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Relationship between hospital safety climate and outcomes. Sara Singer, Alyson Falwell, Shoutzu Lin, Toby Rathgeb, Laurence Baker AcademyHealth Annual Meeting June 26, 2006 - PowerPoint PPT Presentation
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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
.003
.004
.005
.006
.007
.008
PS
Is p
er d
isch
arge
(ave
rage
of 1
4 P
SIs
)
.02 .03 .04 .05 .06
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