Monday, September 2, 2013

Hospital Safety and Teamwork Survey by Marty Makary, MD.

Based on my experience seeing doctors handle dozens of medical conditions, I became convinced that teamwork is a marker of good medical care.  Later, as a health policy researcher, I was eager to measure the phenomena. I called Dr. Bryan Sexton, a teamwork guru and author of a widely used survey showing a strong correlation between airplane-crew teamwork and pilot errors. A Ph.D. in social psychology, Dr. Sexton joined Johns Hopkins shortly after applying his survey to improve safety at Continental Airlines.

Our group brainstormed how to use Dr. Sexton’s methods to measure medical quality and detect bad outliers, i.e. hospitals littered with “danger zones.” We noted a striking similarities between airline cockpits and medical-procedure rooms: both high-stakes environments with a formal hierarchy. Confidentiality was key to eliciting honest responses about workplace culture and safety for both airplane-pilot crews and health care workers.

Dr. Sexton tailored the health care survey questions to specific departments (or clinical areas) within the hospital:

Is the teamwork good?
Would you feel comfortable having your own care performed in the unit in which you work?
Do people work as a coordinated team?
Do doctors and nurses do what’s in the best interest of the patient?
Is communication strong?
Do you feel comfortable speaking up when you have a safety concern?

We set rules for the survey: At least 70 percent of hospital employees must complete it for the results to be statistically accurate, and obviously it must be anonymous so as to elicit honest answers. Based on employee responses, each hospital gets a teamwork score both for the hospital as a whole and for its individual departments and units. The above and other critical questions are used to calculate (on a scale of 0 -100) a Teamwork Culture Score, an Overall Safety Culture Score for a hospital and a score for specific units within the hospital.

We began working on a study now known as the Hopkins Safety Culture Study.  Sixty reputable U.S. hospitals administered the survey to all their employees. We found that safety culture among those sixty hospitals varied enormously. Subsequent studies revealed that teamwork culture could also vary dramatically within a hospital (i.e., one hospital; could have a perfect teamwork culture in surgery and an awful teamwork culture in ob-gyn.

The survey allowed us to measure then insider’s perspective.  It used the “word on the ground” principle for failing businesses: ask executives about the quality of service, and you’ll get one answer; ask the workers on the ground, and you’ll get the real answer.

Thanks to Dr. Sexton, we now had a clear-cut, scientifically valid way to measure hospital quality and safety from frontline providers themselves – the insider’s perspective,. Our research team asked the sixty participating hospitals if they would let s publish the results in the interests of research.  They agreed, on condition that the individual hospital names would be kept anonymous.

We found hospital’s where fewer than 20 percent of their employees reported good teamwork. At one third of the hospitals a majority of employees believed the teamwork was bad. Some hospitals had and impressive 99 percent of their staff reporting that their hospital had good teamwork.

 Not surprisingly survey results correlated to infection rates and patient outcomes. The rate of preventable medical mistakes by doctors  grows as employee teamwork and safety scores decline.

When hospitals make decisions not to staff their intensive care units with an ICU doctor on nights and weekends, that is a “danger zone” that the safety survey readily detects. Similarly, when doctors refuse to use a checklist before doing procedures, the survey yields a low safety-culture score among staff.

While hundreds of U.S. Hospitals now use the survey, all do so under the conditions that results remain top secret, used only for internal reviewing by the government and hospital administrators. Transparency would bring on a shakeout, hospitals that ranked low on safety teamwork and safety culture would quickly address their problems.

The teamwork-safety survey is a powerful tool, but it’s not the only one. To assess the quality of medical care, you should be able to look up the hospital’s infection rate, the number of cases treated there and its patient outcomes, not to mention the comparative costs of similar procedures at different hospitals.  More data transparency, the accountability it delivers, has the capacity to revolutionize the quality of medical care in every city in America, dramatically reshaping our healthcare landscape.

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