Karen Haller

Evaluation of the culture of safety: survey of clinicians and managers in an academic medical center

Background: Despite the emphasis on patient safety in health care, few organizations have evaluated the extent to which safety is a strategic priority or their culture supports patient safety. In response to the Institute of Medicine’s report and to an organizational commitment to patient safety, we conducted a systematic assessment of safety at the Johns Hopkins Hospital (JHH) and, from this, developed a strategic plan to improve safety. The specific aims of this study were to evaluate the extent to which the culture supports patient safety at JHH and the extent to which safety is a strategic priority. Methods: During July and August 2001 we implemented two surveys in disparate populations to assess patient safety. The Safety Climate Scale (SCS) was administered to a sample of physicians, nurses, pharmacists, and other ICU staff. SCS assesses perceptions of a strong and proactive organizational commitment to patient safety. The second survey instrument, called Strategies for Leadership (SLS), evaluated the extent to which safety was a strategic priority for the organization. This survey was administered to clinical and administrative leaders. Results: We received 395 completed SCS surveys from 82% of the departments and 86% of the nursing units. Staff perceived that supervisors had a greater commitment to safety than senior leaders. Nurses had higher scores than physicians for perceptions of safety. Twenty three completed SLS surveys were received from 77% of the JHH Patient Safety Committee members and 50% of the JHH Management Committee members. Management Committee responses were more positive than Patient Safety Committee, indicating that management perceived safety efforts to be further developed. Strategic planning received the lowest scores from both committees. Conclusions: We believe this is one of the first large scale efforts to measure institutional culture of safety and then design improvements in health care. The survey results suggest that strategic planning of patient safety needs enhancement. Several efforts to improve our culture of safety were initiated based on these results, which should lead to measurable improvements in patient safety.

The Accuracy of Substituted Judgments in Patients with Terminal Diagnoses

When patients face end-of-life decisions and are unable to speak for themselves, loved ones are often asked to make substituted judgments. Ethicists have argued that this is an important way of respecting patient autonomy [1, 2], but preliminary studies indicate that substituted judgments may not be very accurate [3-11]. This concern has led some observers to question the usefulness of asking for substituted judgments [8, 12]. If the concept of substituted judgment is to remain clinically useful, health care professionals need a better sense of the circumstances under which substituted judgments made by surrogates are accurate or inaccurate. Such data may alert clinicians to instances in which patients are at risk for having their wishes misrepresented and may aid in the design of education campaigns to improve the accuracy of substituted judgments. Little is known about the factors associated with accurate substituted judgments, especially among patients with terminal diagnoses [8, 11]. In a pilot study of 50 general medical patients [13], we found that accuracy was positively associated with discussions between patients and surrogates and negatively associated with religiosity. Building on this experience, we studied 250 terminally ill patients and their legal surrogates and a comparison group of 50 general medical patients and their surrogates. Our objectives were to 1) assess the accuracy of the substituted judgments made by the surrogates; 2) ascertain the beliefs, practices, and clinical and sociodemographic factors associated with accuracy; 3) assess the preferences of patients for life-sustaining treatments; and 4) compare differences in accuracy across diagnoses. Methods Patients Between November 1993 and February 1996, patients were recruited from the outpatient practices of Johns Hopkins Hospital and the Hopkins Bayview Medical Center, Baltimore, Maryland, and Georgetown University Medical Center, Washington, D.C. Eligible patients were older than 17 years of age, spoke English, and had one of the following conditions known to be associated with a less than 50% chance of surviving for 2 years: New York Heart Association class III or IV congestive heart failure with no possibility of transplantation [14], advanced HIV infection according to the Centers for Disease Control and Prevention case definition for AIDS (before the use of protease inhibitors) [15], amyotrophic lateral sclerosis with respiratory compromise [16], unresectable non-small-cell lung cancer [17], or oxygen-dependent chronic obstructive pulmonary disease with dyspnea at rest [18, 19]. Treating physicians were asked to exclude patients whom they thought they were likely to live longer than 2 years and patients who were cognitively incapable of participating. The comparison group comprised general medical patients who were older than 64 years of age, spoke English, and were expected to live longer than 2 years. To have a power of 0.80 to detect a 15% difference between patient preferences and surrogate predictions at = 0.05, we needed 263 patient-surrogate pairs. Rounding up to 300 gave a power of 0.75 to detect a 25% difference in agreement between diagnostic groupings at = 0.05. Surrogates were chosen according to Marylands legal hierarchy of surrogates for incapacitated patients: durable power of attorney, guardian, spouse, adult child, parent, sibling, other relative, or friend [20]. For uniformity, surrogates of patients recruited at Georgetown University Medical Center were also chosen according to the Maryland hierarchy. Attending physicians were contacted 2 weeks before scheduled patient visits. Patients were initially informed of the general nature of the study and asked to supply the phone number of the surrogate who was highest in Marylands legal hierarchy. At the time of the appointment, details of the study were described and informed consent was obtained. Surrogates were interviewed within 48 hours before or after the patient interview. Patients and surrogates were asked not to speak with each other about the interviews until both interviews were completed. Informed consent was obtained from all participants. The study was approved by the institutional review boards of the Johns Hopkins Medical Institutions and Georgetown University Medical Center. Interview Schedule Structured interviews consisted of closed-ended questions about sociodemographic factors, previous discussions about end-of-life decisions, advance directives, and past experiences. Patients were asked about their treatment preferences, and surrogates were asked to predict patient preferences. Sociodemographic information included age, sex, ethnic group, exposure category for HIV infection, level of education, socioeconomic factors, insurance status, and religious beliefs and practices. We elicited preferences for various medical interventions in the setting of three hypothetical clinical scenarios that would render patients unable to make decisions for themselves: permanent coma, coma with a small chance of recovery (the small chance scenario), and severe dementia (Table 1). For each scenario, the patient was asked to report his or her preferences for intensive care, intubation, cardiopulmonary resuscitation, feeding tube placement, nasotracheal suction, surgery, hemodialysis, esophagogastroduodenoscopy, phlebotomy, and chest roentgenography. All scenarios and interventions were described briefly and simply to ensure understanding. For example, the feeding tube question was worded, Would you want to be fed by a feeding tube (that is, a tube put through your nose or through the skin over your stomach)? Table 1. Clinical Scenarios Requests for a limited trial of an intervention were interpreted as yes responses. Patients and surrogates were urged to give their best judgment. Unsure responses were recoded as yes responses because they would be clinically interpreted that way. The interview schedules had been previously developed and tested for reliability [13] and were based on the Medical Directive of Emanuel and Emanuel [21]. Slight modifications were made for our protocol; the revised instruments showed high internal consistency, with Kuder-Richardson statistics of 0.97 for the permanent coma scenario, 0.94 for the small chance scenario, and 0.93 for the severe dementia scenario. The complete set of instruments is available from the authors on request. Surrogate Accuracy in Matching Patient Preferences Scale Scores We constructed a Surrogate Accuracy in Matching Patient Preferences Scale (SAMPPS) for each of the three scenarios (SAMPPS-1 for permanent coma, SAMPPS-2 for small chance, and SAMPPS-3 for severe dementia). This scale assigns a score of 1 when the surrogates prediction correctly matches the patients preference for each scenario-treatment pair. Mismatches are assigned a score of 0. The sum of the correct answers constitutes the SAMPPS score. For each of the three scenarios, a perfect score is 10 and a complete mismatch has a score of 0. Statistical Analysis Categorical variables were analyzed by using the chi-square test or the Fisher exact test. Two-tailed t-tests were used for paired continuous variables. Analysis of variance was used to compare continuous variables across multiple groups. Differences between surrogate and patient demographic characteristics were examined by using the McNemar test for paired comparisons. The McNemar test was also used to assess any pattern in mismatches between patient and surrogate preferences. Differences in patient preferences for treatment according to modality or scenario were assessed by using the Cochran Q test. Although scores have often been reported in similar studies, we do not report them because of concern about the appropriateness of as a test of surrogate accuracy [11, 22], and the paradox of [23]. We presented elsewhere an alternative to chi for measuring surrogate accuracy [24]. Factors Associated with the Accuracy of Substituted Judgments A skewed distribution was found for SAMPPS scores. The Friedman two-way analysis of variance was used to compare SAMPPS scores across scenarios, and the Kruskal-Wallis one-way analysis of variance was used to compare SAMPPS-1 scores across diagnoses. A binary logit model [25] was constructed using the 10 binary items (correct/incorrect) per patient-surrogate pair of the SAMPPS-1 score. Independent variables were screened for association with SAMPPS-1 score by using the Spearman rank correlation and Kruskal-Wallis tests, as appropriate. Variables that did not contribute significantly to the multivariate model were eliminated in a stepwise manner. When diagnostic categories were stratified by age ( 65 years or <65 years), the log odds differed significantly by age group for patients with amyotrophic lateral sclerosis, but no such interaction was found between education and insurance. Model diagnostics to identify influential observations were examined [26], revealing 9 outliers that were subsequently removed from the final model. Thus, the final model reports on only 291 patient-surrogate pairs. The model was validated by using the independent variables found to be significant in the SAMPPS-1 model to predict the SAMPPS-2 and SAMPPS-3 scores. Results Participants Interviews of both patient and surrogate were completed for 75% of pairs that met study inclusion criteria. Of interviews that were not completed, 51% were not completed because of patient refusal; 25% were not completed because of patient refusal to allow surrogate contact; 15% were not completed because of surrogate refusal; and 9% were not completed for other reasons, chiefly our inability to arrange for a surrogate interview within 48 hours of the patient interview. Compared with participants, nonparticipants were older (68 and 60 years of age; P < 0.001), more likely to be female (65% and 39%; P < 0.001), more likely to receive Medicare (24% and 10%; P < 0.001), and more likely to be in the chr

Senior Executive Adopt-a-Work Unit: A Model for Safety Improvement

BACKGROUND At The Johns Hopkins Hospital (JHH), the patient safety committee created a safety program that focused on encouraging staff in selected units to identify and eliminate potential errors in the patient care environment. As part of this program, senior hospital executives each adopted an intensive care unit and worked with the unit staff to identify issues and to empower staff to address safety issues. JHH PATIENT SAFETY PROGRAM: The program consisted of eight steps, which together require six months for implementation: (1) conduct a culture survey; (2) educate staff on the science of safety; (3) identify staff safety concerns through a staff safety survey; (4) implement the senior executive adopt-a-work unit program; (5) implement improvements; (6-7) document results, share stories, and disseminate results; and (8) resurvey staff. RESULTS The senior executive adopt-a-work unit program was successful in identifying and eliminating hazards to patient safety and in creating a culture of safety. DISCUSSION The program can be broadly implemented. The keys to program success are the active role of an executive advocate and staffs willingness to openly discuss safety issues on the units. Regular meetings between the advocates and the units have provided a forum for enhancing executive awareness, increasing staff confidence and trust in executive involvement, and swiftly and effectively addressing areas of potential patient harm.

Paying the Piper: Investing in Infrastructure for Patient Safety

BACKGROUND Although the best allocation of resources is unknown, there is general agreement that improvements in safety require an organization-level safety culture, in which leadership humbly acknowledges safety shortcomings and allocates resources at the patient care and unit levels to identify and mitigate risks. Since 2001, the Johns Hopkins Hospital has increased its investment in human capital at the patient care, unit/team, and organization levels to improve patient safety. PATIENT CARE LEVEL An inadequate infrastructure, both technical and human, has prompted health care organizations to rely on nurses to help implement new safety programs and to enforce new policies because hospital leaders often have limited ability to disseminate or enforce such changes with the medical staff. UNIT OR TEAM LEVEL At the team or nursing unit level, there is little or no infrastructure to develop, implement, and monitor safety projects. There is limited unit-level support for safety projects, and the resources that are allocated come from overtaxed department budgets. ORGANIZATION LEVEL HOSPITAL LEVEL AND HEALTH SYSTEM: Infrastructure is needed to design, implement, and evaluate the following domains of work-measuring progress in patient safety, translating evidence into practice, identifying and mitigating hazards, improving culture and communication, and identifying an infrastructure in the organization for patient safety efforts. REFLECTIONS Fulfilling a commitment to safe and high-quality care will not be possible without significant investment in patient safety infrastructure. Health care organizations will need to determine the cost-benefit ratio of various investments in patient safety. Yet, predicating safety efforts on the mistaken belief in a short-term return on investments will stall patient safety efforts.

Credentialing: The need for a national research agenda

A national research agenda is needed to promote inquiry into the impact of credentialing on health care outcomes for nurses, patients, and organizations. Credentialing is used here to refer to individual credentialing, such as certification for nurses, and organizational credentialing, such as American Nurses Credentialing Center Magnet recognition for health care organizations or accreditation of providers of continuing education in nursing. Although it is hypothesized that credentialing leads to a higher quality of care, more uniform practice, and better patient outcomes, the research evidence to validate these views is limited. This article proposes a conceptual model in which both credentials and standards are posited to affect outcomes in health care. Potential research questions as well as issues in research design, measurement, data collection, and analysis are discussed. Credentialing in nursing has implications for the health care professions and national policy. A growing body of independent research that clarifies the relationship of credentialing in nursing to outcomes can make important contributions to the improvement of health care quality.

A Mile in Their Shoes: Interdisciplinary Education at the Johns Hopkins University School of Medicine:

An elective course exposing medical students to nonphysician hospital providers and staff was conceived and implemented. Goals and objectives identified were to (1) increase students’ understanding of the roles of nonphysician professionals in hospital care, (2) demonstrate how the services offered by these professionals complement those offered by physicians, (3) improve students’ skill in communicating with nonphysician professionals, (4) develop students’ comfort approaching these professionals about patient care issues, (5) show students “what it is like” to be each of these providers, and (6) demonstrate the common challenges they face. A 2-week elective rotation paired students with experienced preceptors in several nonphysician hospital care disciplines. Quantitative and qualitative data indicate that this experience empowered students to collaborate more actively with the nonphysician colleagues, whom they would encounter in their careers, to provide coordinated patient care.

Clinical application of undergraduate research skills: the Student Teams Utilizing Research (STUR) Project.

Although the desired outcome for undergraduate research curricula is to produce informed consumers/critiquers of research, baccalaureate students often have difficulty linking research concepts with clinical practice. The authors describe an innovative approach to integrating research content with a clinical experience through use of student teams working with practicing nursing preceptors to identify and study research problems.

Building Research Infrastructure in Magnet® Hospitals: Current Status and Future Directions

OBJECTIVE The aim of this study was to describe the infrastructures supporting research in Magnet® hospitals. BACKGROUND Hospitals undertaking the journey toward Magnet designation must build research and evidence-based practice (EBP) infrastructures that support the infusion of research and EBP into clinical practice. METHODS An electronic survey was developed and distributed to the chief nursing officer or Magnet coordinator of all Magnet hospitals between June 10, 2015, and July 8, 2015. RESULTS Of the 418 Magnet hospitals invited, 249 responses (60%) were received. Resources dedicated to nursing research were difficult to isolate from those for EBP. Supporting clinical nurses’ time away from the bedside remains a challenge. Nearly half (44%) indicated that research is conducted within the nurses’ usual clinical hours, and 40% indicated that nurses participate on their own time. CONCLUSIONS Hospitals use a variety of resources and mentor arrangements to support research and EBP, often the same resources. More targeted resources are needed to fully integrate research into clinical practice.