Now that we've talked about defining safety culture and why it's important, let's talk about measuring it. Marty Rubin said 'Every line is the perfect length if you don't measure it'. What does this mean? Well, as humans, we're really good at deluding ourselves into thinking that things are going okay, if we don't have any evidence to the contrary. Even if we sensed that something might be a little bit wrong, we might be willing to accept it if we don't have benchmarks to say that somebody else's experiences is different. Measurement is really important, and safety culture is no exception because it gives us a sense of where are we and where are we going, and have we made any improvement, how are we doing with respect other folks? What's going on really? We've got a measure but the thing about data and measurement is that anecdotes and stories resonate far more with us as humans than just numbers and statistics. It's really important to have both of these things. As an example, we might hear that mortality has increased, or surgical site infections have gone up, but until we can put a face to the names and to the statistics, we don't always feel the same gravity of the importance of what that statistic is really telling us. When we see a little girl who passed away because of a preventable surgical site infection, that resonates with us. That's when we were really willing to make a change. It's really important to have both. Why measure? As I said, we measure so that we know where we started. We know where we want to go and how far we've come. We'll talk about it a little bit particularly when we get to debriefing. Measurement gives us a baseline for where we are so that we can identify our particular strengths and weaknesses within our own units, within our own organizations, and pick areas that we want to focus on improving or that we want to continue strengthening. As we saw earlier, safety culture is multifaceted. It's made up of different areas. And, as I said earlier, it's kind of a misnomer to say that safety culture can be strong or weak because really what we see is that safety culture in different units have different profiles where they're stronger or maybe on their teamwork but weaker on their feedback practices. Other units might have really incredible feedback practices but need to focus on their resource allocation practices a little bit better. That's why we measure to see what our particular profiles are, where we can maybe make improvements, and then help whether we have made those improvements after we have implemented some interventions. It also sends really important messages about what's important within our organizations. We're measuring patient safety experience when we're measuring safety culture. We are saying that these are things that we care about. We care enough about them to ask you to come away from your work for 10-15 minutes and take a survey to give us your thoughts and reactions and perceptions on these things. And, that we want to see these scores improve over time. That's, again, one way to convey our best espoused values that are ultimately driven by those assumptions. How do we measure? What do we do? Well, there's a number of different patient safety culture scales out there. On the screen, we see a couple of examples of safety attitudes questionnaire. The Agency for Healthcare and Research and Qualities, hospital survey on patient safety culture is another. The Veterans Health Administration has their own. And, there's also hybrid methods measures. Here, at Hopkins for example, we actually use a little bit of a hybrid of the SAQ, Safety Attitudes Questionnaire along with some items that we have kind of cherry picked from other surveys as well. These decisions have been made because these are things that align with our values and what we want to know and what we want to focus on as we move forward. Take your pick. There's a number of validated scales out there, and most of them are very similar. All of them have multiple dimensions. Again as we discussed, safety culture is multifaceted. Some common dimensions are definitely teamwork, communication, how your organization responds to error, management commitment, and your leadership practices, those sorts of things. All of them, generally, provide some sort of overall assessment of safety based on these multiple dimensions. Critically, all of them use individual responses that are then aggregated to a group level. The reason that that's important is because culture is in its essence shared. My opinion, my perspective is just an opinion but my shared perspective with my colleagues is our culture. All of these scales measure the individual responses that then roll up to the group level. However, measurement is only as good as what we do after we have the data. Debriefing, coaching, change initiatives, these are all critical to making data speak, if you will. Data are just numbers, but it's debriefing that turns the data into information. We know that teams that debrief actually perform better. As an example from Rhode Island, we saw in some units that with semi-structured debriefs, those units saw a 10.2% reduction in surgical site infection rate. Those that didn't debrief, well, they did see a reduction, it was much smaller. The reason for that is, well there's really several reasons for that and we'll get into some of those in a minute as to why, but the point here is that debriefing is really what makes the data meaningful. It gives us an opportunity to put names and faces to our data. It gives us an opportunity to understand the data in a richer way. Let's talk about that. Debriefing is a semi structured conversation that happens among our stakeholders. Oftentimes, when we're talking about safety culture, it's our front line clinicians and staff who provided the data to our safety culture assessments. These debriefings are usually led by a designated facilitator and the job of that facilitator is not to tell people about the data. It's about trying to get those folks who are living this culture to talk about the culture, to talk about the data. The reason that we debrief is to encourage open communication, transparency, and interactive discussion about the survey results within our unit. Sometimes, if we have low response rates, a very easy question during debriefing is, do these resonate with you? Are these results valid? Is there something that we're missing because many folks didn't voice their opinion and their perspectives. It's really important when we're doing debriefs to try to get, at all levels in all disciplines, to have physicians and nurses and even your environmental services staff if you can. Whoever provided information, it works on that unit to come in and give their perspective and talk openly and honestly about this. As a facilitator, their role is to make sure is to kind of keep the peace and to make sure everybody's voice is being heard and that there's not a whole lot of finger-pointing going on because debriefing is about trying to find ways to use the data in a constructive manner. That really requires everybody's participation. Again, it's to engage the clinicians and staff and then generate ideas about how to create an effective safety culture moving forward. The people who work on the unit, are the people with the best ideas about what it is that can improve the culture, whether they know it or not. Sometimes it takes a little bit of time to get these opinions that requires a really nice facilitator, a really good facilitator, who's capable of picking out the folks who are a little bit quiet in the back of the room to voice their opinion. but the debrief is a platform, It's an opportunity for not just to learn about the data to hear what the results were but to then also respond to that data, to say what it is that we're going to do moving forward, now that we know where we stand as we are now. It's important to plan your debriefs. On the screen, we see a couple of questions and decision points that you might want to think about when you're doing, when you are planning debriefs. Again, remembering that, you're wanting to try to get as many people in the unit as possible to respond some questions. How many debriefing sessions would you want to hold? Who is going to be facilitating them? Where will they be held? When will they be held? Are they going to be held on the unit where folks can kind of come in during their shifts? Are they going to be expected to come some other time? Some units in surgical departments have been able to actually close the OR, to give people dedicated time to come to these debriefings. How are you going to plan your debrief? What are you going to do? If you have more than one debriefing session, who is going to be responsible for collating those notes? You can use some of these are just ideas of ways to think through what are you going to do with your debriefs. Once you do debrief, again, have a facilitator and again use that facilitator there to share the data, to share the results, and then encourage active discussion around that. I really recommend that a designated note taker who is also separate from the facilitator be present that person can be the one responsible for taking notes, and writing down ideas, and sharing the plan that everybody is kind of coming to consensus around. Importantly, during the debrief, it is really critical to share the survey results obviously, but go beyond that, host that meeting to discuss the data, ask for that active participation for it to be open and honest, no finger-pointing allowed, and then focus on identifying what those system issues are that they would like to tackle as a team in the unit or the department. Then, of course, you can't just leave it hanging there. Try to create an agenda or a act, a way to then follow up on. Well, what are we going to do next to address some of these issues that we've decided? Those are really our debriefing best practices. As you're getting a sense, I'm really hammering home that open, honest discussion with an angle at what do we do next, and how can we make sure that we succeed at taking those next steps. One tool that you might find useful is the Culture Check-Up Tool that we have here at Hopkins. You can download it from the link that you see on the screen there. I'll just go through the steps that are in it really quickly. Of course, you can use whatever helps you be more successful. If you want to put a spin on this tool or you have your own tools because we all debrief. I mean, many of us have been involved in debriefs. Feel free to use what makes sense to you, but there are six steps to the Culture Check-Up Tool and it begins by generally identifying the strengths and weaknesses of your unit's culture. Once you have your results sitting down and saying, here's where we're strong, here's where we scored highest, and here's where we scored lowest. What do we do about that? Here they are. Getting specific about the behaviors and attitudes that contribute to those strengths and weaknesses. Maybe you choose one strengths, maybe you choose one weakness, and then you look at the items from the survey related to those dimensions and you say, but what are the really the behaviors that are driving these scores and do those make sense to us? What would we maybe say is different? If they do make sense, what can we do to change that specific behavior? As we've said, change is hard, but when we have specific things that we can focus on that makes it a little bit easier to make incremental change over time. Then, select your opportunities for growth and it's really important again because we want this to be a communal decision, we want people to be bought into committing to these changes to get the group kind of consensus. The facilitator shouldn't be the one sitting there saying and this is what we're going to focus on. I would also encourage not having leadership make the, be all and all decision, but to try to have this be a group consensus for folks to really say, this is where I want to spend my time and I would really think that this is the most valuable thing for us to do. Then, of course, develop that strategy for addressing those group growth opportunities, and putting that plan into action. How are we going to make sure that moving forward? We're really addressing this so that and in 12 months and 18 months, when we do our culture survey again, we see improvements in the areas that we've decided to address. Finally, evaluate again. Of course, share your progress during your safety team meetings. And, again, every 12 to 18 months is generally our rule of thumb for how often we should survey and as things improve, as those areas we focus on improve, maybe focusing on different areas too.
