What Factors Influence Learning from PSEs Research Team

What Factors Influence Learning from PSEs? Research Team: Liane Ginsburg, You-Ta Chuang Peter Norton, Whitney Berta, Deborah Tregunno, Peggy Ng and Julia Richardson

Learning in Context of Patient Safety n Learning from Patient Safety Events: n n n Identification & reporting of patient safety events Analysis of the causes of these events, and Taking appropriate corrective action to reduce reoccurrence of these events in the future

What we have known from our study Five factors influenced sampled 49 hospitals engaging in learning activities following PSEs n n 1. Types of PSEs 2. Patient safety culture n n n Organizational leadership for patient safety Fear of repercussion 3. Patient safety training 4. Inter-organizational linkages 5. Ease of reporting

1. Types of Patient Safety Events n Major events n n Event analysis Dissemination of analysis and knowledge n Moderate events Minor events Major near misses n Differential learning responses among PSEs n n n Saliency, limited resource capacity

Event Types

Quick comparison

2. Effects of Patient Safety Culture n Organizational leadership for patient safety n n The degree of shared beliefs about senior management’s commitment to improve patient safety and quality of care Example of 7 items: n n Senior management has a clear picture of the risk associated with patient care Fear of repercussion n n A collective perception of potential negative reactions by others to patient safety failure events Example of 4 items: n I will suffer negative consequences if I report a patient safety problem

Organizational leadership for patient safety

Fear of repercussion

3. Effects of Patient Safety Training n n Learning from experience depends upon learning capacity Training is an avenue to improve learning capacity Training has been found to be positively associated with organizational performance Manager’s patient safety training n n n Promote “right” attitude toward patient safety failure Help subordinates deal with patient safety failure Items in the PCM survey n n n Receiving a formal quality/process improvement training program Receiving a formal patient safety training program Attending patient safety conferences

Effects of patient safety training

4. Effects of Interorganizational Linkages n n Inter-organizational linkages facilitate information and experience transfer; as such they help organizations learn from others’ experiences. Item in the PSO survey: n n The linkages tend to be: n n n Please list the hospitals/organizations you frequently engage in discussion or information sharing regarding patient safety Nearby hospitals/Teaching hospitals Professional associations: Ontario Healthcare Risk Management Network, Safer Healthcare Now!, Quality Healthcare Network, Canadian Patient Safety Institute Mean: 3 hospitals/organizations, min=0, max=10

Effects of interorganizational linkages

5. Ease of reporting n n Theoretically, ease of reporting systems should have positive effects on learning responses to PSEs However, the effects are complicated – the effects are influenced by fear of repercussion

Moderate events

Minor events

Summary/Implications n Factors at organizational level influence learning from PSEs n n Organizational leadership, fear of repercussion, training, interorganizational linkages, and ease of report systems These factors greatly influence learning from n n Major event dissemination moderate events, minor events, and near misses To improve patient safety, management may want to consider n Foster patient safety culture, provide training opportunities, and share information with other hospitals

Next Steps Span of control Group diversity Unit leadership Group norms Inter-unit linkage Salience Org size Leadership Safety Culture Inter-organizational networks Unit-Level Factors Perceived PLE Characteristics Organization-Level Factors Inter-organizational. Level Factors Level of response to PLE Unit Organization

Next Step n File out USB keys n Please leave mailing addresses with us n Pilot of unit-level learning n THANK YOU!