Issue 1: Quarter 1
February, 2009
Newsletter
Total Benchmark Solution, LLC’s
(TBS) mission is to provide a
solution to analyze and
benchmark Quality Practices and
Performance that executives,
nurses, physicians, and care
professions can understand and
act upon in order to improve
quality of care. We now provide a
solution to automate your AHRQ
Hospital Survey on Patient Safety
Culture needs.
We strongly encourage
healthcare organizations to make
a commitment to measuring and
benchmarking their quality and
patient safety performance. This
is not a one time organizational
event but an ongoing commit-
ment to providing the best
possible care for the patients an
organization serves. We
encourage organizations to
purchase a subscription to our
solution and implement an
organizational process to use our
solution to improve patient safety
and quality of care.
Contact Us:
For more information or a
demo on our Survey
Solutions contact us by
phone at: (800) 940-0424
or online at:
AHRQ@TOTALBENCHMARKS OLUTION.COM
WWW.TOTALBENCHMARKSOLUTION.COM
Hospital SOP’s:
Tips for Increasing Success:
 Benchmark Internally and Externally
 Evaluate change and track progress over time
 Identify differences within units/departments
 Recognize potential for low response rate and survey “fatigue” given competing surveys, busy
clinical environment; undertake strategies to maximize response rates
 Use Graphs as reasons for actions. Where you score lower than your peers, action needs to be
taken. Use this within departments and units too.
 Use a postcard that users can send in when they take the survey. That way you can still know
who took the survey, but will still be anonymous, and non-respondents can be reminded to
participate.
 Use team training meetings as a “The biggest challenge to moving toward a safer
time to have team members health system is changing the culture from one of
complete the survey blaming individuals for errors to one in which errors
 Hold department managers are treated not as personal failures, but as opportuni-
accountable ties to improve the system and prevent harm.”
 Use a Key Point of Contact
IOM (2001). Crossing the Quality Chasm: A New Health
 Set the stage ahead of time System for the 21st Century, P. 79
 Raise staff awareness
Tips from Trending Hospitals:
 Hospitals witnessed response rates increase: One health system saw their response rate
increase 13% between 2 survey implementations; they thought the reason for the increase was
competition among hospitals and departments as well as overall communication of the survey
and why it was being administered. Another health system saw their response rate increase 20%
the second time then another 25% the next time. They used incentives for departments that
had 100% completion rate.
 One health system does formal on-site visits every 2 years focused on Patient Safety to both
increase awareness, and promote the next round of surveys. They felt this was the main
reason as to why their response rates increased from one year to the next
Additional Information:
 The AHRQ Hospital Survey on Patient Safety Culture meets the new Joint Commission leadership
standard, effective January 2009
 2009 AHRQ Benchmark Data will be available in February 2009, and will include 623
participating hospitals
 AHRQ is considering a potential Version 2.0 of HSOPS with that will have N/A question choices,
better wording of some items, and expanding work areas and staff positions
 Next User Group Meeting will be held in February of 2010
Page 1
 Actions Taken by Trending Hospitals:

"The quality, safety and value of care can be no better

than the structures and processes used by providers in
direct contact with the patient. Culture is a lens
through which organizations support providers at the
point of care." Katherine Jones. PT, PhD University of
Nebraska Medical Center

For more information on the

presentations from the conference,
please go to: http://ugm.tbsahrq.com

Four general themes explaining increases in scores over time:

—Adapted from the Interviews Conducted by Westat:
1) Hospitals improved their communication between management & staff on patient safety
 Senior leaders’ engaged with staff during walkabouts
 Continually focused staff meetings on the importance of patient safety
 Staff invited to participate in biweekly “huddles” to discuss patient safety issues, and other topics

2) Hospitals focused on improving error reporting systems and applying non-punitive/”Just Culture” principles
 Educated hospital leaders on making error reporting anonymous, easy, and convenient
 Implemented electronic reporting system
 Set up a hotline for reporting errors and developed anonymous reporting forms for medical errors
 Trained staff to use the new reporting systems
 Provided training on “Just Culture”
“Our systems are too complex
to expect merely extraordinary
3) Hospitals engaged staff in identifying solutions to patient safety problems people to perform perfectly
 Allocated resources for safety needs identified by staff – for example, buying safer beds 100% of the time. We as
 Directly involved staff in designing successful solutions to handoff problems leaders have a responsibility to
 Started an employee engagement committee that included senior leaders put in place systems to support
 Instituted nursing peer review to promote open communication safe practice.”
 Assigned staff to a scheduling team to accommodate staff preferences James Conway

4) Hospitals developed, implemented, and monitored action plans

 Charged department managers with developing and implementing an annual action plan & held them accountable

5) Other explanations
 Implemented SBAR communication tool for unit-to-unit transfers
 Hired a consultant group to work with department directors on specific patient safety problems
 Addressed staffing requirements – filled nursing vacancies and improved patient/staff ratios

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