237 Barriers and facilitators in implementing a new safety climate tool

Introduction Patient safety has improved significantly over the past 20 years, but better is not good enough. Surgical complication rates declined mainly due to technological advancements. A national report has shown that the incidence of avoidable patient harm has not declined over the past years, despite increasing technical advancements and decreasing incidences of complications in the field of surgery. 1 However, human factors also have a significant impact on ‘safety culture’ and therefore, patient outcomes. Safety culture is often defined as ‘the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of an organization’s Health and Safety management’.2 Multiple studies indicate how safety culture affects complications, medication administration errors, and length of stay, as well as staff turnover and job satisfaction among healthcare professionals.3,4,5,6,7,8 Staff turnover and job satisfaction are increasingly important themes in times of overstretched healthcare systems, high turnover rates and staffing shortages. However, there is no golden standard in Dutch healthcare for measuring and improving safety culture.The need for a quick-to-use, adaptive tool was voiced by the Dutch Surgical Society. To address this need, our research group developed the Safety Climate Thermometer tool.9 This communication tool can provide surgical teams with guidance in improving the safety culture, while also allowing adaptability. This study aimed to present perceived barriers and facilitators in implementation of our tool, and to evaluate acceptability, practicality, demand, implementation and adaptation.Methods Context: Implementation of the Safety Climate Thermometer tool was piloted in three surgical teams (1x operating theatre, 2x surgical ward). Team composition and size ranged, as did the hospital setting (1x large referral/teaching hospital, 1x medium-size local hospital, 1x small local hospital), all in the Netherlands. Data collection took place between November 2021 and October 2023. Process: Using the Safety Climate Thermometer tool included the following phases: preparation (connecting with local teams, exploring needs, defining the team), phase I (anonymous input through the Safety Climate Thermometer tool), phase II (interdisciplinary team discussion and improvement initiative), and evaluation (interviews).9 In phase I, each team scores their local safety climate on themes like wellbeing, leadership, incident reporting and teamwork. Response rates were 60, 29 and 65%. In phase II, each team was presented their climate scores, and - through interdisciplinary discussion - formulated an intended improvement for the upcoming half year. During this period, the team kept track of their goals and improvements in interdisciplinary team meetings. After this period, all participants were interviewed individually to gather more information on their feelings concerning the goal achievement and if they had felt the use of the communication tool the Safety Climate Thermometer had helped them improve communication/collaboration in their team. Data collection: Implementation outcome measures were adapted from Bowen et al. and include: acceptability, practicality, demand, implementation and adaptation.10 Research methods included focus groups (observations, minutes, joint reflections by the research team) and semi-structured in-depth interviews with questions on implementation outcomes acceptability, practicality, demand, implementation and adaptation. Interviews were conducted in Dutch, lasted 25 minutes on average and were either live and audio recorded or virtual and video recorded with Microsoft Teams software. Data analysis: All interviews were recorded and transcribed in Dutch using Trint online transcription software.11 A thematic analysis was performed and findings were summarized per implementation outcome.Results Using the Safety Climate Thermometer, surgical teams initiated an interdisciplinary team meeting about safety and set actionable goals using input from the thermometer. Barriers and facilitators The most important factor in implementation was time. Planning issues were common in all three teams. Getting physicians, nurses and other professionals ‘at the table’ for an interdisciplinary team discussion can be challenging due to the ad hoc nature of the healthcare profession. Despite these difficulties, the average duration of phase II was only 7 months (proposed timeline was 6 months). Having existing periodic, interdisciplinary meetings about team functioning already in place, makes achieving improvement goals easier by bypassing some of these planning hurdles. With team meetings structurally in place, no additional time needs to be spent on scheduling meetings periodically.Each team should have at least one ‘driving force’ that is intrinsically motivated to coach the team. We have encountered that any participating professional, like manager, team leader or healthcare professional, can take up this role. Without this driving force, implementation without external support would not stand a chance.Other hurdles encountered included ‘finger-pointing’ towards management, keeping the entire team informed, engaged, and motivated, and teams lacking cohesion to begin with (leading to ‘us and they’).An important facilitator was renumeration support. We observed that especially for nurses, it is essential that the time they invest in initiatives to improve safety can be scheduled within their regular working hours or recorded as overtime. To them, it demonstrates the hospital is investing in and prioritizing safety.Team size can serve as a facilitator or barrier in implementation. For use of the Safety Climate Thermometer, small to medium sized teams of less than sixty healthcare professionals seem most suitable. All three teams had five to ten representatives attend the interdisciplinary team meetings, which turned out work well in practice. Implementation outcomes Acceptability:Satisfaction with content and design was high overall.Two sentences in the online Safety Climate Thermometer scoring were rephrased to minimize confusion and ‘finger-pointing’ to leadership.Practicality:Participants were able to carry out their improvement plans, without significant or unforeseen hurdles.Usability was high overall. Participants were unanimous in their appreciation of ease with which they could score safety climate online (using a thermometer sliding bar) and the following interdisciplinary meetings. Demand: Around half of participants intended to continue use. Participants mainly valued the implementation of the interdisciplinary team meetings and intended to continue those. Use of the online scoring tool as part of the Safety Climate Thermometer was perceived as less essential.Fit within organizational culture was perceived as high. Participants praised the practical and simple nature of the online scoring. For example, some drew similarities with the visual analogue scale for pain. Implementation: The most important observed resource needed to implement was time. Planning interdisciplinary team meetings in a surgical setting proved challenging.Efficiency, speed and quality of implementation was observed to vary greatly between the three teams. Reasons for this included: difficult/unclear team or stakeholder dynamics, planning difficulties, impact of the COVID-19 pandemic during the study period and an (in hindsight) insufficient preparation phase. Adaptation: The Safety Climate Thermometer tool was adaptable to local team context. We noticed not all teams initially wanted to change the contents, although we explicitly offered to customize the content for online scoring. After the implementation, some participants voiced that in hindsight they should have customized the content to better fit local context. Local outcomes included a revision of the patient clustering model on the surgical ward initiated by the nurses, improvements in onboarding for junior doctors on the surgical ward and the introduction of crew resource management trainings.Conclusions For an interdisciplinary safety culture tool -including ours- to work, one needs time/prioritization of the project, broad endorsement from the team and stakeholders, ample motivation or a clear need for improvement, a small to medium-sized team, a renumeration agreement, and a ‘driving force’ to tackle all practical issues and coach the team. And most of all: time. Good implementation (research) takes a lot of time, because trust and change take time. Take even more time to establish trust and prepare: ‘lay the groundwork’ in the preparation phase.The preparation phase is crucial to implementation success. In the preparation phase, attention should be given to building connection and trust with the participating team, extensive exploration of team and stakeholder dynamics (e.g. through a review of existing hierarchy, participating in ‘walkrounds’ or ‘shadowing days’, and having individual conversations with participating healthcare professionals), inventory of past improvement experiences, adaptation of the online Safety Climate Thermometer scoring tool to local/team context, and establishing a clear-cut definition of the team using it, as determined in accordance with team representatives.Having periodic interdisciplinary team meetings already in place, as well as having a motivated ‘driving force’ to coach the team are crucial factors for successful implementation.The main thing participating nurses indicated in the focus groups and individual interviews was that they finally felt heard by team leaders, managers and boards. Through implementation of this tool, they perceived to be taken more seriously and felt their needs were better incorporated in important decision-making.Finally, although time is needed for change, change can also be in small things that do not necessarily require much time or money. By choosing small intended outcomes, the focus is more on building a routine of interdisciplinary team meetings.References NIVEL. 2022. Monitor Zorggerelateerde Schade 2019: Dossieronderzoek bij overleden patiënten in Nederlandse ziekenhuizen [in Dutch], issue ISBN 978-94-6122-720-1. Accessed: May 16th 2022: https://www.nivel.nl/sites/default/files/bestanden/1004156.pdfACSNI (Advisory Committee on the Safety of Nuclear Installations) study group on human factors. London (United Kingdom) HM Stationery Office, 1993.Babic, et al. Sustained culture and surgical outcome improvement. Am J Surg. 2018;216(5):841–845. doi: 10.1016/j.amjsurg.2018.02.016.Odell, et al. Association between hospital safety culture and surgical outcomes in a statewide surgical quality improvement collaborative. J Am Coll Surg. 2019;229(2):175–183. doi: 10.1016/j.jamcollsurg.2019.02.046.Hansen, Williams, Singer. Perceptions of hospital safety climate and incidence of readmission. Health Serv Res 2011;46(2):596–616. doi: 10.1111/j.1475-6773.2010.01204.xHofmann, Mark. An investigation of the relationship between safety climate and medication errors as well as other nurse and patient outcomes. Personnel Psychology 2006;59(4):847–869. doi: 10.1111/j.1744-6570.2006.00056.xVogus, et al. Safety organizing, emotional exhaustion, and turnover in hospital nursing units. Med Care 2014;52(10):870–6. doi: 10.1097/MLR.0000000000000169Mossburg, Dennison Himmelfarb. The association between professional burnout and engagement with patient safety culture and outcomes: a systematic review. J Patient Saf 2021;17(8):e1307-e1319. doi: 10.1097/PTS.0000000000000519Van der Linde, et al. Design of the safety climate thermometer to promote team dialogue in surgical teams, using a thematic literature review and international expert panel study. Discov Health Systems 2024;3:100. doi: 10.1007/s44250-024-00161-yBowen, et al. How we design feasibility studies. Am J Prev Med. 2009 May;36(5):452–457. doi: 10.1016/j.amepre.2009.02.002Trint online transcription software. Trint Ltd. Retrieved from: https://trint.com.

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