Chapter 8. What's Next? Action Planning for Improvement
2008 Comparative Database Report
After the initial release of the Hospital Survey on Patient Safety Culture in November of 2004, AHRQ held a series of national conference calls to provide technical assistance and guidance to hospitals interested in administering the survey. The seven steps of action planning outlined in this chapter are primarily based on the third conference call presentation by an organizational psychologist (Church, 2005; available on the AHRQ web site at (www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/index.html), and based on the book “Designing and Using Organizational Surveys: A Seven-Step Process” (Church & Waclawski, 1998).
Seven Steps of Action Planning
While administering the Hospital Survey on Patient Safety Culture can be considered an “intervention”—a means of educating hospital staff and building awareness about issues of concern related to patient safety—this should not be the only goal of conducting the survey. Administering the survey is not enough. Keep in mind that the delivery of survey results is not the end point in the survey process, it is actually just the beginning. It is often the case that the perceived failure of surveys as a means for creating lasting change is actually due to faulty or nonexistent action planning or survey follow-up. Seven steps of action planning are provided to help your hospital go beyond simply conducting a survey to realizing patient safety culture change.
Step No.1: Understand Your Survey Results
It is important to review the survey results and interpret them before you develop action plans. Develop an understanding of your hospital's key strengths and areas for improvement. Examine your hospital's overall percent positive scores on the patient safety culture composites and items:
- Which areas were most and least positive?
- How do your hospital's results compare to the results from the database hospitals?
Next, consider examining your survey data broken down by work area/unit or staff position.
- Are there different areas for improvement for different hospital units?
- Are there different areas for improvement for different hospital staff?
- Do any patterns emerge?
- How do your hospital's results for these breakouts compare to the results from the database hospitals?
Finally, if your hospital administered the survey more than once, compare your most recent results to your previous results to examine change over time.
- Did your hospital have an increase in its scores on any of the survey composites or items?
- Did your hospital have a decrease in its scores?
- When you consider the types of patient safety actions that your hospital implemented between each survey administration, do you notice improvements in those areas?
After reviewing the survey results carefully, identify two to three areas for improvement at the hospital level. While your hospital may want to improve in almost all areas, it is better to avoid focusing on too many issues at one time.
Step No. 2: Communicate and Discuss the Survey Results
Common complaints among survey respondents are that they never get any feedback about survey results and have no idea whether anything ever happens as a result of a survey. It is therefore important to thank your staff for taking the time to complete the survey and let them know that you value their input. Sharing results from the survey throughout the hospital shows your commitment to the survey and improvement process.
Use survey feedback as an impetus for change. Feedback can be provided at the hospital level and/or at the department or unit level. However, to ensure respondent anonymity/ confidentiality, it is important to only report data if there are enough respondents in a particular category or group. One common rule-of-thumb recommends not reporting data if there are fewer than 10 respondents in a category. For example, if there are only 4 respondents from a department, that department's data should not be reported separately because there are too few respondents to provide complete assurance of anonymity/confidentiality.
Summaries of the survey results should be distributed throughout the hospital in a top-down manner beginning with senior management, administrators, medical and senior leaders, and committees, followed by department or unit managers and then staff. Managers at all levels should be expected to carefully review the findings. Summarize key findings, but also encourage discussion about the results throughout the hospital. What do others see in the data and how do they interpret the results?
In some cases, it may not be completely clear why an area of patient safety culture was particularly low. Keep in mind that surveys are only one way of examining culture, so strive for a deeper understanding when needed, by conducting follow-up activities such as focus groups or interviews with staff to find out more about an issue, why it is problematic, and how it can be improved.
Step No. 3: Develop Focused Action Plans
Once areas for patient safety culture improvement have been identified, formal, written action plans need to be developed to ensure progress toward change. Hospital-wide and department- or unit-based action plans can be developed. Major goals can be established as hospital-wide action plans. Unit-specific goals can be fostered by encouraging and empoweringstaff to develop action plans at the unit level.
Encourage action plans that are “SMART”:
Identify funding or other resources needed to implement action plans. It is also important to identify quantitative and qualitative measures that can be used to evaluate progress and the impact of changes implemented.
Step No. 4: Communicate Action Plans and Deliverables
Once action plans have been developed, the plans, deliverables and expected outcomes of the plans need to be communicated. Those directly involved or affected will need to know their roles, responsibilities, and the time frame for implementation. Action plans and goals should also be shared widely so that their transparency encourages further accountability and demonstrates the hospital-wide commitments being made in response to the survey results.
At this step it is important for senior hospital managers and leaders to understand that they are the primary owners of the change process and that success depends on their full commitment and support. Senior-level commitment to taking action must be strong; without buy-in from the top, including medical leadership, improvement efforts are likely to fail.
Step No. 5: Implement Action Plans
Implementing action plans is one of the hardest steps. Taking action requires the provision of necessary resources and support. It requires tracking quantitative and qualitative measures of progress and success that have already been identified. It requires publicly recognizing those individuals and units that take action to drive improvement. And it requires adjustments along the way.
This step is critical to realizing patient safety culture improvement. While communicating the survey results is important, taking action makes the real difference. However, as the Institute for Healthcare Improvement (IHI, 2006) suggests, actions do not have to be major, permanent changes that are enacted. In fact, it is worthwhile to strive to implement easier, smaller changes that are likely to have a positive impact rather than big changes with unknown probability of success.
The “Plan-Do-Study-Act” cycle (Langley, et al, 1996) is a pilot-study approach to change that involves first developing a small-scale plan to test a proposed change (Plan), carrying out the plan (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the plan (Act). Implementation of action plans can occur on a small scale, within a single unit, to examine impact and refine plans before rolling out the changes on a larger scale to other units or hospitals.
Actions taken by the 2008 trending hospitals. Eighty-five of the 98 trending hospitals (that administered the patient safety culture survey and submitted data twice) provided basic information about the types of patient safety actions they had taken in between their previous and most recent survey administrations.
Most of the trending hospitals (76 hospitals or 89 percent) reported that they had shared their previous survey results with hospital administrators. In addition, 79 percent (67 hospitals) reported they had also shared their previous survey results with hospital staff, but fewer had shared the results with their Board of Directors (53 hospitals or 62 percent) or with physicians (46 hospitals or 54 percent). Table 8-1 shows the percentages of trending hospitals that reported they had implemented various types of actions. The action most frequently taken was conducting training (54 hospitals or 64 percent). About 13 percent (11 hospitals) indicated they had developed action plans but had not implemented them yet.
Most of the trending hospitals (79 or 93 percent) indicated they had implemented more than one action. Hospitals described the types of “other” actions implemented, such as: yearly patient safety fairs; handoff communication tools and policies; electronic medical record; “just culture” training; patient safety bulletin boards, newsletters, and handouts; medication error reduction strategies; root cause analyses; and many other actions. Given that the average length of time between survey administrations was 14 months, it appears that the trending hospitals were able to begin implementation of these activities within a relatively short period of time after their previous survey administration.
Step No. 6: Track Progress and Evaluate Impact
Use quantitative and qualitative measures to review progress and evaluate whether a specific change actually leads to improvement. Ensure that there is timely communication of progress toward action plans on a regular basis. If you determine that a change has worked, communicate that success to staff by telling them what was changed, and that it was done in response to the safety culture survey results. Be sure to make the connection to the survey so that the next time the survey is administered, staff will know that it will be worthwhile to participate again because actions were taken based on the prior survey's results. Alternatively, your evaluation may discover that a change is not working as expected or has failed to reach its goals and will need to be modified or replaced by another approach. Before dropping the effort completely, try to determine why it failed and whether adjustments might be worth trying.
Keep in mind that it is important not to reassess culture too frequently because lasting culture change will be slow and may take years. Frequent assessments of culture are likely to find temporary shifts or improvements that may come back down to baseline levels in the longer term if changes are not sustained. When planning to reassess culture, it is also very important to obtain high survey response rates. Otherwise, it will not be clear whether changes in survey results over time are due to true changes in attitudes, or due to the fact that you may be surveying different staff each time.
Step No. 7: Share What Works
In step six, you tracked measures to be able to identify which changes result in improvement. Once your hospital has found effective ways to address a particular area, the changes can be implemented on a broader scale to other departments within the hospital and to other hospitals. Be sure to share your successes with outside hospitals and heath care systems as well.
Church AH. The Importance of Taking Action, Not Just Sharing Survey Feedback. Powerpoint® presentation for the Third Technical Assistance Conference Call: Hospital Survey on Patient Safety Culture. www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/index.html.. April 2005.
Hospital Survey on Patient Safety Culture. Rockville, MD: Agency for Healthcare Research and Quality www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/index.html, 2004