1 Relationship between hospital safety climate and outcomes Sara Singer, Alyson Falwell, Shoutzu Lin, Toby Rathgeb, Laurence Baker AcademyHealth Annual Meeting June 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

2 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

3 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?

4 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

5 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 % of active, hospital-based physicians, 100% of senior managers (dept heads or above) 10% random sample of all other personnel 52% response rate

6 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

7 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

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

9 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

10 Safety climate in 92 hospitals If I make a mistake that has significant consequences and nobody notices, I do not tell anyone about it My unit recognizes individual safety achievement through rewards and incentives

11 Safety climate in 92 hospitals If I make a mistake that has significant consequences and nobody notices, I do not tell anyone about it Asking for help is a sign of incompetence Telling others about my mistakes is embarrassing

12 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

13 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

14 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

15 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

16 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

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

18 PSI-safety climate relationship differences by type of personnel

19 PSI-safety climate relationship differences by type of personnel

20 PSI-safety climate relationship differences by type of personnel

21 PSI-safety climate relationship differences by type of personnel

22 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

23 Strengths and limitations Strengths One of the first studies to link safety climate directly to clinical safety outcomes Results representative of US hospitals Limitations Need to explore other dimensions of safety climate Need verification of adverse event rates Need longitudinal study to establish causality

24 Conclusion Findings support the claim that culture and outcomes are strongly related Both strength and uniformity of safety climate matter Senior 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