SLIDE 1 T he Cultur e of Safe ty and L e ade r ship Style in L
T e r m Car e F ac ilitie s
Sa id Ab usa le m, PhD, RN T imo thy Cra wfo rd, PhD, MPH Ba rb a ra Po livka , PhD, RN
SLIDE 2
his study wa s suppo rte d b y the Unive rsity o f L
I nte rna l Re se a rc h a nd ST T I Gra nts.
he re se a rc h te a m wo uld like to tha nk a ll a no nymo us pa rtic ipa nts a nd pe rso ns who he lpe d c o nduc t this study:
Vic kie T e nc e r Chris Ha nno n Je ssic a Jo ne s
Ac knowle dgme nts
SLIDE 3 Cultur e of Safe ty
Building a pe rso n-c e nte re d c ulture o f sa fe ty is a c o re e le me nt in
impro ving re side nt sa fe ty a nd c a re q ua lity in L T CF s.
An e ffe c tive c ulture o f sa fe ty a ffe c ts re side nts’ c a re e xpe rie nc e s
a s we ll a s he a lthc a re wo rke rs’ mo tiva tio n, c o mmitme nt, pro duc tivity, a nd e ffe c tive ne ss.
T
e a mwo rk, a ppro pria te sta ffing ra te a nd mix, no n-punitive re spo nse s to mista ke s, a nd e ffe c tive c o mmunic a tio n a nd le a de rship a re a ll pa rt o f a n e ffe c tive c ulture o f sa fe ty.
Cre a ting he a lthy e nviro nme nts tha t c o ntrib ute to pro mo ting
- ptima l re side nt a nd sta ff o utc o me s re q uire s o rg a niza tio na l
syste ms tha t e mpha size b uilding he a lthy c ulture s o f sa fe ty.
SLIDE 4
Cultur e of Safe ty- Continue d
I
n c o ntra st, to xic wo rkpla c e c ulture s ha ve se rio us c o nse q ue nc e s fo r re side nt o utc o me s a nd sta ff we ll-b e ing . Hig h le ve ls o f sic k le a ve , po o r sta ff re te ntio n, a nd psyc ho lo g ic a l ill he a lth o f e mplo ye e s a re pre va le nt in to xic wo rkpla c e e nviro nme nts.
SLIDE 5
Adve r se E ve nts in L T CF
Ove r 1.63 millio n Ame ric a ns re side in 18,000 L
T CF s.
Se ve ra l studie s ha ve re po rte d hig he r ra te s o f a dve rse e ve nts in
L T CF s.
Adve rse e ve nts in L
T CF s a re ma inly fa lls a nd pre ssure ulc e rs. T he pre va le nc e o f pre ssure ulc e rs in L T CF s ra ng e s fro m 6% to 25%, de pe nding o n fa c to rs suc h a s sta ff mix, o rg a niza tio na l c o mmitme nt, a nd e nfo rc ing e vide nc e -b a se d g uide line s.
L
T CF re side nts fa ll a t a n a nnua l ra te o f 1.7 pe r b e d, with 10% to 25% susta ining se rio us injurie s e ve ntua lly le a ding to de a th. T he re la tio nship b e twe e n a dve rse e ve nts a nd a c ulture o f sa fe ty in L T CF s ha s no t ye t b e e n a de q ua te ly e xplo re d.
SLIDE 6 L
- we r a dve rse e ve nts a nd lo we r mo rta lity ra te s ha ve b e e n
a ttrib ute d to a n a ppro pria te RN ra tio in he a lthc a re o rg a niza tio ns.
Altho ug h re se a rc he rs ha ve re c o mme nde d impro ve d
c o mmunic a tio n a mo ng L T CF sta ff a s a me tho d o f re duc ing a dve rse e ve nts, limite d re se a rc h is a va ila b le in this a re a .
I
t is c ruc ia l in the c urre nt c ha ng ing he a lth c a re e nviro nme nt to ide ntify o rg a niza tio na l fa c to rs tha t a ffe c t a dve rse e ve nts a nd re side nts’ sa fe ty c ulture in L T CF s.
Adve r se E ve nts in L T CF
SLIDE 7
L e a de rship in L T CF
Curre nt e vide nc e sug g e sts re la tio nships b e twe e n po sitive
le a de rship style s a nd hig he r pa tie nt sa tisfa c tio n a nd lo we r pa tie nt mo rta lity, me dic a tio n e rro rs, re stra int use a nd ho spita l- a c q uire d infe c tio ns.
I
n a syste ma tic L ite ra ture re vie w Cumming s e t a l. (2010) fo und tha t 24 studie s re po rte d tha t le a de rship style s fo c use d o n pe o ple a nd re la tio nships (tra nsfo rma tio na l, re so na nt, suppo rtive , a nd c o nside ra tio n) we re a sso c ia te d with hig he r nurse jo b sa tisfa c tio n.
T
he re is la c k o f kno wle dg e o f po sitive le a de rship in pro c e sse s e nha nc ing pe rso n-c e nte re d c ulture o f c a re in nursing ho me s.
SLIDE 8
Study Purpo se
Asse ss c ulture o f sa fe ty, le a de rship style a nd its
re la tio nships with o rg a niza tio na l fa c to rs in L T CF s a nd se le c te d a dve rse e ve nts a s fa lls a nd UT I s.
SLIDE 9
Study Aims
1. I
de ntify o rg a niza tio na l fa c to rs a sso c ia te d with: (a )c ulture o f sa fe ty, (b ) le a de rship style sc o re s, a nd (c ) se le c te d a dve rse e ve nts.
2. E
va lua te the re la tio nships o f c ulture o f sa fe ty, le a de rship style with: (a ) sta ff turno ve r ra te s, (b ) sta ffing le ve ls, a nd (c ) c o mmunic a tio n pe rfo rma nc e .
SLIDE 10 Study De sign and Se tting
T
his study use d b o th a c ro ss-se c tio na l surve y de sig n a nd se c o nda ry a na lysis
Using sta nda rdize d re lia b le a nd va lid instrume nts, he a lthc a re sta ff, inc luding
nursing supe rviso rs a nd a dministra to rs, RNs, lic e nse d pra c tic a l nurse s (L PNs), a nd nursing a ssista nts (NAs) in pa rtic ipa ting L T CF s we re surve ye d.
Administra to rs o f a stra tifie d ra ndo m sa mple , 5 o ut o f the 70 e lig ib le L
T CF s c o nta c te d a g re e d to pa rtic ipa te a nd pro vide d pe rmissio n fo r the ir fa c ility to pa rtic ipa te .
Se c o nda ry a na lysis o f e xisting da ta fro m the Nursing Ho me Co mpa re
We b site wa s c o nduc te d.
Nursing Home Compa re we b site ha s info rma tio n a b o ut the q ua lity o f c a re , a dve rse
e ve nts, a nd sta ffing ra tio s pro vide d b y Me dic a re o r Me dic a id fo r c e rtifie d nursing
home s thro ug ho ut the na tio n.
SLIDE 11
Sample
L
imiting the sa mple to o nly Me dic a id-c e rtifie d L T CF s e nsure d a ho mo g e no us sa mple with simila r o rg a niza tio na l c ha ra c te ristic s a nd re q uire me nts.
A sa mple o f L
T CF s wa s re c ruite d a nd e nro lle d (N = 5).
I
nc lusio n c rite ria fo r surve y pa rtic ipa nts we re E ng lish spe a king a nd c urre nt re side nt c a re e mplo ye e s suc h a s nursing supe rviso rs, RNs, L PNs, NAs, SWs, PT s, a nd OT s.
SLIDE 12 Pr
e
T
ra ine d re se a rc h sta ff visite d the fa c ility during a sc he dule d sta ff me e ting to e xpla in the study a nd re q ue st pa rtic ipa tio n.
T
he surve y pa c ke t, inc luding a pre a mb le le tte r de sc rib ing the study, the surve y, a nd a n e nve lo pe we re distrib ute d to a ll re side nt c a re e mplo ye e s o n e ve ry shift.
Re fre shme nts we re pro vide d to sta ff to impro ve the re spo nse ra te . Re minde r flye rs we re po ste d in a re a s suc h a s sta ff b re a k ro o ms a nd
lo c ke r ro o ms fo r o ne mo nth fo llo wing the sta ff me e ting .
Da ta we re c o lle c te d a no nymo usly, pa rtic ipa nts we re pro vide d with
a n e nve lo pe to re turn the ir c o mple te d surve y in a study ma il b o x.
SLIDE 13 Me asur e s
Re side nt safe ty c ultur
e . T
he Nursing Ho me Surve y o n pe rso n- c e nte re d c ulture o f sa fe ty wa s de ve lo pe d b y AHRQ (2008). Re po rte d Cro nb a c h’ s a lpha s ra ng e d fro m .63 to .84. T he NHSPSC ha s 42 ite ms tha t me a sure 12 c o mpo site s:
T e a mwo rk -4 ite ms Sta ffing - 4 ite ms Co mplia nc e With Pro c e dure s-3 ite ms T ra ining & Skills- 3 ite ms No npunitive Re spo nse to Mista ke s- 4 ite ms Supe rviso r E xpe c ta tio ns & Ac tio ns Pro mo ting Re side nt Sa fe ty- 3 ite ms Ha ndo ffs- 4 ite ms F e e db a c k & Co mmunic a tio n Ab o ut I nc ide nts- 4 ite ms Co mmunic a tio n Ope nne ss- 3 ite ms Ove ra ll Pe rc e ptio ns o f Re side nt Sa fe ty – 3 ite ms Ma na g e me nt Suppo rt fo r Re side nt Sa fe ty – 3 ite ms Org a niza tio na l L e a rning - 4 ite ms
SLIDE 14 ML Q L e a de rship Sc a le s
Sc a le Ite ms Ide a lize d Influe nc e
1, 8, 15
Inspira tiona l Motiva tion
2, 9, 16
Inte lle c tua l Stimula tion
3, 10, 17
Individua lize d Conside ra tion
4, 11, 18
Conting e nt Re wa rd
5, 12, 19
Ma na g e me nt- by- e xc e ption
6, 13, 20
L a isse z- fa ire L e a de rship
7, 14, 21
Sc ore Ra ng e : Hig h = 9- 12, Mode ra te = 5- 8, L
SLIDE 15
F indings
T
he 211 re spo nde nts we re : lic e nse d nurse s (27%), nursing a ssista nts (35%), a dministra to rs/ ma na g e rs (8%), a dministra tive suppo rt (3%), a nd re ha b ilita tio n sta ff (13%).
Nine ty-e ig ht pa rtic ipa nts (46%) wo rke d o ve rtime . T
he ma jo rity o f pa rtic ipa nts we re ne utra l (ne ithe r a g re e d no r disa g re e d) with re g a rd to sta te me nts c o nc e rning c o mplia nc e with pro c e dure s, a de q ua te sta ffing le ve ls, a nd no n-punitive re spo nse s to e rro rs.
SLIDE 16
F inding s- Co ntinue d
Hig he st me a n sc o re s we re fe e db a c k a nd c o mmunic a tio n a b o ut
inc ide nts with a me a n o f 4.35 (SD = 0.71), me a n supe rviso r e xpe c ta tio ns a nd a c tio ns pro mo ting re side nt sa fe ty 4.03 (SD = 0.89), a nd me a n sc o re o f o ve ra ll pe rc e ptio ns o f re side nt sa fe ty 4.24 (SD = 0.68). (A sc o re o f 4 = a g re e a nd 5 = stro ng ly a g re e ).
A Spe a rma n's ra nk-o rde r c o rre la tio n wa s run to de te rmine the
re la tio nship b e twe e n ra te o f fa lls a nd ha ndo ffs re po rts. T he re wa s a ne g a tive c o rre la tio n b e twe e n ha ndo ffs re po rt a nd ra te o f fa lls rs = -0.247, p<0.0001, a nd the re wa s a ne g a tive re la tio nship b e twe e n ha ndo ffs a nd ra te o f UT I s rs = - 0.143, p<0.05.
SLIDE 17
F inding s- Co ntinue d
Risk fo r fa lls inc re a se d a s the numb e r o f re side nts pe r fa c ility
inc re a se d [Ra te Ra tio (RR) = 1.02 (95% Co nfide nc e I nte rva l (CI ) = 1.01 -1.02)] a nd a s the numb e r o f L PN ho urs pe r re side nt inc re a se d [RR = 37.7 (18.5 – 76.5)].
As the numb e r o f lic e nse d RN plus L
PN sta ff ho urs pe r re side nt pe r da y inc re a se d, ra te o f fa lls de c re a se d 79% [RR = 0.21 (95% CI = 0.13 – 0.34)].
As the c ulture o f sa fe ty sc o re s inc re a se d, the risk o f fa ll de c re a se d
26% [RR = 0.74 (95% CI = 0.67 -0.82)], UT I s de c re a se d 20% [RR = 0.80 (95% CI = 0.75 - 0.86)], a nd sho rt-sta y ulc e rs de c re a se d 7% [RR = 0.93 (95% CI = 0.90 – 0.97)].
SLIDE 18 Ge ne r alizing E stimating E quations (Poisson Distr ibution) to Pr e dic t Rate of Car e E r r
Rate s
F a lls Urina ry T ra c t Infe c tions Short- Sta y Ulc e r s
RR (95% CI ) RR (95% CI ) RR (95% CI )
Numbe r of Re side nts
1.02 (1.01 – 1.02) 1.01 (1.01 – 1.01) 0.98 (0.98 – 0.98)
Numbe r of L ic e nse d Nurse Sta ff Hours pe r Re side nt Da y
0.21 (0.13 – 0.34) 0.21(0.15 – 0.31)
- RN Hours Pe r Re side nt Da y
- 0.12 (0.09 – 0.15)
Physic a l the ra py sta ff hours
L PN/ L VN Hours pe r Re side nt Da y
37.7 (18.5 – 76.5) 61.5 (36.6 – 102.4)
0.74 (0.67 – 0.82) 0.80 (0.75 – 0.86) 0.93 (0.90 – 0.97)
RR = Ra te Ra tio CI = Confide nc e Inte rva l Note : Va ria ble s with a no informa tion we re not inc lude d in the re spe c tive mode ls.
SLIDE 19
SLIDE 20
Conc lusions
T
he finding s sug g e st tha t the re is a ne e d to b uild a stro ng c ulture o f sa fe ty to impro ve L T CF e mplo ye e re te ntio n a nd fo ste r PCCS a ttrib ute s.
With the sho rta g e o f RNs in L
T CF s a nd ne w re imb urse me nt re g ula tio ns, ma ny L T CF s a re hiring L PNs to ha ve full sta ffing a nd sa ve mo ne y. L PNs ma y la c k e sse ntia l le a de rship kno wle dg e to de c re a se the ra te o f pre ssure ulc e rs.
One o ptio n is to de ve lo p a Pe rso n-Ce nte re d Co mpre he nsive
Unit-b a se d Sa fe ty Pro g ra m (CUSP) fo r L T CF s simila r to the AHRQ
