Executive Summary
The participants in the pilot study of the AHRQ Ambulatory Surgery Survey on Patient Safety Culture were able to compare themselves with peers and find areas for improvement.
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The area showing the most room for improvement was “Staffing, Work Pressure and Pace.” This area measures the extent to which staff members don’t feel rushed, whether they have enough time to properly prepare for procedures, and whether there are enough staff members to handle the workload.
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Changes were made by participating centers to address staff concerns about better communication, staffing, training, and speaking up.
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The survey tools are available for any surgery center to use. AHRQ also offers a Hospital Survey on Patient Safety Culture and one on Medical Office Survey on Patient Safety Culture.
Are you looking for ideas to improve your facility’s patient safety culture? Would you like to compare your safety culture to that of other ambulatory surgery centers (ASCs)? Your wishes are granted, thanks to the recent pilot study involving the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture. The pilot study was held to refine the survey and share the results with ambulatory surgery centers.
The pilot study results were presented recently by the Agency for Healthcare Research and Quality and pilot study participants in a webinar.1 In 2014, more than 1,800 staff in 59 ASCs participated in the pilot test of the survey. The survey participants included a wide range of ASCs. A quarter of the ASCs were hospital-affiliated. Seventeen percent of ASCs were considered single specialty or nonsurgical centers, with areas such as ophthalmology, dermatology, or pain management. Forty-three percent had three or fewer OR/procedure rooms; 15% had seven or more.
The survey was developed for everyone working in the ASC, including full- and part-time employees, per diem employees, contract staff members, and doctors who worked at least four times a month at the ASC and who also had been working at the ASC for at least six months. Respondents also included nurses, certified registered nurse anesthetists, physician assistants, nurse practitioners, technicians, and management, administrative, clerical, and business staff.
Based on survey results, the area showing the most room for improvement was “Staffing, Work Pressure and Pace,” which measures whether staff members feel rushed, don’t have enough time to properly prepare for procedures, and don’t have enough staff members to handle the workload. Specifically, when staff were asked whether they felt pressure to do tasks that they hadn’t been trained to do, 72% answered positively. When asked if they felt rushed when taking care of patients, 58% responded positively. (To see all the areas that were surveyed, go to http://1.usa.gov/1haAK75.)
Participants in the pilot test have taken the results and responded with changes. Two facilities shared the following changes:
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They assigned recovery nurses to specific rooms to improve communication between physicians and staff.
The first area Idaho Endoscopy Center in Boise, ID, addressed was “Communication Openness,” in which their result was 73% positive versus 85% for all of the pilot ASCs. “…[W]e found that lack of effective communication was the reoccurring concern expressed by staff,” said Erin Brown, RN, director of nursing services at the Center and at Digestive Health Clinic in Boise.
Based on this information, the facility assigned recovery nurses to specific rooms each day to help improve face-to-face communication with physicians, facilitate continuity of care, and validate staff concerns. Previously, nurses rotated as needed and were not assigned to specific recovery rooms, Brown said. With the new system, “[t]he nurse can then discuss intraop concerns, plan of care, and have an open discussion regarding patient issues with the provider,” she said. “And an example of an intraop concern would be if the recovery nurse has a question regarding the patient’s response to sedation, it can be addressed with the physician at this time, thus validating the nurse’s concerns.”
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They trained certified medical assistants to remove patient IVs prior to discharge.
Brown’s center also focused on “Staffing, Work Pressure and Pace,” for which their result was 55% positive versus 76% for all ASCs in the pilot study. The facility was going through a staffing transition, and staff members thought the facility didn’t have enough nursing staff to handle the workload. “Staff also felt rushed when taking care of patients,” Brown said. “And nurses felt there were areas where certified medical assistants could help more, but were not yet trained.”
The center leaders trained the certified medical assistants to remove patient IVs prior to discharge, especially when there was a shortage of nursing staff. “And this task is within the CMA’s scope of practice,” Brown said.
The medical assistants enjoyed learning a new skill and taking on a new task, she said. “Furthermore, the team dynamic with this change contributes to the overall balance of patient flow and solidifies the importance of patient safety,” Brown said.
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They added ongoing staff training and additional drills.
In the “Response to Mistakes” area, Brown’s center scored 78% positive versus 82% for the pilot study ASCs. Breaking down the result “showed areas for improvement related to ‘Staff Training/Response to Mistakes’ as a learning opportunity instead of blame, and enhancing communication between staff members when patient safety problems occur,” Brown said.
The center added ongoing staff training and additional drills to develop staff confidence in performing tasks, she said. “Additional drills included more disaster drills, event of patient transfer, and more incapacitated provider drills,” Brown said. “In regard to staff training, we covered areas of IV insertion, conscious sedation, scope reprocessing, and overall infection control. Training is also reinforced in our monthly company newsletter that is distributed to all staff.”
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They implemented a new surgical procedure checklist.
The survey process indicated that 40% of the staff at Underwood Surgery Center in Orlando, FL, didn’t feel comfortable speaking up.
“[I]f you don’t feel like the doctor is encouraging you to speak up, then that is definitely a problem,” said Terry Tinsley, RN, clinical nurse manager. Physicians were surprised that the employees felt somewhat intimidated, Tinsley said, “and it does start with the doctor in the room, with a culture of feeling safe to speak up.”
A new surgical procedure checklist has everyone involved with the case say his or her name at the beginning of the procedure. Sometimes there are vendor representatives in the room or X-ray technicians whom everyone doesn’t know, Tinsley pointed out, but “even if you know the people for a long time, it just helps to open your mouth and get a good feeling of being able to speak up.”
The process also includes having the physician say, “Is there anyone who has any safety issues?” Also, signs in the rooms remind staff members to speak up, especially if they need to voice a concern, Tinsley said. “It’s important that all staff feels a freedom and encouragement to speak up during the procedure,” she said.
The medical director has become a champion of this effort and meets with the other physician partners quarterly, Tinsley said. The director explains to the physicians that staff members might feel intimidated and that physicians need to say out loud that staff members can speak up, Tinsley said.
“It’s a work in progress, but we are doing much better than we have before,” she said.
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They give treats to staff.
Staff members are rewarded when they share a safety concern, such as an expired medication, or when they share an idea, Tinsley said. Treats have included candy, movie tickets, and candles.
“[W]e just want to encourage them to bring it to us and to share their ideas, because it’s very important that everyone feels a part of making this a very safe environment for our patients,” Tinsley said.
1. Agency for Healthcare Research and Quality. Introducing the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture. July 15, 2015. Accessed at http://bit.ly/1IOrXUF.
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Agency for Healthcare Research and Quality. Patient safety resources including tools and training. Web: http://1.usa.gov/1eQ7MI1.
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ASC Survey on Patient Safety Culture web site. Download the survey, the user’s guide, and the pilot study results. The results provide breakouts by multispecialty versus single specialty, not hospital-affiliated versus hospital-affiliated, number of surgery/procedure rooms, and staff positions. A Data Entry and Analysis Tool is an Excel file that has tabs and macros. This tool helps to administer the survey on paper, because it allows the center to take respondent data and put it into the tool. It automatically generates charts and statistics of results. Web: http://1.usa.gov/1IGj5dC.
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AHRQ also offers a Hospital Survey on Patient Safety Culture at http://1.usa.gov/1mzyvVQand a Medical Office Survey on Patient Safety Culture at http://1.usa.gov/1Df3PIk.
