A Longitudinal Study of an A Longitudinal Study of an Intervention to Enhance Intervention to Enhance

Organizational Emphasis on Organizational Emphasis on SafetySafetyAcademy HealthAcademy Health

June 9, 2008June 9, 2008

Sara J. SingerSara J. Singer

Coauthors: Anita Tucker, Shoutzu Lin, Coauthors: Anita Tucker, Shoutzu Lin, Alyson Falwell, Jennifer HayesAlyson Falwell, Jennifer Hayes

Financial support was provided by AHRQ RO1 HSO13920 and Wharton’s Fishman Davidson Center

Motivation for studyingMotivation for studying Organizational Emphasis on Organizational Emphasis on

SafetySafety Organizational emphasis on safety (OES)Organizational emphasis on safety (OES) can can Improve safety performance (Weiner et al, 1997; Improve safety performance (Weiner et al, 1997;

Vogus & Sutcliffe, 2007; Zohar & Luria 2003)Vogus & Sutcliffe, 2007; Zohar & Luria 2003) Shape worker behavior and attitudes (Carroll et al Shape worker behavior and attitudes (Carroll et al

2002, Edmondson 2003)2002, Edmondson 2003) OES comes from managers who are visibly OES comes from managers who are visibly

committed to safety (Gaba 2000, Weick 2001)committed to safety (Gaba 2000, Weick 2001) Less in known about Less in known about mechanisms mechanisms for for

increasing OES in organizations where it is increasing OES in organizations where it is low (Dixon and Shofer 2006)low (Dixon and Shofer 2006) Notable exceptions Frankel et al 2005, Pronovost Notable exceptions Frankel et al 2005, Pronovost

et al 2004et al 2004

Possible mechanism for Possible mechanism for increasing Organizational increasing Organizational

Emphasis on SafetyEmphasis on Safety Low levels of OES may result from Low levels of OES may result from

decoupling of Senior Managers (SM) decoupling of Senior Managers (SM) from the frontlinesfrom the frontlines SM may be unaware of safety risks and SM may be unaware of safety risks and

opportunities for improvementopportunities for improvement SMs shape resource allocation, process SMs shape resource allocation, process

design, and organizational culture design, and organizational culture Which influence frontline staff’s ability to Which influence frontline staff’s ability to

provide safe patient care provide safe patient care Challenge for SMs is leveraging Challenge for SMs is leveraging

frontline knowledge about system frontline knowledge about system weaknessesweaknesses

Our intervention: Our intervention: Leveraging Front Line Leveraging Front Line

Expertise (LFLE)Expertise (LFLE) Over 18-month period, expose SMs to Over 18-month period, expose SMs to

frontline work systems in contextfrontline work systems in context FrontlineFrontline work system visitwork system visit:: Observe staff in Observe staff in

context context Safety communication forumSafety communication forum: : Listen to staff Listen to staff

concerns about patient safetyconcerns about patient safety Debrief meeting:Debrief meeting: Prioritize “operational Prioritize “operational

failures,” propose resolutions and assign failures,” propose resolutions and assign responsibility for actionresponsibility for action

Feedback to staff: Feedback to staff: Communicate about actions Communicate about actions takentaken

Through LFLE, SMs are more likely to Through LFLE, SMs are more likely to Recognize need for improvementRecognize need for improvement Allocate resources appropriatelyAllocate resources appropriately Make decisions supportive of safetyMake decisions supportive of safety

Repeat every 3 months

on a different

work area

One hospital’s implementationOne hospital’s implementation

ED Med/Surg Outpatient

Physical Therapy

Endoscopy

Hypotheses: Hypotheses: Expected impact of LFLE on Expected impact of LFLE on

OESOES

HypothesisHypothesis

By increasing SM exposure to

frontlines, which increases SM

understanding of safety risks,

Over time,

Participation in the intervention…

SM perceptions (H1a)

nurse perceptions (H2a)

IdentificationIdentification of of more operational more operational failures…failures…

SM perceptions SM perceptions (H1b)(H1b)

nurse perceptions nurse perceptions (H2b)(H2b)

More More actionaction to to address address failures…failures…

SM perceptions (H1c)

nurse perceptions (H2c)

More More feedbackfeedback to nurses…to nurses…

NANA nurse perceptions (H2d)

MethodsMethods 24 hospitals randomly selected (from 24 hospitals randomly selected (from

a random, stratified sample of 92) for a random, stratified sample of 92) for an 18-month intervention (2005 – an 18-month intervention (2005 – 2006)2006) 20 hospitals completed intervention20 hospitals completed intervention Intervention hospitals did not differ Intervention hospitals did not differ

significantly from US hospitals with significantly from US hospitals with respect to urban location and teaching respect to urban location and teaching statusstatus

Work areas where intervention was most Work areas where intervention was most commonly implemented: ED, ICU, commonly implemented: ED, ICU, OR/PACU, and Medical/Surgical WardsOR/PACU, and Medical/Surgical Wards

DataData Pre (2004-5) and Post (2006-7) Pre (2004-5) and Post (2006-7)

survey of personnel in 49 control survey of personnel in 49 control hospitals and 20 intervention hospitals and 20 intervention hospitalshospitals Sample: 100% senior managers (dept Sample: 100% senior managers (dept

head and above); 10% nursing staffhead and above); 10% nursing staff Response rates: 76% SM and 67% Response rates: 76% SM and 67%

nurses in 2004, 62% SM and 50% nurses in 2004, 62% SM and 50% nurses in 2006nurses in 2006

MeasureMeasure Organizational emphasis on safety (OES) (Organizational emphasis on safety (OES) (

Senior management considers patient safety when Senior management considers patient safety when program changes are discussed.program changes are discussed.

Senior management has a clear picture of the risk Senior management has a clear picture of the risk associated with patient care.associated with patient care.

I have enough time to complete patient care tasks I have enough time to complete patient care tasks safely.safely.

My unit provides training on teamwork in order to My unit provides training on teamwork in order to improve patient care performance and safety.improve patient care performance and safety.

Overall, the level of patient safety at this facility is Overall, the level of patient safety at this facility is improving.improving.

All items used 5-point Likert response scaleAll items used 5-point Likert response scale Computed mean of all items, weighted equallyComputed mean of all items, weighted equally

AnalysisAnalysisSenior managersSenior managers Used Used two-level HLMtwo-level HLM to to

compare post-compare post-interventionintervention perception perception of OESof OES among SMamong SM in in intervention intervention hospitalshospitals (n=20) to non-(n=20) to non-intervention hospitals intervention hospitals (n=49)(n=49)

NursesNurses Used Used three-level HLMthree-level HLM to to

compare post-intervention compare post-intervention perception of OES among perception of OES among nursesnurses in intervention in intervention work areaswork areas (ED, ICU, (ED, ICU, OR/PACU, Med/Surg) OR/PACU, Med/Surg) (n=66) to same areas in (n=66) to same areas in non-intervention hospitals non-intervention hospitals (n=172)(n=172)

Examined impact of intervention assignment Examined impact of intervention assignment and of greater implementation (# failures and of greater implementation (# failures identified, % failures acted upon, and % identified, % failures acted upon, and % failures with feedback)failures with feedback)

Controlled for DV baseline and for individual, Controlled for DV baseline and for individual, work area, and hospital characteristicswork area, and hospital characteristics

Impact of LFLE on Organizational Emphasis Impact of LFLE on Organizational Emphasis on Safety:on Safety:

Mean post-differences controlling for pre-Mean post-differences controlling for pre-differencesdifferences

Coefficient OES (SM) OES (nurses)

1. Intervention assignment1. Intervention assignment .087 (0.21).087 (0.21) -.166 (0.31)-.166 (0.31)

2. Failure identification2. Failure identification-.001^ (0.00) -.002 (0.00)

3. Percent failures acted upon3. Percent failures acted upon .206* (0.10) .018 (0.14)

4. Percent failures with feedback4. Percent failures with feedback .116 (0.15) .393* (0.19)

Pre-intervention baseline in DV.865** (0.14) .250** (0.06)

Constant 1.889* (0.81)

2.976** (0.25)

Observations 2113 1709

Number of groups 69 238

A positive coefficient is associated with an improved perception (OES “got better”)

** p<0.01, * p<0.05, ^ p<0.1Standard errors in parenthesesSM model compared intervention v non-intervention hospitals; Nurse model compares work areas. Models included as control variables: age, tenure, discipline, teaching status, urban location, number of hospital beds, and in the nurse model only, work area.

ConclusionsConclusions

Our research represents one of the first quasi-Our research represents one of the first quasi-experimental controlled studies to test an experimental controlled studies to test an intervention to increase exposure of senior intervention to increase exposure of senior managers to frontlines managers to frontlines Demonstrated ability to conduct intervention with Demonstrated ability to conduct intervention with

senior managers in a healthcare settingsenior managers in a healthcare setting Exposing senior managers to frontline safety Exposing senior managers to frontline safety

hazards in context improved SM and nurses’ hazards in context improved SM and nurses’ assessment of organizational emphasis on assessment of organizational emphasis on safetysafety Which we expect in turn may improve patient safetyWhich we expect in turn may improve patient safety

Thank YouThank You

Summary of resultsSummary of results H1: SM perception of OESH1: SM perception of OES

Were not influenced by hospital Were not influenced by hospital participationparticipation in LFLE in LFLE Declined marginally with Declined marginally with identificationidentification of more of more

operational failuresoperational failures Improved with more Improved with more actionaction to address failures to address failures

0.206 increase in OES represents a 5% change in the mean 0.206 increase in OES represents a 5% change in the mean (.206/4.00) or 31% of a SD (0.206/0.66) (.206/4.00) or 31% of a SD (0.206/0.66)

H2: Nurse perception of OESH2: Nurse perception of OES Were not influenced by work area participation,

identificationidentification, or , or actionaction Improved with more Improved with more feedbackfeedback

0.393 increase in OES represents a 11% change in the 0.393 increase in OES represents a 11% change in the mean (.393/3.50) or 49% of a SD (0.393/0.81) mean (.393/3.50) or 49% of a SD (0.393/0.81)

With more with action and feedback, the With more with action and feedback, the intervention produced an effect among senior intervention produced an effect among senior managers in intervention hospitals and among managers in intervention hospitals and among nurses in intervention work areasnurses in intervention work areas