Development and testing of Baylor Scott & White Health's "Attitudes and Practices of Patient Safety Survey".

Improving the quality of patient care requires a culture attuned to safety. We describe the development, implementation, and psychometric evaluation of the Attitudes and Practices of Patient Safety Survey (APPSS) within the Baylor Scott & White Health system. The APPSS was designed to enable safety culture data to be collected and aggregated at the unit level to identify high-priority needs. The survey, with 27 Likert-scale core questions divided into 4 concept domains and 2 open-ended questions, was administered electronically to employees with direct patient care responsibilities (n = 16,950). The 2015 response rate was 50.4%. The Cronbach's α values for the four domains ranged from 0.78 to 0.90, indicating strong internal consistency. Confirmatory factor analysis results were mixed but were comparable to those of established safety culture surveys. Over the years, the adaptability of the APPSS has proven helpful to administrative and clinical leaders alike, and the survey responses have led to the creation of programs to improve the organization's patient safety culture. In conclusion, the APPSS provides a reliable measure of patient safety culture and may be useful to other health care organizations seeking to improve the quality and safety of the care they provide.

Development of a tool to measure user experience following electronic health record implementation.

OBJECTIVE: The aim of this study was to develop a survey tool to assess electronic health record (EHR) implementation to guide improvement initiatives. BACKGROUND: Survey tools are needed for ongoing improvement and have not been developed for aspects of EHR implementation. METHODS: The Baylor EHR User Experience (UX) survey was developed to capture 5 concept domains: training and competency, usability, infrastructure, usefulness, and end-user support. Validation efforts included content validity assessment, a pilot study, and analysis of 606 nurse respondents. The revised tool was sent to randomly sampled EHR nurse-users in 11 acute care facilities. RESULTS: A total of 1,301 nurses responded (37%). Internal consistency of the survey tool was excellent (Cronbach's α = .892). Survey responses including 1,819 open comments were used to identify and prioritize improvement efforts in areas such as education, support, optimization of EHR functions, and vendor change requests. CONCLUSION: The Baylor EHR UX survey was a valid tool that can be useful for prioritizing improvement efforts in relation to EHR implementation.

Characterization of adverse events detected in a large health care delivery system using an enhanced global trigger tool over a five-year interval.

OBJECTIVE: To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system. STUDY SETTING: Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed. STUDY DESIGN: We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems. DATA COLLECTION: Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs). PRINCIPAL FINDINGS: Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were "preventable/possibly preventable." Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were "preventable/possibly preventable"; the most common category was "surgical/procedural" (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs. CONCLUSIONS: AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.

Description and evaluation of adaptations to the global trigger tool to enhance value to adverse event reduction efforts.

OBJECTIVE: To adapt the Global Trigger Tool (GTT) as a sustainable monitoring tool able to characterize adverse events (AEs) for organizational learning, within the context of limited resources. METHODS: Baylor Health Care System (BHCS) expanded the AE data collected to include judgments of preventability, presence on admission, relation to care provided or not provided, and narrative descriptions. To reduce costs, we focused on patients with length of stay (LOS) of 3 days or more, suspecting greater likelihood they had experienced an AE; adapted the sample size and frequency of review; and used a single nurse reviewer followed by quality assurance review within the Office of Patient Safety. We compared AE rates in patients with LOS of less than 3 days versus 3 days or greater, assessed trigger yields and interrater reliability, and submitted identified AEs to each hospital for validation as event types targeted for reduction. RESULTS: In 2008, 91% of identified AEs were in patients with LOS of 3 days or greater; there were 6.4 AEs per 100 discharges with LOS of less than 3 days versus 27.1 AEs per 100 discharges with LOS of 3 days or greater. Over 4 years, we reviewed 16,172 medical records; 14,184 had positive triggers, 17.1% of which were associated with an AE. Most AEs were identified via the "surgical" (36.3%) and "patient care" (36.0%) trigger modules. Reviewers showed fair to good agreement (κ = 0.62), and hospital clinical leaders strongly agreed that the identified events were AEs. CONCLUSIONS: The GTT can be adapted to health-care organizations' goals and resource limitations. This flexibility was essential in crossing our organization's "value threshold."

Implementing SBAR across a large multihospital health system.

BACKGROUND: Communication problems among health care personnel during critical clinical situations can jeopardize patient safety. SBAR, a structured-communication technique, has been adapted from aviation and the military as a strategy for clear communication based on a statement of the situation, background, assessment, and recommendations related to a critical issue. Nurses' use of SBAR and physician perception of communication quality after SBAR implementation was assessed at a 13-hospital health care system. METHODS: Baylor Health Care System initiated a campaign to implement SBAR and train staff in SBAR techniques across its hospitals. Nurse surveys and physician audits were conducted. FINDINGS: Of 156 nurses interviewed, 152 (97.4%) had been educated about SBAR, and 91 (58.3%) used SBAR for critical communication. Of 84 nurses whose proficiency with SBAR was assessed, 72.6% demonstrated good or high proficiency. Of the 155 physicians who responded to the physician survey, 121 (78.1%) said that the last report they received was adequate to make clinical decisions. Of the 27 who indicated that the last report was not adequate to make clinical decisions, 25 (92.6%) had not received the report in SBAR format. CONCLUSIONS: SBAR was generally well understood. Challenges included inconsistent uptake across facilities, lack of physician education about SBAR, and a tendency to view SBAR as a document rather than a verbal technique. Future research will address the need for refresher education with nurses after initial SBAR education, the need for formal physician education about SBAR use, and the possibility of conducting annual competency validation of the utilization of SBAR. Research should also examine the effect of SBAR on quality of care and patient outcomes in controlled trials.

Journey to no preventable risk: the Baylor Health Care System patient safety experience.

The patient safety vision at Baylor Health Care System (BHCS) has 3 components: (1) achieving no preventable deaths, (2) ensuring no preventable injuries, and (3) seeking no preventable risk. These goals require strategic efforts in the categories of culture, processes, and technology. Culture focuses on tactics such as teamwork training and quality improvement education. Processes are measured using the percentage adoption of a variety of target clinical processes such as order set use and adherence to National Patient Safety Goals. Technology includes focus areas such as clinical decision support and reliability of the electronic health record. BHCS has also achieved significant systemwide standardization of safety processes and development of the systemwide Office of Patient Safety to facilitate the implementation of evidence-based patient safety practices. Associated with these improvements, BHCS has made significant progress toward reducing hospital-standardized mortality rates and rates of hospital-acquired adverse events.