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Hitting the Mark
A Hopkins questionnaire reveals more about safety than you might think.

The figure "60 percent" holds a special meaning for Hopkins psychologist Bryan Sexton, creator of the Safety Attitudes Questionnaire.

When at least six of every 10 caregivers on a clinical unit have positive attitudes about the level of patient safety—as measured by the questionnaire—good things happen. Rates of ventilator-associated pneumonia, sepsis, surgical site infections and bed sores are significantly lower than when attitudes are below that mark. When at least 60 percent report good teamwork, rates of nurse turnover, absenteeism and bloodstream infection are lower.

"We've found a threshold above which there's a meaningful consensus of caregivers in a clinical area," says Sexton, whose survey has been used both at Hopkins and throughout the health care industry. "Across 1,300 hospitals and hundreds of thousands of caregivers, 60 percent really leaps out."

The results of this year's Hopkins Hospital safety culture survey—the third institution-wide SAQ since late 2004—indicate that more units are meeting or exceeding that critical threshold.

Of the 98 clinical areas that have reliable results going back three years, 69 percent either maintained a safety climate score above the threshold or improved significantly (by 10 points or more). When it came to perceptions of teamwork, 74 percent either maintained a teamwork climate score above the threshold or improved significantly.

There's no single formula for improving safety culture, but some characteristics are common to high-scoring clinical areas. They often have participated in the Comprehensive Unit-based Safety Program, a six-step program created by Hopkins intensivist Peter Pronovost to help teams identify hazards and fix them. Successful units have often received training in the science of safety, in which they're instructed to view adverse events as the product of faulty systems. Many have adopted tools and processes, such as preoperative briefings or daily goals, that provide structure for communicating in a more standardized and interdisciplinary manner.

Successful units have also used the survey results to identify and address problems. For example, Linda Huffman, nurse manager on Meyer 8, a neuroscience unit, goes over responses to individual questions—broken down by caregiver type—and brings them up during focus group meetings. The group discusses what steps would create more positive attitudes.

Sexton has found some factors that often coincide with slumping attitudes: moving a unit to a new location, adopting new technologies, and changing nurse managers or physician leaders (even those who are disliked). Often it takes about a year for the scores to bounce back. This doesn't mean that units should shy away from changes that promise long-term benefits. However, he notes. "If your unit is introducing new technology or moving, maybe you don't want to enroll in a big collaborative to fix a safety problem."

—Jamie Manfuso



Johns Hopkins Medicine

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