The TeamSTEPPS for Improving Diagnosis Team Assessment Tool: Scale Development and Psychometric Evaluation.

INTRODUCTION: One in three patients is affected by diagnosis-related communication failures. Only a few valid and reliable instruments that measure teamwork and communication exist, and none of those focus on improving diagnosis. The authors developed, refined, and psychometrically evaluated the TeamSTEPPSⓇ for Improving Diagnosis Team Assessment Tool (TAT), which assesses diagnostic teamwork and communication in five critical teamwork domains and can be used to identify strengths and opportunities for improvement and monitor performance. METHODS: The TAT was administered as a cross-sectional survey to 360 health professionals across nine diverse US health systems. Content and construct validity were evaluated through pilot implementation and subject matter expert review. Reliability and internal consistency were assessed with Cronbach's alpha. To understand sources of variation in TAT scores and assess the tool's consistency across diverse health care organizations, generalizability theory (G-theory) was used. Best practices in screening for careless responding identified participants with random or nonvarying responses. RESULTS: Analyses indicated strong support for the tool. Content validity findings indicated that the TAT encompassed relevant diagnostic improvement teamwork and communication content. Construct validity, evaluated through pilot implementations, demonstrated the tool's effectiveness in assessing teamwork categories. Reliability analyses confirmed the TAT's internal consistency, with an overall Cronbach's alpha of 0.97. Each dimension of the TAT exhibited good reliability coefficients, ranging from 0.83 to 0.95. G-theory analysis showed that variations in TAT scores were primarily attributed to respondents (28.0%) and scale dimensions (59.6%); both are desirable facets of variation. Further, examination of careless respondents ensured the accuracy and quality of the results, enhancing the TAT's credibility as a valuable diagnostic improvement tool. CONCLUSION: Psychometric evaluation demonstrated that the TAT is a reliable and valid instrument for assessing teamwork and communication among and across diagnostic teams. The TAT adds a novel, evidence-based, psychometrically sound measurement tool to help advance diagnostic teamwork and communication to improve patient care and outcomes.

The PRIDx framework to engage payers in reducing diagnostic errors in healthcare.

OBJECTIVES: No framework currently exists to guide how payers and providers can collaboratively develop and implement incentives to improve diagnostic safety. We conducted a literature review and interviews with subject matter experts to develop a multi-component 'Payer Relationships for Improving Diagnoses (PRIDx)' framework, that could be used to engage payers in diagnostic safety efforts. CONTENT: The PRIDx framework, 1) conceptualizes diagnostic safety links to care provision, 2) illustrates ways to promote payer and provider engagement in the design and adoption of accountability mechanisms, and 3) explicates the use of data analytics. Certain approaches suggested by PRIDx were refined by subject matter expert interviewee perspectives. SUMMARY: The PRIDx framework can catalyze public and private payers to take specific actions to improve diagnostic safety. OUTLOOK: Implementation of the PRIDx framework requires new types of partnerships, including external support from public and private payer organizations, and requires creation of strong provider incentives without undermining providers' sense of professionalism and autonomy. PRIDx could help facilitate collaborative payer-provider approaches to improve diagnostic safety and generate research concepts, policy ideas, and potential innovations for engaging payers in diagnostic safety improvement activities.

Operational measurement of diagnostic safety: state of the science.

Reducing the incidence of diagnostic errors is increasingly a priority for government, professional, and philanthropic organizations. Several obstacles to measurement of diagnostic safety have hampered progress toward this goal. Although a coordinated national strategy to measure diagnostic safety remains an aspirational goal, recent research has yielded practical guidance for healthcare organizations to start using measurement to enhance diagnostic safety. This paper, concurrently published as an Issue Brief by the Agency for Healthcare Research and Quality, issues a "call to action" for healthcare organizations to begin measurement efforts using data sources currently available to them. Our aims are to outline the state of the science and provide practical recommendations for organizations to start identifying and learning from diagnostic errors. Whether by strategically leveraging current resources or building additional capacity for data gathering, nearly all organizations can begin their journeys to measure and reduce preventable diagnostic harm.

A modified Delphi study to identify the features of high quality measurement plans for healthcare improvement projects.

BACKGROUND: The design and execution of measurement in quality improvement (QI) initiatives is often poor. Better guidance on "what good looks like" might help to mitigate some of the problems. We report a consensus-building process that sought to identify which features are important to include in QI measurement plans. METHODS: We conducted a three-stage consensus-building approach: (1) identifying the list of features of measurement plans that were potential candidates for inclusion based on literature review and the study team's experience; (2) a two-round modified Delphi exercise with a panel of experts to establish consensus on the importance of these features; and (3) a small in-person consensus group meeting to finalise the list of features. RESULTS: A list of 104 candidate questions was generated. A panel of 19 experts in the Delphi reviewed these questions and produced consensus on retaining 46 questions in the first round and on a further 22 in the second round. Thematic analysis of open text responses from the panellists suggested a number of areas of debate that were explicitly considered by the consensus group. The exercise yielded 74 questions (71% of 104) on which there was consensus in five categories of measurement relating to: design, data collection and management, analysis, action, and embedding. CONCLUSIONS: This study offers a consensus-based view on the features of a good measurement plan for a QI project in healthcare. The results may be of use to QI teams, funders and evaluators, but are likely to require further development and testing to ensure feasibility and usefulness.

Examining influences on speaking up among critical care healthcare providers in the United Arab Emirates.

OBJECTIVE: Assess perceived barriers to speaking up and to provide recommendations for reducing barriers to reporting adverse events and near misses. DESIGN, SETTING, PARTICIPANTS, INTERVENTION: A six-item survey was administered to critical care providers in 19 Intensive Care Units in Abu Dhabi as part of an organizational safety and quality improvement effort. MAIN OUTCOME MEASURES: Questions elicited perspectives about influences on reporting, perceived barriers and recommendations for conveying patient safety as an organizational priority. Qualitative thematic analyses were conducted for open-ended questions. RESULTS: A total of 1171 participants were invited to complete the survey and 639 responded (response rate = 54.6%). Compared to other stakeholders (e.g. the media, public), a larger proportion of respondents 'agreed/strongly agreed' that corporate health system leadership and the health regulatory authority encouraged and supported error reporting (83%; 75%), and had the most influence on their decisions to report (81%; 74%). 29.5% of respondents cited fear of repercussion as a barrier, and 21.3% of respondents indicated no barriers to reporting. Barriers included perceptions of a culture of blame and issues with reporting procedures. Recommendations to establish patient safety as an organizational priority included creating supportive environments to discuss errors, hiring staff to advocate for patient safety, and implementing policies to standardize clinical practices and streamline reporting procedures. CONCLUSIONS: Influences on reporting perceived by providers in the UAE were similar to those in the US and other countries. These findings highlight the roles of corporate leadership and regulators in developing non-punitive environments where reporting is a valuable and safe activity.

CLABSI Conversations: Lessons From Peer-to-Peer Assessments to Reduce Central Line-Associated Bloodstream Infections.

A national collaborative helped many hospitals dramatically reduce central line-associated bloodstream infections (CLABSIs), but some hospitals struggled to reduce infection rates. This article describes the development of a peer-to-peer assessment process (CLABSI Conversations) and the practical, actionable practices we discovered that helped intensive care unit teams achieve a CLABSI rate of less than 1 infection per 1000 catheter-days for at least 1 year. CLABSI Conversations was designed as a learning-oriented process, in which a team of peers visited hospitals to surface barriers to infection prevention and to share best practices and insights from successful intensive care units. Common practices led to 10 recommendations: executive and board leaders communicate the goal of zero CLABSI throughout the hospital; senior and unit-level leaders hold themselves accountable for CLABSI rates; unit physicians and nurse leaders own the problem; clinical leaders and infection preventionists build infection prevention training and simulation programs; infection preventionists participate in unit-based CLABSI reduction efforts; hospital managers make compliance with best practices easy; clinical leaders standardize the hospital's catheter insertion and maintenance practices and empower nurses to stop any potentially harmful acts; unit leaders and infection preventionists investigate CLABSIs to identify root causes; and unit nurses and staff audit catheter maintenance policies and practices.

Sustaining Reductions in Central Line-Associated Bloodstream Infections in Michigan Intensive Care Units: A 10-Year Analysis.

This article describes the interventions that sustained low central line-associated bloodstream infection (CLABSI) rates in the Michigan Keystone ICU Project. This analysis included data from March 2004 to December 2013 for 121 intensive care units (ICUs) in 73 hospitals. The Keystone Project was a cohort collaborative with an improvement team in each ICU. During the sustainability period, teams integrated the intervention into staff orientation, collected and submitted monthly data, and reported infection rates to leaders. The annual mean rate of BSIs dropped from 2.5 infections/1000 catheter-days in 2004 to 0.76 in 2013. A subset analysis found nearly double the percentage of ICUs with a mean rate of <1 infection/1000 catheter-days in 2013 compared with baseline. Active involvement of hospital leaders and the Keystone Center as well as ongoing monitoring and feedback of performance were important in sustaining results. These findings suggest that large-scale improvement projects can be sustained, establishing a new normal for care.

Simulation in the Executive Suite: Lessons Learned for Building Patient Safety Leadership.

INTRODUCTION: Simulation is a powerful learning tool for building individual and team competencies of frontline health care providers with demonstrable impact on performance. This article examines the impact of simulation in building strategic leadership competencies for patient safety and quality among executive leaders in health care organizations. METHODS: We designed, implemented, and evaluated a simulation as part of a larger safety leadership network meeting for executive leaders. This simulation targeted knowledge competencies of governance priority, culture of continuous improvement, and internal transparency and feedback. Eight teams of leaders in health care organizations-a total of 55 participants-participated in a 4-hour session. Each team performed collectively as a new chief executive officer (CEO) tasked with a goal of rescuing a hospital with a failing safety record. Teams worked on a modifiable simulation board reflecting the current dysfunctional organizational structure of the simulated hospital. They assessed and redesigned accountability structures based on information acquired in encounter sessions with confederates playing the role of internal staff and external consultants. RESULTS: Data were analyzed, and results are presented as qualitative themes arising from the simulation exercise, participant reaction data, and performance during the simulation. Key findings include high degrees of variability in solutions developed for the dysfunctional hospital system and generally positive learner reactions to the simulation experience. CONCLUSIONS: This study illustrates the potential value of simulation as a mechanism for learning and strategy development for executive leaders grappling with patient safety issues. Future research should explore the cognitive or functional fidelity of organizational simulations and the use of custom scenarios for strategic planning.

Implementing a multifaceted intervention to decrease central line-associated bloodstream infections in SEHA (Abu Dhabi Health Services Company) intensive care units: the Abu Dhabi experience.

OBJECTIVE To determine whether implementation of a multifaceted intervention would significantly reduce the incidence of central line-associated bloodstream infections. DESIGN Prospective cohort collaborative. SETTING AND PARTICIPANTS Intensive care units of the Abu Dhabi Health Services Company hospitals in the Emirate of Abu Dhabi. INTERVENTIONS A bundled intervention consisting of 3 components was implemented as part of the program. It consisted of a multifaceted approach that targeted clinician use of evidence-based infection prevention recommendations, tools that supported the identification of local barriers to these practices, and implementation ideas to help ensure patients received the practices. Comprehensive unit-based safety teams were created to improve safety culture and teamwork. Finally, the measurement and feedback of monthly infection rate data to safety teams, senior leaders, and staff in participating intensive care units was encouraged. The main outcome measure was the quarterly rate of central line-associated bloodstream infections. RESULTS Eighteen intensive care units from 7 hospitals in Abu Dhabi implemented the program and achieved an overall 38% reduction in their central line-associated bloodstream infection rate, adjusted at the hospital and unit level. The number of units with a quarterly central line-associated bloodstream infection rate of less than 1 infection per 1,000 catheter-days increased by almost 40% between the baseline and postintervention periods. CONCLUSION A significant reduction in the global morbidity and mortality associated with central line-associated bloodstream infections is possible across intensive care units in disparate settings using a multifaceted intervention.

Locating Errors Through Networked Surveillance: A Multimethod Approach to Peer Assessment, Hazard Identification, and Prioritization of Patient Safety Efforts in Cardiac Surgery.

OBJECTIVES: The objectives were to develop a scientifically sound and feasible peer-to-peer assessment model that allows health-care organizations to evaluate patient safety in cardiovascular operating rooms and to establish safety priorities for improvement. METHODS: The locating errors through networked surveillance study was conducted to identify hazards in cardiac surgical care. A multidisciplinary team, composed of organizational sociology, organizational psychology, applied social psychology, clinical medicine, human factors engineering, and health services researchers, conducted the study. We used a transdisciplinary approach, which integrated the theories, concepts, and methods from each discipline, to develop comprehensive research methods. Multiple data collection was involved: focused literature review of cardiac surgery-related adverse events, retrospective analysis of cardiovascular events from a national database in the United Kingdom, and prospective peer assessment at 5 sites, involving survey assessments, structured interviews, direct observations, and contextual inquiries. A nominal group methodology, where one single group acts to problem solve and make decisions was used to review the data and develop a list of the top priority hazards. RESULTS: The top 6 priority hazard themes were as follows: safety culture, teamwork and communication, infection prevention, transitions of care, failure to adhere to practices or policies, and operating room layout and equipment. CONCLUSIONS: We integrated the theories and methods of a diverse group of researchers to identify a broad range of hazards and good clinical practices within the cardiovascular surgical operating room. Our findings were the basis for a plan to prioritize improvements in cardiac surgical care. These study methods allowed for the comprehensive assessment of a high-risk clinical setting that may translate to other clinical settings.

Eliminating central line-associated bloodstream infections: a national patient safety imperative.

BACKGROUND: Several studies demonstrating that central line-associated bloodstream infections (CLABSIs) are preventable prompted a national initiative to reduce the incidence of these infections. METHODS: We conducted a collaborative cohort study to evaluate the impact of the national "On the CUSP: Stop BSI" program on CLABSI rates among participating adult intensive care units (ICUs). The program goal was to achieve a unit-level mean CLABSI rate of less than 1 case per 1,000 catheter-days using standardized definitions from the National Healthcare Safety Network. Multilevel Poisson regression modeling compared infection rates before, during, and up to 18 months after the intervention was implemented. RESULTS: A total of 1,071 ICUs from 44 states, the District of Columbia, and Puerto Rico, reporting 27,153 ICU-months and 4,454,324 catheter-days of data, were included in the analysis. The overall mean CLABSI rate significantly decreased from 1.96 cases per 1,000 catheter-days at baseline to 1.15 at 16-18 months after implementation. CLABSI rates decreased during all observation periods compared with baseline, with adjusted incidence rate ratios steadily decreasing to 0.57 (95% confidence intervals, 0.50-0.65) at 16-18 months after implementation. CONCLUSION: Coincident with the implementation of the national "On the CUSP: Stop BSI" program was a significant and sustained decrease in CLABSIs among a large and diverse cohort of ICUs, demonstrating an overall 43% decrease and suggesting the majority of ICUs in the United States can achieve additional reductions in CLABSI rates.

Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.

Catheter-associated urinary tract infection (CAUTI) represents a significant proportion of healthcare-associated infections (HAIs). The US Department of Health and Human Services issued a plan to reduce HAIs with a target 25% reduction of CAUTI by 2013. Michigan's successful collaborative to reduce unnecessary use of urinary catheters and CAUTI was based on a partnership between diverse hospitals, the state hospital association (SHA), and academic medical centers. Taking the lessons learned from Michigan, we are now spreading this work throughout the 50 states. This national spread leverages the expertise of different groups and organizations for the unified goal of reducing catheter-related harm. The key components of the project are (1) centralized coordination of the effort and dissemination of information to SHAs and hospitals, (2) data collection based on established definitions and approaches, (3) focused guidance on the technical practices that will prevent CAUTI, (4) emphasis on understanding the socioadaptive aspects (both the general, unit-wide issues and CAUTI-specific challenges), and (5) partnering with specialty organizations and governmental agencies who have expertise in the relevant subject area. The work may serve in the future as a model for other large improvement efforts to address other hospital-acquired conditions, such as venous thromboembolism and falls.

Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: the Spanish experience.

OBJECTIVE: Prevention of catheter-related bloodstream infection is a basic objective to optimize patient safety in the ICU. Building on the early success of a patient safety unit-based comprehensive intervention (the Keystone ICU project in Michigan), the Bacteremia Zero project aimed to assess its effectiveness after contextual adaptation at large-scale implementation in Spanish ICUs. DESIGN: Prospective time series. SETTING: A total of 192 ICUs throughout Spain. PATIENTS: All patients admitted to the participating ICUs during the study period (baseline April 1 to June 30, 2008; intervention period from January 1, 2009, to June 30, 2010). INTERVENTION: Engagement, education, execution, and evaluation were key program features. Main components of the intervention included a bundle of evidence-based clinical practices during insertion and maintenance of catheters and a unit-based safety program (including patient safety training and identification and analysis of errors through patient safety rounds) to improve the safety culture. MEASUREMENTS AND MAIN RESULTS: The number of catheter-related bloodstream infections was expressed as median and interquartile range. Poisson distribution was used to calculate incidence rates and risk estimates. The participating ICUs accounted for 68% of all ICUs in Spain. Catheter-related bloodstream infection was reduced after 16-18 months of participation (median 3.07 vs 1.12 episodes per 1,000 catheter-days, p<0.001). The adjusted incidence rate of bacteremia showed a 50% risk reduction (95% CI, 0.39-0.63) at the end of the follow-up period compared with baseline. The reduction was independent of hospital size and type. CONCLUSIONS: Results of the Bacteremia Zero project confirmed that the intervention significantly reduced catheter-related bloodstream infection after large-scale implementation in Spanish ICUs. This study suggests that the intervention can also be effective in different socioeconomic contexts even with decentralized health systems.

Decreasing central-line-associated bloodstream infections in Connecticut intensive care units.

Central-line-associated bloodstream infections (CLABSIs) are a significant cause of preventable harm. A collaborative project involving a multifaceted intervention was used in the Michigan Keystone Project and associated with significant reductions in these infections. This intervention included the Comprehensive Unit-based Safety Program, a multifaceted approach to CLABSI prevention, and the monitoring and reporting of infections. The purpose of this study was to determine whether the multifaceted intervention from the Michigan Keystone program could be implemented in Connecticut and to evaluate the impact on CLABSI rates in intensive care units (ICUs). The primary outcome was the NHSN-defined rate of CLABSI. Seventeen ICUs, representing 14 hospitals and 104,695 catheter days were analyzed. The study period included up to four quarters (12 months) of baseline data and seven quarters (21 months) of postintervention data. The overall mean (median) CLABSI rate decreased from 1.8 (1.8) infections per 1,000 catheter days at baseline to 1.1 (0) at seven quarters postimplementation of the intervention. This study demonstrated that the multifaceted intervention used in the Keystone program could be successfully implemented in another state and was associated with a reduction in CLABSI rates in Connecticut. Moreover, even though the statewide baseline CLABSI rate in Connecticut was low, rates were reduced even further and well below national benchmarks.

Using a logic model to design and evaluate quality and patient safety improvement programs.

Quality improvement programs often pose unique project management challenges, including multi-faceted interventions that evolve over time and teams with few resources for data collection. Thus, it is difficult to report methods and results. We developed a program to reduce central line-associated bloodstream infections (CLABSIs) and improve safety culture in intensive care units (ICUs). As previously reported, we worked with 103 Michigan ICUs to implement this program, and they achieved a 66% reduction in the median CLABSI rate and sustained the reduction. This success prompted the spread of this program to Spain, England, Peru and across the USA. We developed a logical framework approach (LFA) to guide project management; to incorporate the cultural, clinical and capacity variations among countries; and to ensure early alignment of the project's design and evaluation. In this paper, we describe the use of the LFA to systematically design, implement and evaluate large-scale, multi-faceted, quality improvement programs.

Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center.

BACKGROUND: Briefings and debriefings, previously shown to be a practical and feasible strategy to improve interdisciplinary communication and teamwork in the operating room (OR), was then assessed as a strategy to prospectively surface clinical and operational defects in surgical care--and thereby prevent patient harm. METHODS: A one-page, double-sided briefing and debriefing tool was used by surgical teams during cases at the William Beaumont Hospital Royal Oak (Royal Oak, Michigan) campus to surface clinical and operational defects during the study period (October 2006-May 2010). Defects were coded into six categories (with each category stratified by briefing or debriefing period) during the first six months, and refinement of coding resulted in expansion to 16 defect categories and no further stratification. A provider survey was used in January 2008 to interview a sample of 40 caregivers regarding the perceived effectiveness of the tool in surfacing defects. FINDINGS: The teams identified a total of 6,202 defects--an average of 141 defects per month--during the entire study period. Of 2,760 defects identified during the six-defect coding period, 1,265 (46%) surfaced during briefings, and the remaining 1,495 (54%) during debriefings. Equipment (48%) and communication (31%) issues were most prominent. Of 3,442 defects identified during the 16-defect coding period, the most common were Central Processing Department (CPD) instrumentation (22%) and Communication/Safety (15%). Overall, 70 (87%) of the 80 responses were in agreement that briefings were effective for surfacing defects, as were 59 (76%) of the 78 responses for debriefings. CONCLUSIONS: Briefings and debriefings were a practical and effective strategy to surface potential surgical defects in the operating rooms of a large medical center.

Using the Opportunity Estimator tool to improve engagement in a quality and safety intervention.

Teams throughout the United States participating in a program to reduce central line-associated bloodstream infections (CLABSIs) are using the Opportunity Estimator. This web-based tool translates CLABSI-related data into "opportunity estimates" of the patient lives and money that could be saved by reducing these infections.

Eradicating central line-associated bloodstream infections statewide: the Hawaii experience.

The authors' goal was to determine if a national intensive care unit (ICU) collaborative to reduce central line-associated bloodstream infections (CLABSIs) would succeed in Hawaii. The intervention period (July 2009 to December 2010) included a comprehensive unit-based safety program; a multifaceted approach to CLABSI prevention; and monitoring of infections. The primary outcome was CLABSI rate. A total of 20 ICUs, representing 16 hospitals and 61 665 catheter days, were analyzed. Median hospital bed size was 159 (interquartile range [IQR] = 71-212) and median ICU bed size was 10 (IQR = 8-12). Median unit catheter days per month were 112 (IQR = 52-197). The overall mean CLABSI rate decreased from 1.5 infections per 1000 catheter days at baseline (January to June 2009) to 0.6 at 16 to 18 months postintervention (October to December 2010). The median rate was zero CLABSIs per 1000 catheter days at baseline and remained zero throughout the study period. Hawaii demonstrated that the national program can be successfully spread, providing further evidence that most CLABSIs are preventable.