PSCIT

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Hospital: Year:

⌈…… Leader Training ……⌉ ⌈……… Workload ………⌉ ⌈… Team Management …⌉ ⌈… Clinical Risk Management …⌉

1.Leaders2.Evaluation3.Workload4.Fatigue5.TRM6.Organizational7.IMS8.Disclosure9.Risk

Evidence:


Main	Erji	Yuansheng	Nanji	Luji	Yunji	Youmin	Ludong	DongJi

Pingji

Table 2. Current Status by Dimension

Maturity Levels
Level		Maturity of Safety Culture
Pathological	0	Why waste our time on safety?
Reactive	1	We do something only when we have an incident
Bureaucratic	2	We have systems in place to manage safety
Proactive	3	We are always on alert for risks
Generative	4	Risk management is an integral part of everything we do

Level of Implementation:
Length of colored bar indicates completeness of design
(percent possible items for that area already
designed and ready to use).
Color of bar indicates extent implemented, e.g.

≤1/3 of staff participate

1/3~2/3 of staff participate

≥2/3 of staff participate

Milestones
2009 Planning, Annual improvement plan approved
2010 Implement plan: current level=[1~2]
2011 Improved to Level [2~3]: continue plan

References
Fleming M, Wentzell N. Patient safety culture improvement tool: development and guidelines for use. Healthcare Quarterly 2008; 11(3 Spec No.): 10~5.
Law MP, Zimmerman R, Baker GR, Smith T. Assessment of safety culture maturity in a hospital setting. Healthcare Quality 2010 13: (Spec No.):110-5.

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Level	Patient Safety Leader Education and Training	Head	Drs	Admn	Coal
0	No patient safety education/training is provided to leaders
1	General information on patient safety is provided to leaders
	…including policies and procedures
	…including how it is measured
2	Leaders receive information about their role in improving patient safety
	… about leadership behaviours that promote patient safety
	… the information is knowledge-based
	… the information is supplied on a non-recurring basis (not regular)
3	Leaders are taught interpersonal competencies to improve patient safety
	… through skill-based training
	… to motivate colleagues to improve patient safety
	… to motivate subordinates to improve patient safety
	… training is recurrent (at least annual)
	… and includes target setting to improve interpersonal skills
4	Leaders receive individual patient safety leadership development
	… the leadership development is mandatory
	… the development is based on upward appraisal and evaluation
	… leaders behavioural change is evaluated
	… the evaluation is ongoing
	… the evaluation is formal
	Column totals (adjusted to max=4.0)

Level	Patient Safety Leader Performance Evaluation	Head	Drs	Admn	Coal
0	Leaders are not evaluated on patient safety
1	Leaders' job description includes promoting patient safety
	… and assessing patient safety
	Leader performance is evaluated following a significant patient safety event (e.g. unexpected death) within their area of responsibility
2	There is a formal system in place to monitor performance
	… performance reviews are conducted for leaders
	… leaders' performance is monitored through regular discussions (of cases and outcomes)
3	Performance is monitored
	… routinely
	… using a variety of techniques
	…… e.g. performance reviews
	…… e.g. retrospective chart reviews
	… input from colleagues is sought
	… results from monitoring are discussed with individual being reviewed
4	Performance is monitored with leading indicators of patient safety
	Observations of practice are conducted
	… observations are systematic
	… observations are ongoing
	The results from performance monitoring are used to develop individual learning plans
	Peers routinely monitor each other's performance
	… and provide constructive feedback for improvement
	Column totals (adjusted to max=4.0)

Level	Workload	Drs	Nrs	RMO	Para
0	No consideration of the impact of workload on patient safety
1	Guidelines for the ratio of healthcare workers to patients are used to manage workload levels
2	Minimum healthcare worker-to-patient ratios are set
	… based on available evidence and best practice
	… these levels are monitored closely
	… and actions taken when minimum standards are not met
3	In addition to evidence-based minimum staffing levels
	… staffing decisions take into consideration client group's needs
	… and the experience and skill mix of the healthcare team
4	There is a holistic approach to workload management that considers all the demands placed on healthcare workers
	… such as the intensity of the work environment (ie the tasks to be performed, number of client interactions)
	… and client acuity
	… and the skill mix of the healthcare team
	… this approach involves providing additional resources for high-intensity situations, where treatment must be provided immediately and when members of the healthcare team are less experienced
	Column totals (adjusted to max=4.0)

Level	Fatigue Management	Drs	Nrs	RMO	Para
0	No consideration of the impact of fatigue on patient safety.
1	Fatigue is acknowledged as a patient safety risk factor.
	Fatigue-management efforts focus on limiting the number of hours worked
	… per shift
	… per week.
2	Strategic plan developed to redesign shift rotations (length and timing) that are increasing fatigue or are contrary to evidence and best practice.
3	Fatigue-management plan (ensures shift rotation does not contribute to increasing healthcare worker fatigue) is implemented and monitored.
3	This plan includes leading practices in fatigue management such as sleep contracts (formal agreements about the amount of sleep between shifts that encourage healthcare workers to rest while they are off shift).
4	Fatigue is identified as a form of impairment influencing cognitive performance (e.g. decision-making, digit span).
	Performance is routinely monitored using validated instruments
	… to provide information on the level of impairment
	… and enables healthcare workers to self-asses their performance
	… and take remedial action (eg request support from colleagues).
	Column totals (adjusted to max=4.0)

Level	Resource Management: Training	Clin	NonC	Mgr
0	No resource management training (interpersonal skills, communication, team working, personal awareness or decision-making) is provided.
1	Information about resource management is provided to promote working effectively within a team environment.
2	Knowledge-based interdisciplinary resource management training is provided.
3	Skill-based (includes practice and feedback) resource management training is provided.
	… The training program is developed/adapted to address the specific needs of the interdisciplinary team.
	… and is based on analysis of team working challenges.
4	Resource management training includes practice in a simulated environment.
	… and is followed by behavioural observation of performance.
	… using validated indicators.
	… Feedback is provided to all individuals after training,
	… and a formal evaluation of the training's effectiveness is conducted.
	Column totals (adjusted to max=4.0)

Level	Sharing and Learning: Organizational Learning	Level
0	There are no systems in place to support organizational learning.
1	Events that result in significant harm (eg wrong-site surgery) are investigated.
	… and actions are specified .
	… to prevent the recurrence of this specific event .
2	All event reports are investigated.
	… using validated tools and processes (eg root-cause analysis).
	… patient safety improvement actions are identified from the investigation.
	… and implementation tracked.
3	An integrated investigation system is implemented.
	… eg incident reporting system
	… retrospective chart reviews
	… and clinical audit process.
	Detailed results of investigations for each department.
	… are discussed with staff
	… on a regular basis,
	… and summary results are shared across the organization.
4	A comprehensive organizational learning system is in place that includes
	… incident reporting,
	… retrospective chart review
	… and audits.
	The organization learns from both negative outcomes
	… and positive outcomes
	… by identifying the practices that protect patients
	… as well as those that increase risk
	Column totals (adjusted to max=4.0)

Level	Sharing and Learning: Incident Reporting	Level
0	There are no reporting systems in place.
1	Incident report forms or electronic reporting system is available to enable staff to report patient safety events and concerns.
2	Incident reporting system (either paper or electronic) is in place.
	… Training on how to use the system is provided to all staff.
	… Learning from reported incidents is used in patient safety training.
	… Reports have the option for individuals to identify themselves so that additional information about the incident can be obtained.
3	Independent incident reporting system is used to facilitate confidential (not anonymous) reporting.
	… Managers identify common themes from the reports
	… and discuss them at department meetings.
	… There are mechanisms in place to provide information to all staff
	… (eg monthly summaries are provided to all staff).
4	Incident reporting system includes detailed description of the event.
	… Events are coded by a human factors expert
	… and follow-up discussions (eg by telephone) are conducted with the person who reported the incident.
	… There is a formal process in place to track every incident and the outcomes associated with it.
	… Incidents are used as learning tools;
	… each incident is described to all staff members and the actions resulting from the report are explained
	Column totals (adjusted to max=4.0)

Level	Sharing and Learning: Disclosure	Level
0	No disclosure policy in place.
1	Disclosure policy in place
1	… as per the Canadian Council on Health Services Accreditation (CCHSA) guidelines.
2	Disclosure training including requirements under the policy offered to all staff
2	… including physicians
3	Disclosure training is given to all staff
	… including physicians.
	Patients and families of those involved in an adverse event provide input into the training
	… and are consulted on an ongoing basis to seek feedback on how disclosure is managed.
4	Use of retrospective chart audit to assess quality (and extent) of disclosure when harm has occurred.
	Column totals (adjusted to max=4.0)

Level	Risk Analysis: Safety Analysis Systems	Level
0	No systematic use of safety analysis systems to promote patient safety.
1	1.1 Safety analysis tools are used for major events.
	… For example, retrospective analysis tools (eg root-cause analysis) are used to investigate the causes of events that resulted in significant harm (eg wrong-site surgery),
	… and prospective analysis tools are used when planning major organizational changes such as a new building.
2	Safety analysis tools are used frequently.
	… The analysis is led by patient safety specialists
	… with involvement of healthcare workers.
3	A wide range of healthcare workers.
	… are competent in using safety analysis tools.
	Healthcare workers regularly use these tools
	… to learn from incidents
	… and to identify ways of improving patient care.
4	Safety analysis systems are integrated into the routine activities of healthcare workers.
	… the effectiveness of the system is monitored
	… For example, actions identified during a prospective analysis are tracked to ensure they were implemented and worked as intended.
	Column totals (adjusted to max=4.0)

Article Information
Title:	Patient Safety Culture Improvement Tool
Subtitle:	Patient Safety Culture Improvement Tool (PSCIT)
Author:
Article URL:	http://www.qi.org.tw/Safety/SAQ/PSCIT.aspx
Created:	2010-11-17 11:23
Updated:	2012-05-19 11:49
Keywords:	Patient Safety Culture, PSCIT
Description:	Patient Safety Culture Improvement Tool (PSCIT)

Patient Safety Culture Improvement Tool