Safety Culture and Workforce Well-Being Associations with Positive Leadership WalkRounds.

BACKGROUND: Interventions to decrease burnout and increase well-being in health care workers (HCWs) and improve organizational safety culture are urgently needed. This study was conducted to determine the association between Positive Leadership WalkRounds (PosWR), an organizational practice in which leaders conduct rounds and ask staff about what is going well, and HCW well-being and organizational safety culture. METHODS: This study was conducted in a large academic health care system in which senior leaders were encouraged to conduct PosWR. The researchers used data from a routine cross-sectional survey of clinical and nonclinical HCWs, which included a question about recall of exposure of HCWs to PosWR: "Do senior leaders ask for information about what is going well in this work setting (e.g., people who deserve special recognition for going above and beyond, celebration of successes, etc.)?"-along with measures of well-being and safety culture. T-tests compared work settings in the first and fourth quartiles for PosWR exposure across SCORE (Safety, Communication, Operational Reliability, and Engagement) domains of safety culture and workforce well-being. RESULTS: Electronic surveys were returned by 10,627 out of 13,040 possible respondents (response rate 81.5%) from 396 work settings. Exposure to PosWR was reported by 63.1% of respondents overall, with a mean of 63.4% (standard deviation = 20.0) across work settings. Exposure to PosWR was most commonly reported by HCWs in leadership roles (83.8%). Compared to work settings in the fourth (< 50%) quartile for PosWR exposure, those in the first (> 88%) quartile revealed a higher percentage of respondents reporting good patient safety norms (49.6% vs. 69.6%, p < 0.001); good readiness to engage in quality improvement activities (60.6% vs. 76.6%, p < 0.001); good leadership accessibility and feedback behavior (51.9% vs. 67.2%, p < 0.001); good teamwork norms (36.8% vs. 52.7%, p < 0.001); and good work-life balance norms (61.9% vs. 68.9%, p = 0.003). Compared to the fourth quartile, the first quartile had a lower percentage of respondents reporting emotional exhaustion in themselves (45.9% vs. 32.4%, p < 0.001), and in their colleagues (60.5% vs. 47.7%, p < 0.001). CONCLUSION: Exposure to PosWR was associated with better HCW well-being and safety culture.

Perceptions of Institutional Support for "Second Victims" Are Associated with Safety Culture and Workforce Well-Being.

OBJECTIVE: This study was performed to determine whether health care worker (HCW) assessments of good institutional support for second victims were associated with institutional safety culture and workforce well-being. METHODS: HCWs' awareness of work colleagues emotionally traumatized by an unanticipated clinical event (second victims), their perceptions of level of institutional support for such colleagues, safety culture, and workforce well-being were assessed using a cross-sectional survey (SCORE [Safety, Communication, Operational Reliability, and Engagement] survey). Safety culture scores and workforce well-being scores were compared across work settings with high (top quartile) and low (bottom quartile) perceptions of second victim support. RESULTS: Of the 10,627 respondents (81.5% response rate), 36.3% knew at least one work colleague who had been traumatized by an unanticipated clinical event. Across 396 work settings, the percentage of respondents agreeing (slightly or strongly) that second victims receive appropriate support ranged from 0% to 100%. Across all respondents, significant correlations between perceived support for second victims and all SCORE domains (Improvement Readiness, Local Leadership, Teamwork Climate, Safety Climate, Emotional Exhaustion, Burnout Climate, and Work-Life Balance) were found. The 24.9% of respondents who knew an actual second victim and reported inadequate institutional support were significantly more negative in their assessments of safety culture and well-being than the 42.2% who reported adequate institutional support. CONCLUSION: Perceived institutional support for second victims was associated with a better safety culture and lower emotional exhaustion. Investment in programs to support second victims may improve overall safety culture and HCW well-being.

Differences in Safety Report Event Types Submitted by Graduate Medical Education Trainees Compared With Other Healthcare Team Members.

OBJECTIVES: Graduate medical education (GME) trainees have a unique perspective from which to identify and report patient safety concerns. However, it is not known how safety reports submitted by GME trainees differ from those submitted by other clinical staff. We hypothesized that GME trainees were more likely to submit safety reports regarding transitions of care, delays in care, and lapses in communication, and reports of higher severity compared with other frontline staff such as nurses, pharmacists, and other providers. METHODS: Patient safety reports submitted by clinical staff for 1 year at an academic tertiary care children's hospital were retrospectively reviewed and categorized by reporter type. Severity level and event type were analyzed by reporter type, and repeat χ2 tests were used to compare the percentage of reports at each severity level and in each event type submitted by GME trainees compared with each other reporter type. RESULTS: Graduate medical education trainees submitted reports of greater severity (level E/F/G) compared with nurses (10% versus 5%, P = 0.021) and pharmacists (10% versus 2%, P = 0.001). A greater percent of GME trainees' reports were categorized as errors in transitions of care, diagnosis, ordering, laboratory collection, and care delays compared with several other reporter types. CONCLUSIONS: Graduate medical education trainees identify system vulnerabilities not detected by other personnel, supporting efforts to increase safety reporting by GME trainees.

Teaching patient safety in global health: lessons from the Duke Global Health Patient Safety Fellowship.

Health systems in low-income and middle-income countries (LMICs) have a high burden of medical errors and complications, and the training of local experts in patient safety is critical to improve the quality of global healthcare. This analysis explores our experience with the Duke Global Health Patient Safety Fellowship, which is designed to train clinicians from LMICs in patient safety, quality improvement and infection control. This intensive fellowship of 3-4 weeks includes (1) didactic training in patient safety and quality improvement, (2) experiential training in patient safety operations, and (3) mentorship of fellows in their home institution as they lead local safety programmes. We have learnt several lessons from this programme, including the need to contextualise training to local needs and resources, and to focus training on building interdisciplinary patient safety teams. Implementation challenges include a lack of resources and data collection systems, and limited recognition of the role of safety in global health contexts. This report can serve as an operational guide for intensive training in patient safety that is contextualised to global health challenges.

Building a safety culture in global health: lessons from Guatemala.

Programmes to modify the safety culture have led to lasting improvements in patient safety and quality of care in high-income settings around the world, although their use in low-income and middle-income countries (LMICs) has been limited. This analysis explores (1) how to measure the safety culture using a health culture survey in an LMIC and (2) how to use survey data to develop targeted safety initiatives using a paediatric nephrology unit in Guatemala as a field test case. We used the Safety, Communication, Operational Reliability, and Engagement survey to assess staff views towards 13 health climate and engagement domains. Domains with low scores included personal burnout, local leadership, teamwork and work-life balance. We held a series of debriefings to implement interventions targeted towards areas of need as defined by the survey. Programmes included the use of morning briefings, expansion of staff break resources and use of teamwork tools. Implementation challenges included the need for education of leadership, limited resources and hierarchical work relationships. This report can serve as an operational guide for providers in LMICs for use of a health culture survey to promote a strong safety culture and to guide their quality improvement and safety programmes.

Improving Resident and Fellow Engagement in Patient Safety Through a Graduate Medical Education Incentive Program.

BACKGROUND: Collaboration between graduate medical education (GME) and health systems is essential for the success of patient safety initiatives. One example is the development of an incentive program aligning trainee performance with health system quality and safety priorities. OBJECTIVE: We aimed to improve trainee safety event reporting and engagement in patient safety through a GME incentive program. METHODS: The incentive program was implemented to provide financial incentives to drive behavior and engage residents and fellows in safety efforts. Safety event reporting was measured beginning in the 2014-2015 academic year. A training module was introduced and the system reporting link was added to the institution's Resident Management System homepage. The number of reports by trainees was tracked over time, with a target of 2 reports per trainee per year. RESULTS: Baseline data for the year prior to implementation of the incentive program showed less than 0.5% (74 of 16 498) of safety reports were submitted by trainees, in contrast with 1288 reports (7% of institutional reports) by trainees in 2014-2015 (P < .0001). A total of 516 trainees (57%), from 37 programs, received payment for the metric, based on a predefined program target of a mean of 2 reports per trainee. In 2015-2016 and 2016-2017 the submission rate was sustained, with 1234 and 1350 reports submitted by trainees, respectively. CONCLUSIONS: An incentive program as part of a larger effort to address safety events is feasible and resulted in increased reporting by trainees.

Heimlich valve orientation error leading to radiographic tension pneumothorax: analysis of an error and a call for education, device redesign and regulatory action.

Medical errors are commonly multifactorial, with adverse clinical consequences often requiring the simultaneous failure of a series of protective layers, termed the Swiss Cheese model. Remedying and preventing future medical errors requires a series of steps, including detection, mitigation of patient harm, disclosure, reporting, root cause analysis, system modification, regulatory action, and engineering and manufacturing reforms. We describe this process applied to two cases of improper orientation of a Heimlich valve in a thoracostomy tube system, resulting in enlargement of an existing pneumothorax and the development of radiographic features of tension pneumothorax. We analyse elements contributing to the occurrence of the error and depict the implementation of reforms within our healthcare system and with regulatory authorities and the manufacturer. We identify features of the Heimlich valve promoting this error and suggest educational, design, and regulatory reforms for enhanced patient safety.

Practice and quality improvement: successful implementation of TeamSTEPPS tools into an academic interventional ultrasound practice.

OBJECTIVE: The goal of this study was to implement an evidence-based teamwork system to improve communication and teamwork skills among health care professionals (TeamSTEPPS) into an academic interventional ultrasound program and to assess safety and team-work climate across team members both before and after implementation. MATERIALS AND METHODS: Members of a change team (including master trainers) selected specific tools available within TeamSTEPPS to implement into an academic interventional ultrasound service. Tools selected were based on preimplementation survey data obtained from team members (n = 64: 11 attending faculty physicians, 12 clinical abdominal imaging fellows or residents, 17 sonographers, 19 nurses, and five technologist aides or administrative personnel). The survey included teamwork climate and safety climate domains from the Safety Attitudes Questionnaire. Four months after implementation, respondents were resurveyed and post-implementation data were collected. RESULTS: Teamwork climate scores improved from a mean of 67.9 (SD, 12.8) before implementation to a mean of 87.8 (SD, 14.1) after implementation (t = -7.6; p < 0.001). Safety climate scores improved from a mean of 76.5 (SD, 12.8) before implementation to a mean of 88.3 (SD, 13.4) after implementation (t = -4.6; p < 0.001). In particular, teamwork items about "input being well received" and "speaking up" were the most responsive to the intervention. CONCLUSION: The implementation of TeamSTEPPS tools was associated with statistically significant improvements in safety and teamwork metrics in an academic interventional ultrasound practice. The most notable improvements were seen in communication among team members and role clarification. We think that this model, which has been successfully implemented in many nonradiologic areas in medical care, is also applicable in imaging practice.

A closer look at associations between hospital leadership walkrounds and patient safety climate and risk reduction: a cross-sectional study.

Leadership walkrounds (WRs) are widely used in health care organizations to improve patient safety. This retrospective, cross-sectional study evaluated the association between WRs and caregiver assessments of patient safety climate and patient safety risk reduction across 49 hospitals in a nonprofit health care system. Linear regression analyses using units' participation in WRs were conducted. Survey results from 706 hospital units revealed that units with ≥ 60% of caregivers reporting exposure to at least 1 WR had a significantly higher safety climate, greater patient safety risk reduction, and a higher proportion of feedback on actions taken as a result of WRs compared with those units with <60% of caregivers reporting exposure to WRs. WR participation at the unit level reflects a frequency effect as a function of units with none/low, medium, and high leadership WR exposure.