottsdale in December versus Omaha, boy it’s going to be great.

Alexander Alonso: Okay. And then we have another person who’s raised their hand, but has not typed in a question. Let’s see here, okay and now they’ve lowered their hand so they’re not asking the question anymore. Oh, okay now they’ve raised their hand again.

Operator perhaps you have some...

Operator: Well, we’ll make a reminder. So, ladies and gentlemen if you’d like to register for an audio question, please press the 1 followed by the 4 on your telephone.

Alexander Alonso: Okay, thank you operator. We also have a question that says how does one become a TeamSTEPPS master trainer? We ask that you go ahead and contact us directly at teamsteppscontact@air.org so that we can go ahead and answer that question for you.

At this time, I don’t see any further questions. Operator, I’ll give you another second to determine whether or not you have questions.

Operator: And we do not appear to have any questions at this time.

Alexander Alonso: Okay. Then I want to thank everyone for participating today, I greatly appreciate your attendance. And we look forward to a second chance to chat about Critical Access Hospitals coming up at a future Webinar and Katherine will be joining for that again in October.

So, thank you very much and have a great day.

Katherine Jones: Thank you Alex.

Operator: Ladies and gentlemen, that does conclude the conference call for today, we thank you for your patience and ask that you please disconnect your line. Have a good afternoon everyone.