1. Patient Safety Culture Measurement and Improvement
Mark Fleming
Saint Mary’s University

2. Objectives
Understand the nature and importance of culture and relationship with patient safety
Evaluate current culture
Measure, track, monitor culture
Develop a strategic plan for safety culture measurement and improvement
Implement culture improvement strategies
Identify barriers to improvement

3. We can't solve problems by using the same kind of thinking we used when we created them
Albert Einstein

4. Importance of culture
“Health care organizations must develop a culture of safety such that an organization's care processes and workforce are focused on improving the reliability and safety of care for patients.” (p. 14; IOM, 1999)
“The biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm.” (p. 79; Crossing the Quality Chasm, 2001)

5. Culture and patient safety
Safety Culture
Norms and
Behaviour
Patient Safety
Enabler/
Barrier
Patient Safety Interventions

6. Patient safety culture
A culture of safety can be defined as an integrated pattern of individual and organizational behaviour, based upon shared beliefs and values, that continuously seeks to minimize patient harm that may result from the processes of care delivery (Kizer, 1999).

7. Patient safety culture elements
Leadership commitment to safety
Organizational resources for patient safety
Priority of safety versus production
Effectiveness and openness of communication
Openness about problems and errors
Organizational learning
Frequency of unsafe acts
(Singer et al. 2003)

8. Measurement and Improvement
Organizational level
Major system wide change process requiring significant resources
Step change in patient safety outcomes
Unit level
Focused intervention
Incremental improvement

9. 1. Investigate Build expertise in safety culture
Form small assessment and improvement team
Select appropriate instrument
Agency for Health Care Research and Quality
Hospital survey on patient safety (79 items) (Sorra & Nieva, 2004)
Safety Attitudes Questionnaire
SAQ (60 items) (Sexton & Thomas 2003)
York University
Modified Stanford (32 items) (Ginsburg et al, 2009)

10. York University Modified Stanford
Based on PSCI and Capital Health questionnaire
Organizational leadership for safety
Unit leadership for safety
Perceived state of safety
Shame and repercussions
Learning
Good psychometrics (alpha’s )
Currently used by Accreditation Canada
Large Canadian data set

11. 2. Initiate Obtain Informed senior leadership support
Involve health care staff
Planning and implementation of assessment
Keep staff informed about progress

12. 3. Implement
Collect data
Interpret results
Feedback results to staff

17. Unit level assessment and improvement
Conduct safety culture survey (e.g. MSI )
Group exercise
Representative group of frontline caregivers
30 – 60 minutes to complete
Helps to make sense out of culture survey results and create actions for improvement
Normalizes patient safety culture conversations
The “Culture Check-up” was developed by Sexton and colleagues in The purpose of this tool is to provide structure and direction for patient safety culture discussions and action planning sessions. The culture check-up is meant to be completed as a group exercise with a representative sample of frontline caregivers. The exercise is broken down into three tasks:
Using the results from the SAQ (or another validated patient safety culture survey) the group selects one item which less than 60% of respondents agreed upon. There is also an option to chose upon a list of diagnostic items provided.
For the item chosen, the group members discuss what that item means to them, if the item score is reflective of their experiences, and what 100% agreement for this item would look like.
The final task is for the group to identify one actionable idea to improve the results related to this item.
The culture check-up can be a useful tool when trying to make sense out of culture survey results and make decisions on the next actions to take to improve the culture of the organization. The tool can be used immediately after the organization received culture survey results or periodically through the year as a way of keeping in a finger on the pulse of the culture. The more often the culture check-up tool is completed, the more it will help in normalizing conversations about patient safety culture.

19. 4. Improve
Involve cross section of staff in development of improvement plan
Implement an improvement plan
Monitor the implementation of plan
Evaluate effectiveness of plan
Assess change in culture

20. Patient Safety Culture Improvement Tool (PSCIT)
Perceptions are based in reality
i.e. perceptions of leadership commitment reflect their interactions with leaders
Organisations and units with different cultures have different practices
Safety culture improvement involves system change
e.g. perceptions of leader commitment is improved through training and evaluating safety leadership practices

21. Patient safety culture elements
Leadership
Senior Manager
Clinical Manager
Physician
Risk analysis
Workload management
Sharing and learning
Resource management

22. Example element

23. How to use the audit
Self assessment of systems supporting the safety culture
Completed by unit or department to assist in identifying opportunities to improve
Completed by senior management team to form basis for improvement workshop

24. Improving patient safety culture
Leadership
Judged by actions not words
Solution focused approach
Assess current culture
Work at team level to develop local action plan
Implement changes
Reassess culture
Health care specific challenges
Unclear management control
Limited acceptance of need to change

25. Taking Action Culture is shared by group members
Groups consist of individuals
Culture change requires individuals to change their values, beliefs and behaviour
Cultural change can begin at the:
Organizational level
Unit level
Individual level
So what are you going to do to change the culture?
Fundamentally patient safety culture is about people and it changes by the actions of people. With your greater understanding of culture what are you going to do differently? Consider the current culture within your organization and your department or unit.
What aspects of the culture could be improved?
Identify one action that would improve the culture within your organization.
Identify one action that would improve the culture within your department or unit.
List one thing that you are going to do to promote a positive safety culture.

26. Summary Creating a culture of patient safety is crucial
The culture determines what behaviours are acceptable and unacceptable
Patient safety culture consists of a number of dimensions
It is important to understand the current culture before trying to change it
Cultural change can be conducted at the organisational or unit level

27. References
Kizer, K. W Large system change and a culture of safety. In: Enhancing Patient Safety and Reducing Errors in Health Care. Chicago, IL: National Patient Safety Foundation
Ginsburg L, Gilin D, Tregunno D, Norton P G, Flemons W. and Fleming M (2009) Advancing measurement of patient safety culture Health Services Research Vol 44 no 1 pp
Sexton JB, Paine LA, Manfuso J, Holzmueller CG, Martinez EA, Moore D, Hunt DG, & Pronovost PJ.(2007) A check-up for safety culture in "my patient care area". Joint Commission journal on quality and patient safety. Nov;33(11): , 645
Fleming, M. and Wentzell, N. (2008) Patient Safety culture improvement tool: development and guidelines for use. Healthcare Quarterly Volume 11 Special issue pp10-15
Jackson, J. Sarac, C. and Flin R. (2010) Hospital safety climate surveys: measurement issues Current Opinion in Critical Care , 16:632–638