Patient Safety Tip of the Week
June 28, 2016
Culture of Safety and Catheter-Associated Infections
A study recently published garnered lots of national
headlines implying that we don’t need to change our culture to improve
outcomes. While we can’t speak for the authors of that study, we don’t think
the headlines generated were what they intended.
University of Michigan researchers (Meddings
2016) looked at responses on the Hospital Survey on Patient Safety Culture (HSOPS) survey at hospitals
participating in two prospective cohort studies from acute-care intensive care
units (ICUs) and non-ICUs participating in the AHRQ CLABSI and CAUTI collaboratives, including one (Saint 2016) we’ve highlighted in our July 2016 What's New
in the Patient Safety World column “Holy
Moly, My Patient has a Foley!”. Among responding units, infection rates
declined over the project periods, by 47% for CLABSI and 23% for CAUTI. But Meddings and colleagues found no correlation between the
CLABSI and CAUTI rates at these units and the HSOPS measures either at baseline
or at one year. Those results were contrary to the authors’ hypothesis that the
improvements seen would correlate with scores indicating a culture of safety as
measured by HSOPS.
Meddings et al. conclude their results show one of
two possible things:
- The reduction in infection rates seen was due primarily to such
components as standardization of techniques and procedures, independent of
changes in culture or
- Changes in culture that were pertinent to improvement in infection
rates did occur but were not adequately accounted for by the HSOPS tool
The implications are
significant. If the former is true, many projects could be streamlined by
eliminating many of the time and other resources put into developing a culture
of safety. If the latter is true, time could also be saved by eliminating a
measure that is also time-consuming and adds little value.
Yes, you can use
constraints or forcing functions to promote use of standardized techniques and
procedures (for example, requiring completion of a checklist before a central venous
catheter kit can be opened). But if you don’t get buy-in from most physician
and nursing staff that the standardized techniques and procedures are the right
thing to do to improve patient safety, your likelihood of success will be
diminished.
Note that we have stressed over and over that, in our
opinion, the primary reason we’ve failed to significantly improve patient
safety has been our inability to develop a culture of safety in our
organizations. You’ve heard us use the phrase “culture trumps ________” (fill
in the blank with words like policy, procedure, strategy, tactics, vision, etc). In fact, “Culture
trumps…Everything!”. When we do root cause
analyses (RCA’s) on cases with adverse outcomes we very often find that the
culture of the unit tolerated workarounds or shortcuts or was such that it
discouraged healthcare workers from speaking up when they knew something was
wrong. We have wholeheartedly agreed with John Nance’s view that the reason
healthcare has not achieved the results that the aviation industry has attained
in safety is that healthcare has failed to change our culture (see our June 2,
2009 Patient Safety Tip of the Week “Why
Hospitals Should Fly...John Nance Nails It!” and our January 2011 What's
New in the Patient Safety World column “No
Improvement in Patient Safety: Why Not?”).
And “failure to embrace a culture of safety” made the most
recent ECRI Institute’s Top Ten Patient Safety Concerns for 2016 (see our May
2016 What's New in the Patient Safety World column “ECRI
Institute’s Top Ten Patient Safety Concerns for 2016”).
And all the good work done at Johns Hopkins and the Michigan
Keystone Collaborative utilizing CUSP’s (Comprehensive Unit-based Safety
Programs) has emphasized the importance of culture at the unit level (see our
March 2011 What's New in the Patient Safety World column “Michigan
ICU Collaborative Wins Big”). In fact, CUSP principles were a key component
of the two national collaboratives in the current Meddings study.
So does the recent Michigan study really mean you don’t have
to change organizational culture to effect improvement and you should abandon
your efforts to develop a culture of safety? Or does it just mean that the
tools used to “measure” culture are not very useful. We’ll opt for the latter
explanation. We’ve never been fans of the variety of “culture” surveys that are
widely used. When applied to assess the “culture” of an organization as a whole
they can be terribly misleading. Culture at the unit level is much more
important. All the surveys out there tend to show the same thing: physicians
and administrators all have a more positive view of the “organizational culture”
than do nurses and other frontline personnel. And the culture often varies dramatically
from unit to unit. And people often respond to such surveys with the answers
they think you want to hear rather than what they actually think, even when the
surveys are “anonymous”.
We’ve always found that you get a much better feel for the “culture”
of a unit on your Patient Safety Walk
Rounds than you get from any formal survey. When you have direct
interaction with frontline staff in an informal and non-punitive fashion, they
are more likely to be forthcoming and point out potential vulnerabilities that
they might not when responding to a formal survey or questionnaire. Our October
7, 2014 Patient Safety Tip of the Week “Our
Take on Patient Safety Walk Rounds” discusses in detail how you can make
such rounds valuable and help improve your culture of safety (and also warns
how you can misuse such rounds to be detrimental in promoting a culture of
safety!).
Where we do concur with Meddings
et al. is that using HSOPS responses in large quality improvement collaboratives is time-consuming and may add little value. It
should be noted that in the Meddings study HSOPS response
rates were low overall, 24% for the CLABSI collaborative and 43% for the CAUTI
collaborative. Those low rates of response may well reflect that participants
found HSOPS to be time-consuming and they gave little importance to its
inclusion in the projects. We really doubt that the authors would recommend
eliminating use of the CUSP principles from such projects. Rather, we concur
with the second theory espoused by Meddings et al.
that HSOPS was not designed to provide a valid measure of safety culture impacting
care at the bedside. Meddings et al. also point out
that safety culture can be very difficult to measure over time, particularly
since changes in staffing and resources and competing priorities commonly occur
during the timeframes of such measurement. If you are going to eliminate
anything from such quality improvement projects, take out the culture surveys.
So beware of media headlines that seem to imply that safety
culture may not be so important.
Some of our prior
columns related to the “culture of safety”:
April 2009 “New
Patient Safety Culture Assessments”
June 2, 2009 “Why
Hospitals Should Fly...John Nance Nails It!”
January 2011 “No
Improvement in Patient Safety: Why Not?”
March 2011 “Michigan
ICU Collaborative Wins Big”).
March 29, 2011 “The
Silent Treatment: A Dose of Reality”
May 24, 2011 “Hand
Hygiene Resources”
March 2012 “Human
Factors and Operating Room Safety”
July 2012 “A
Culture of Disrespect”
July 2013 “"Bad
Apples" Back In?”
July 22, 2014 “More
on Operating Room Briefings and Debriefings”
October 7, 2014 “Our
Take on Patient Safety Walk Rounds”
July 7, 2015 “Medical
Staff Risk Issues”
September 22, 2015 “The
Cost of Being Rude”
May 2016 “ECRI
Institute’s Top Ten Patient Safety Concerns for 2016”
References:
Meddings J, Reichert H, Greene MT,
et al. Evaluation of the association between Hospital Survey on Patient Safety
Culture (HSOPS) measures and catheter-associated infections: results of two
national collaboratives. BMJ Qual
Saf 2016; Published Online First 24 May 2016
http://qualitysafety.bmj.com/content/early/2016/05/24/bmjqs-2015-005012.short?rss=1
Saint S, Greene MT, Krein SL, et
al. A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute
Care. N Engl J Med 2016; 374: 2111-2119
http://www.nejm.org/doi/full/10.1056/NEJMoa1504906
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