John Nance’s new book (see our June 2, 2009 Patient Safety Tip of the Week “Why Hospitals Should Fly…John Nance Nails It!”) drives home the compelling message that our failure to significantly impact patient safety outcomes since the 1999 IOM report “To Err is Human” is really due to our failure to develop a culture of safety. We have talked in the past on numerous occasions about tools used to assess the culture of safety in healthcare organizations. Our endorsement of these tools has been a cautious one because we have seen that the “culture” in one area of the organization may be significantly different from that in other areas. We also feel that you can get a much better understanding of the culture at the unit level when you routinely do patient safety walk rounds. Most published reports on survey results confirm marked variation in perception of patient safety culture by unit type and by type of respondent.
But that does not mean that these tools do not provide useful information. Just doing the survey raises awareness of patient safety issues and does allow identification of problem areas where extra attention needs to be focused.
Hospitals have been using the AHRQ Survey on Patient Safety Culture since 2004. That survey focuses on 12 areas of patient safety culture and contains 42 items in all. Since 2007 AHRQ has been releasing a comparative database report on the survey results, allowing hospitals to compare where they stand compared to other hospitals. AHRQ has just released its Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report. The results are also made available sorted by hospital type, size (bed number), and the position/specialty of the reporters.
Not surprisingly, reporters not having direct patient care responsibilities (eg. hospital administrators) typically have a more positive perception of patient safety culture at their institutions than do those reporters with direct patient care responsibilities. We saw the same trend in Press Ganey's 2009 report on Safety Culture which we commented on in our April 2009 What’s New in the Patient Safety World column “April 2009 New Patient Safety Culture Assessments”. This certainly highlights the importance of understanding whose perception of patient safety you are seeing. If you are a Board member of a healthcare organization, you can expect that your C-suite evaluation of the patient safety culture will be rosier than what it is in reality. Therefore, you should be looking for the perception of those on the front lines, those with direct patient care responsibilities.
The AHRQ trended surveys show overall positive responses for the areas of “teamwork within units” and “overall patient safety grade”. But areas for improvement include “nonpunative response to error” and “handoffs and transitions”. The Press Ganey report also highlighted these as weaknesses. The AHRQ surveys also found “number of events reported” as an area needing improvement. That is no surprise to us. For years we saw striking disparities in incident reporting by hospitals in New York. And, of course, it is those hospitals reporting greater numbers of incidents that have begun to develop that culture of safety and are learning from their experiences. That is a big criticism of statewide “comparative” incident reporting systems in that their publication of “numbers of incidents” may unintentionally steer patients to hospitals that actually have more patient safety problems.
Smaller hospitals generally had more positive responses to all the patient safety culture survey areas. The difference when compared to large hospitals was most noticeable for “handoffs and transitions”. That is not surprising, since at smaller hospitals you tend to find more staff very familiar with each other. We still don’t know the “optimum” size for hospitals at which quality and patient safety outcomes are best. But we are always reminded of the “magic number” from Malcolm Gladwell’s book “The Tipping Point”. He cited research from multiple sources and multiple different organizations showing that when organizations or units exceed 150 members, organizational dysfunction increases. That is most likely due to the fact that in the smaller organization most people know each other by first name, are more likely to work together as a team, and better utilize both peer pressure and peer learning to reach their common goals.
AHRQ. Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report
Press Ganey. P u l s e R e port 2009®. Safety Culture. Staff Perspectives on American Health Care. 2009
Most of you know that the trend in hospital design has been toward providing more single patient rooms. That has largely been driven by the epidemic of hospital-acquired infections such as MRSA, VRE, and C. diff. but there are a variety of other evidence-based concepts suggesting single patient rooms should be the wave of the future.
In the past year we have seen two monographs on evidence-based hospital design, The Joint Commission’s “Guiding Principles for the Development of the Hospital of the Future” and a paper in this year IHI’s Innovation Series entitled “Using Evidence-Based Environmental Design to Enhance Safety and Quality”. And since we are big on John Nance this month, his description of the patient rooms and relationship to nursing presence in his new book (see our June 2, 2009 Patient Safety Tip of the Week “Why Hospitals Should Fly…John Nance Nails It!”) uses heavily the concepts in these works.
But is everyone on board? Of interest, two publications in the lay press last month just days apart but an ocean apart seemed to espouse different views. An article in the New York Times focused on the benefits of single-patient rooms. Benefits include increased privacy, improved sleep, and reduced infections and stress. But an article in The Herald highlighted a new Scottish study that more than half of hospital patients in Scotland would prefer to stay in a ward than a private room. They note that some of the prior studies showing that patients would prefer single private rooms had been done on younger, primarily surgical patients. They feel that their new study, done on older mixed med/surg patients, may be more reflective of the general hospital population. They point out that the Scottish Single Room Provision Steering Group Report, which mandated all new hospitals in Scotland should be built with only single beds, pointed out that the evidence base is, in fact, not terribly strong.
Perhaps the “loneliness” factor cited in The Herald article can be overcome by design features that can still occur with single rooms. Many of the features described in John Nance’s book where patients are kept in proximity not only to other patients but also to their primary nurse are probably important design features.
At any rate, all the above articles are good reading since they get you to think about incorporating patient safety and communication principles into the design of new things.
Guiding Principles for the Development of the Hospital of the Future.
The Joint Commission. 2008
Sadler BL, Joseph A, Keller A, Rostenberg B. Using Evidence-Based Environmental Design to Enhance Safety and Quality. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2009
Health Outcomes Driving New Hospital Design
By CAROL ANN CAMPBELL
NY Times Published: May 18, 2009
Carolyn Churchill. Hospital patients want wards rather than private rooms. The Herald. Web Edition. May 21 2009
The Scottish Government. Single Room Provision Steering Group Report. December 2008.
Ulrich R, Quan X, Zimring C, Joseph A, Choudhary R. The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity.
Chaudhury H, Mahmood A, Valente M. Advantages and disadvantages of single- versus multiple-occupancy rooms in acute care environments: A review and analysis of the literature. Environment and Behavior 2005; 37(6): 760-786
As most of you know, The Joint Commission plans no new National Patient Safety Goals for 2010. Instead, it is reviewing and revising the current NPSG’s. On May 12 they posted the suggested revisions to the NPSG’s and Universal Protocol. These are available for downloading at this site. Most of the revisions are wordsmithing and consolidation of several elements of performance for each NPSG into one element of performance. Others involve moving a NPSG or element of performance to standards. You may submit for comments about the proposed revisions to The Joint Commission via that site for most of June.
Joint Commission. Proposed Revisions to National Patient Safety Goals and Universal Protocol for Hospitals