Relationship between hospital safety climate and outcomes

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Relationship between hospital safety climate and outcomesSara Singer, Alyson Falwell, Shoutzu Lin, Toby Rathgeb, Laurence Baker

AcademyHealth Annual MeetingJune 26, 2006

Financial support for this study has been provided by the Agency for Healthcare Research and Quality RO1 HSO13920 and by the VA HSR&D

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Patient safety and safety culture

Significant patient safety problems plague US hospitals

A culture of safety is increasingly recognized as a key to reducing adverse events in hospitals

Yet we lack conclusive evidence of the relationship between safety culture and patient safety outcomes

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Research questions

How do individuals working in hospitals perceive the culture of safety in their facilities?

Does perceived safety culture relate to hospital safety performance?

Do both strength and uniformity of safety climate matter?

Whose perception of safety culture corresponds most to safety outcomes?

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Hospital safety culture and its measurement Shared values, beliefs, and norms of behavior,

articulated by senior management and translated consistently into effective work practices

Measured using the Patient Safety Climate in Healthcare Organizations (PSCHO) survey

PSCHO measures safety climate, i.e., perceptions of safety culture at a point in time

We examine rates of “problematic responses,” i.e., those indicating a lack of safety culture

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Survey content and sample Survey includes 38 questions and 9 sub-scales

specific to individual aspects of safety culture Surveyed 18,361 individuals from a stratified

random sample of 92 US hospitals, representing four regions of the US and three size categories between March 2004 and May 2005 100% of active, hospital-based physicians, 100% of senior managers (dept heads or above) 10% random sample of all other personnel

52% response rate

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Comparison of safety climate to outcomes Two individual-level factors, most proximate

determinants of safety behaviors Willingness to seek help (alpha = 0.58)

Asking for help is a sign of incompetence Telling others about my mistakes is embarrassing If I make a mistake that has significant consequences and

nobody notices, I do not tell anyone about it Fear of blame & punishment (alpha = 0.61)

If people find out that I made a mistake, I will be disciplined Clinicians who make serious mistakes are usually punished

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Examination of strength and uniformity of safety climate to outcomes Strength of safety climate (mean problematic

response) Uniformity of safety climate (variance in

problematic response) Interaction between them

Safety culture strength

Safety outcomes

Safety culture uniformity

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Consideration of alternative perceptions of safety culture Nurses v. doctors Front line workers v. senior managers

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Outcomes measures and analysis Measured clinical outcomes using AHRQ patient safety

indicators (PSIs), computed using 2000 HCUP data Selected 14 out of 20 PSIs that we hypothesized would

be related to safety climate. Excluded indicators: Whose outcome is driven by a single unit (obstetrics) That have been criticized as highly unreliable (failure to rescue) For which no events occurred in study hospitals (transfusion

reaction) Included in analysis a stratified random sample of 47

hospitals from 15 states for which PSCHO and PSI data are available

Analyzed relationship of safety climate to all PSIs or groups of PSIs

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0

10

20

30

40

50

13 12 10 09 21 06 02 27 38 04 18 22 05 36 07 19 03 23 34 24 08 28 17 01 11 30 32 37 20 16 31 15 35 26 25 29 33 14

Percent Problematic Response by Survey Question

Per

cent

Pro

blem

atic

Res

pons

e

Safety climate in 92 hospitals

If I make a mistake that hassignificant consequences andnobody notices, I do not tellanyone about it

My unit recognizes individual safety achievement through rewards and incentives

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0

10

20

30

40

50

13 12 10 09 21 06 02 27 38 04 18 22 05 36 07 19 03 23 34 24 08 28 17 01 11 30 32 37 20 16 31 15 35 26 25 29 33 14

Percent Problematic Response by Survey Question

Per

cent

Pro

blem

atic

Res

pons

e

Safety climate in 92 hospitals

If I make a mistake that hassignificant consequences andnobody notices, I do not tellanyone about it

Asking for help is a sign of incompetence

Telling others about my mistakes is embarrassing

12

0

10

20

30

40

50

13 12 10 09 21 06 02 27 38 04 18 22 05 36 07 19 03 23 34 24 08 28 17 01 11 30 32 37 20 16 31 15 35 26 25 29 33 14

Percent Problematic Response by Survey Question

Per

cent

Pro

blem

atic

Res

pons

e

Safety climate in 92 hospitals

If people find out that I made a mistake, I will be disciplined

Clinicians who make serious mistakes are usually punished

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Relationship of safety climate dimensions to PSIs

Safety climate related more strongly to PSIs than did other hospital characteristics: nurse-to-patient hour ratios, early technology adoption, and incident reporting activity

(1) (2) (3) (4)

COEFFICIENT All 14 PSIsPostoperative complications

Nurse sensitive events

Technical adverse events

Overall safety culture -0.00954 -.0398409* 0.0231916 -0.0032069Willingness to seek help 0.0384** 0.0790** 0.0603 0.0174**Fear of blame & punishment 0.0146*** 0.0283*** 0.0343** 0.00172Controls Yes Yes Yes YesConstant -0.00315 -0.0229*** 0.0106 -0.00118Observations 47 44 47 47R-sqaured 0.37 0.50 0.33 0.31*** p<0.01, ** p<0.05, * p<0.1

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Relationship of safety climate dimensions to PSIs

Safety climate related more strongly to PSIs than did other hospital characteristics: nurse-to-patient hour ratios, early technology adoption, and incident reporting activity

(1) (2) (3) (4)

COEFFICIENT All 14 PSIsPostoperative complications

Nurse sensitive events

Technical adverse events

Overall safety culture -0.00954 -.0398409* 0.0231916 -0.0032069Willingness to seek help 0.0384** 0.0790** 0.0603 0.0174**Fear of blame & punishment 0.0146*** 0.0283*** 0.0343** 0.00172Controls Yes Yes Yes YesConstant -0.00315 -0.0229*** 0.0106 -0.00118Observations 47 44 47 47R-sqaured 0.37 0.50 0.33 0.31*** p<0.01, ** p<0.05, * p<0.1

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Relationship of safety climate dimensions to PSIs

Safety climate related more strongly to PSIs than did other hospital characteristics: nurse-to-patient hour ratios, early technology adoption, and incident reporting activity

(1) (2) (3) (4)

COEFFICIENT All 14 PSIsPostoperative complications

Nurse sensitive events

Technical adverse events

Overall safety culture -0.00954 -.0398409* 0.0231916 -0.0032069Willingness to seek help 0.0384** 0.0790** 0.0603 0.0174**Fear of blame & punishment 0.0146*** 0.0283*** 0.0343** 0.00172Controls Yes Yes Yes YesConstant -0.00315 -0.0229*** 0.0106 -0.00118Observations 47 44 47 47R-sqaured 0.37 0.50 0.33 0.31*** p<0.01, ** p<0.05, * p<0.1

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Relationship of safety climate dimensions to PSIs

Safety climate related more strongly to PSIs than did other hospital characteristics: nurse-to-patient hour ratios, early technology adoption, and incident reporting activity

(1) (2) (3) (4)

COEFFICIENT All 14 PSIsPostoperative complications

Nurse sensitive events

Technical adverse events

Overall safety culture -0.00954 -.0398409* 0.0231916 -0.0032069Willingness to seek help 0.0384** 0.0790** 0.0603 0.0174**Fear of blame & punishment 0.0146*** 0.0283*** 0.0343** 0.00172Controls Yes Yes Yes YesConstant -0.00315 -0.0229*** 0.0106 -0.00118Observations 47 44 47 47R-sqaured 0.37 0.50 0.33 0.31*** p<0.01, ** p<0.05, * p<0.1

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Relationship of strength and uniformity of willingness to seek help to PSIs

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Variance in problematic responses regarding willingness to seek help

Hospitals with higher rates of problematic response

Hospitals with lower rates of problematic response

Uniformity may moderate relationship between willingness to seek help and safety performance

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PSI-safety climate relationship differences by type of personnel

(1) (2) (3) (4) (5) (6) (7) (8)

COEFFICIENT All 14 PSIsPostoperative complications

Nurse sensitive events

Technical adverse events All 14 PSIs

Postoperative complications

Nurse sensitive events

Technical adverse events

Willingness to seek help -0.00315 0.0323** -0.0338* 0.00236 0.00213 0.0259 -0.011 -0.000728Fear of blame & punishment 0.00177 0.0134* 0.00625 -0.0012 0.00185 0.00288 0.0146 -0.00436**

Willingness to seek help 0.00102 -0.0103 0.0126 -0.0023 0.0249* 0.0570* 0.0466 0.00632

Fear of blame & punishment 0.00968*** 0.00775 0.0291*** 0.00103 0.0118*** 0.0236*** 0.0236* 0.00157Bed size controls Yes Yes Yes Yes Yes Yes Yes YesConstant 0.00172 -0.00628 0.00767 0.00105 -0.00315 -0.0159*** -0.00106 0.000684Observations 47 44 47 47 47 44 47 47R-squared 0.24 0.3 0.33 0.17 0.26 0.35 0.23 0.28*** p<0.01, ** p<0.05, * p<0.1

Physicians Senior Managers

Nurses Front Line Workers

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PSI-safety climate relationship differences by type of personnel

(1) (2) (3) (4) (5) (6) (7) (8)

COEFFICIENT All 14 PSIsPostoperative complications

Nurse sensitive events

Technical adverse events All 14 PSIs

Postoperative complications

Nurse sensitive events

Technical adverse events

Willingness to seek help -0.00315 0.0323** -0.0338* 0.00236 0.00213 0.0259 -0.011 -0.000728Fear of blame & punishment 0.00177 0.0134* 0.00625 -0.0012 0.00185 0.00288 0.0146 -0.00436**

Willingness to seek help 0.00102 -0.0103 0.0126 -0.0023 0.0249* 0.0570* 0.0466 0.00632

Fear of blame & punishment 0.00968*** 0.00775 0.0291*** 0.00103 0.0118*** 0.0236*** 0.0236* 0.00157Bed size controls Yes Yes Yes Yes Yes Yes Yes YesConstant 0.00172 -0.00628 0.00767 0.00105 -0.00315 -0.0159*** -0.00106 0.000684Observations 47 44 47 47 47 44 47 47R-squared 0.24 0.3 0.33 0.17 0.26 0.35 0.23 0.28*** p<0.01, ** p<0.05, * p<0.1

Physicians Senior Managers

Nurses Front Line Workers

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PSI-safety climate relationship differences by type of personnel

(1) (2) (3) (4) (5) (6) (7) (8)

COEFFICIENT All 14 PSIsPostoperative complications

Nurse sensitive events

Technical adverse events All 14 PSIs

Postoperative complications

Nurse sensitive events

Technical adverse events

Willingness to seek help -0.00315 0.0323** -0.0338* 0.00236 0.00213 0.0259 -0.011 -0.000728Fear of blame & punishment 0.00177 0.0134* 0.00625 -0.0012 0.00185 0.00288 0.0146 -0.00436**

Willingness to seek help 0.00102 -0.0103 0.0126 -0.0023 0.0249* 0.0570* 0.0466 0.00632

Fear of blame & punishment 0.00968*** 0.00775 0.0291*** 0.00103 0.0118*** 0.0236*** 0.0236* 0.00157Bed size controls Yes Yes Yes Yes Yes Yes Yes YesConstant 0.00172 -0.00628 0.00767 0.00105 -0.00315 -0.0159*** -0.00106 0.000684Observations 47 44 47 47 47 44 47 47R-squared 0.24 0.3 0.33 0.17 0.26 0.35 0.23 0.28*** p<0.01, ** p<0.05, * p<0.1

Physicians Senior Managers

Nurses Front Line Workers

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PSI-safety climate relationship differences by type of personnel

(1) (2) (3) (4) (5) (6) (7) (8)

COEFFICIENT All 14 PSIsPostoperative complications

Nurse sensitive events

Technical adverse events All 14 PSIs

Postoperative complications

Nurse sensitive events

Technical adverse events

Willingness to seek help -0.00315 0.0323** -0.0338* 0.00236 0.00213 0.0259 -0.011 -0.000728Fear of blame & punishment 0.00177 0.0134* 0.00625 -0.0012 0.00185 0.00288 0.0146 -0.00436**

Willingness to seek help 0.00102 -0.0103 0.0126 -0.0023 0.0249* 0.0570* 0.0466 0.00632

Fear of blame & punishment 0.00968*** 0.00775 0.0291*** 0.00103 0.0118*** 0.0236*** 0.0236* 0.00157Bed size controls Yes Yes Yes Yes Yes Yes Yes YesConstant 0.00172 -0.00628 0.00767 0.00105 -0.00315 -0.0159*** -0.00106 0.000684Observations 47 44 47 47 47 44 47 47R-squared 0.24 0.3 0.33 0.17 0.26 0.35 0.23 0.28*** p<0.01, ** p<0.05, * p<0.1

Physicians Senior Managers

Nurses Front Line Workers

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Discussion Two dimensions of safety climate were

statistically significantly associated with PSI performance Lack of willingness to seek help (p<.05) and Fear of blame & punishment (p<.01)

Uniformity moderated the relationship between willingness to seek help and safety performance

Nurse and front line workers’ perceptions correlated more strongly with adverse safety events than did physician and senior managers’ perceptions respectively

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Strengths and limitations

StrengthsOne of the first studies to link safety climate

directly to clinical safety outcomesResults representative of US hospitals

LimitationsNeed to explore other dimensions of safety

climateNeed verification of adverse event ratesNeed longitudinal study to establish causality

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Conclusion

Findings support the claim that culture and outcomes are strongly relatedBoth strength and uniformity of safety climate

matterSenior managers may misperceive important

aspects of safety climate Presence of blame and unwillingness to

seek help suggest interventions that address deeply-ingrained beliefs are needed to improve hospital safety culture