What do we really assess with organisational culture tools in healthcare? An interpretive systematic umbrella review of tools in healthcare

The anatomy of safe surgical teams: an interview-based qualitative study among members of surgical teams at tertiary referral hospitals in Norway

BACKGROUND

In spite of the global implementation of surgical safety checklists to improve patient safety, patients undergoing surgical procedures remain vulnerable to a high risk of potentially preventable complications and adverse outcomes. The present study was designed to explore the surgical teams' perceptions of patient safety culture, capture their perceptions of the risk for adverse events, and identify themes of interest for quality improvement within the surgical department.

METHODS

This qualitative study had an explorative design with an abductive approach. Individual semi-structured in-depth interviews were conducted between 10/01/23 and 11/05/23. The participants were members of surgical teams (n = 17), general and orthopedic surgeons (n = 5), anesthesiologists (n = 4), nurse anesthetists (n = 4) and operating room nurses (n = 4). Middle managers recruited purposively from general and orthopedic surgical teams in two tertiary hospitals in Norway, aiming for a maximum variation due to gender, age, and years within the specialty. The data material was analyzed following Braun and Clarke's method for reflexive thematic analysis to generate patterns of meaning and develop themes and subthemes.

RESULTS

The analysis process resulted in three themes describing the participants' perceptions of patient safety culture in the surgical context: (1) individual accountability as a safety net, (2) psychological safety as a catalyst for well-being and safe performance in the operating room, and (3) the importance of proactive structures and participation in organizational learning.

CONCLUSIONS

This study provided an empirical insight into the culture of patient safety in the surgical context. The study highlighted the importance of supporting the individuals' competence, building psychological safety in the surgical team, and creating structures and culture promoting a learning organization. Quality improvement projects, including interventions based on these results, may increase patient safety culture and reduce the frequency of adverse events in the surgical context.

Factors determining safety culture in hospitals: a scoping review

OBJECTIVE

To evaluate and synthesise the factors determining patient safety culture in hospitals.

METHODS

The scoping review protocol was based on the criteria of the Joanna Briggs Institute. Eligibility criteria were as follows: (1) empirical study published in a peer-reviewed journal; (2) used methods or tools to assess, study or measure safety culture or climate; (3) data collected in the hospital setting and (4) studies published in English. Relevant literature was located using PubMed, CINAHL, Web of Science and PsycINFO databases. Quantitative and qualitative analyses were performed using RStudio and the R interface for multidimensional analysis of texts and questionnaires (IRaMuTeQ).

RESULTS

A total of 248 primary studies were included. The most used instruments for assessing safety culture were the Hospital Survey on Patient Safety Culture (n=104) and the Safety Attitudes Questionnaire (n=63). The Maslach Burnout Inventory (n=13) and Culture Assessment Scales based on patient perception (n=9) were used in association with cultural instruments. Sixty-six articles were included in the qualitative analysis. In word cloud and similarity analyses, the words 'communication' and 'leadership' were most prominent. Regarding the descending hierarchical classification analysis, the content was categorised into two main classes, one of which was subdivided into five subclasses: class 1a: job satisfaction and leadership (15.56%), class 1b: error response (22.22%), class 1c: psychological and empowerment nurses (20.00%), class 1d: trust culture (22.22%) and class 2: innovation worker (20.00%).

CONCLUSION

The instruments presented elements that remained indispensable for assessing the safety culture, such as leadership commitment, open communication and learning from mistakes. There was also a tendency for research to assess patient and family engagement, psychological safety, nurses' engagement in decision-making and innovation.

How does patient-centered hospital culture affect clinical physicians' medical professional attitudes and behaviours in chinese public hospitals: a cross-sectional study?

BACKGROUND

An increasing number of studies on physicians' professionalism have been done since the 2002 publication of Medical Professionalism in the New Millennium: A Physician Charter. The Charter proposed three fundamental principles and ten responsibilities. However, most studies were done in developed countries, and few have been done in China. Additionally, few studies have examined the effect of patient-centered hospital culture (PCHC) on physicians' professionalism. We aimed to investigate physicians' medical professionalism in public hospitals in China, and to assess mediating effect of professional attitudes in the relationship of PCHC with professional behaviours.

METHODS

Self-administered questionnaires including professional attitudes (20 items) and behaviours (10 items) survey and PCHC scale (22 items) were given to clinical physicians in five public hospitals, China. The mediating effect of professional attitudes in the relationship of PCHC with professional behaviours was tested.

RESULT

232 valid questionnaires were collected. More than 90% (208) respondents agreed with 15 of 20 specific statements on medical professionalism. As for the responsibility of improving quality of care, 54 (23%) respondents disagreed with reporting of incompetent colleagues and as for the responsibility of maintaining professional competence, 49 (21%) disagreed with recertification. More than 185 (83%) respondents reported that they sometimes, usually, or always showed the four positive behaviours on the questionnaire, and 173 (77%) reported that they never showed the six negative behaviours. Mediating effect analysis revealed that two dimensions of PCHC (i.e. value/institution culture and behaviour/material culture) had a significant positive impact on physicians' professional behaviour, and professional attitude played a complete mediation role between them, but another dimension of PCHC (i.e. negative evaluation of hospital) directly affected professional behaviour without influencing professional attitude.

CONCLUSION

Chinese physicians showed positive professional attitudes and behaviours. Different dimensions of PCHC affected physicians' attitudes and behaviours in different ways.

The association between patient safety culture and adverse events - a scoping review

BACKGROUND

Adverse events (AEs) affect 10% of in-hospital patients, causing increased costs, injuries, disability and mortality. Patient safety culture (PSC) is an indicator of quality in healthcare services and is thus perceived as a proxy for the quality of care. Previous studies show variation in the association between PSC scores and AE rates. The main objective of this scoping review is to summarise the evidence on the association between PSC scores and AE rates in healthcare services. In addition, map the characteristics and the applied research methodology in the included studies, and study the strengths and limitations of the evidence.

METHODS

We applied a scoping review methodology to answer the broad research questions of this study, following the PRISMA-ScR checklist. A systematic search in seven databases was conducted in January 2022. The records were screened independently against eligibility criteria using Rayyan software, and the extracted data were collated in a charting form. Descriptive representations and tables display the systematic mapping of the literature.

RESULTS

We included 34 out of 1,743 screened articles. The mapping demonstrated a statistical association in 76% of the studies, where increased PSC scores were associated with reduced AE rates. Most of the studies had a multicentre design and were conducted in-hospital in high-income countries. The methodological approaches to measuring the association varied, including missing reports on the tools` validation and participants, different medical specialties, and work unit level of measurements. In addition, the review identified a lack of eligible studies for meta-analysis and synthesis and demonstrated a need for an in-depth understanding of the association, including context complexity.

CONCLUSIONS

We found that the vast majority of studies report reduced AE rates when PSC scores increase. This review demonstrates a lack of studies from primary care and low- and- middle-income countries. There is a discrepancy in utilised concepts and methodology, hence there is a need for a broader understanding of the concepts and the contextual factors, and more uniform methodology. Longitudinal prospective studies with higher quality can enhance efforts to improve patient safety.

Safe Medication of Elderly Through Development and Evaluation of an Intervention (SAME): Protocol for a Fully Integrated Mixed Methods Study with Co-creative Approach (Preprint)

BACKGROUND

Medication safety is increasingly challenging patient safety in growing aging populations. Developing positive patient safety cultures is acknowledged as a primary goal to improve patient safety, but evidence on the interventions to do so is inconclusive. Nursing home residents are often cognitively and physically impaired and are therefore highly reliant on frontline health care providers. Thus, interventions to improve medication safety of nursing home residents through patient safety culture among providers are needed. Using cocreative partnerships, integrating knowledge of residents and their relatives, and ensuring managerial support could be beneficial.

OBJECTIVE

The primary aim of the Safe Medication of Nursing Home Residents Through Development and Evaluation of an Intervention (SAME) study is to improve medication safety for nursing home residents through developing an intervention by gaining experiential knowledge of patient safety culture in cocreative partnerships, integrating knowledge of residents and their relatives, and ensuring managerial support.

METHODS

The fully integrated mixed method study will be conducted using an integrated knowledge translation approach. Patient safety culture within nursing homes will first be explored through qualitative focus groups (stage 1) including nursing home residents, their relatives, and frontline health care providers. This will inform the development of an intervention in a multidisciplinary panel (stage 2) including cocreators representing the medication management process across the health care system. Evaluation of the intervention will be done in a randomized controlled trial set at nursing homes (stage 3). The primary outcome will be changes in the mean scale score of an adapted version of the Danish "Safety Attitudes Questionnaire" (SAQ-DK) for use in nursing homes. Patient safety-related outcomes will be collected through Danish health registers to assess safety issues and effects, including medication, contacts to health care, diagnoses, and mortality. Finally, a mixed methods analysis on patient safety culture in nursing homes will be done (stage 4), integrating qualitative data (stage 1) and quantitative data (stage 3) to comprehensively understand patient safety culture as a key to medication safety.

RESULTS

The SAME study is ongoing. Focus groups were carried out from April 2021 to September 2021 and the workshop in September 2021. Baseline SAQ-DK data were collected in January 2022 with expected follow-up in January 2023. Final data analysis is expected in spring 2024.

CONCLUSIONS

The SAME study will help not only to generate evidence on interventions to improve medication safety of nursing home residents through patient safety culture but also to give insight into possible impacts of using cocreativity to guide the development. Thus, findings will address multiple gaps in evidence to guide future patient safety improvement efforts within primary care settings of political and scientific scope.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04990986; https://clinicaltrials.gov/ct2/show/NCT04990986.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/43538.

Changes in Safety and Teamwork Climate After Adding Structured Observations to Patient Safety WalkRounds

BACKGROUND

Patient safety is essential for the reliable delivery of health care. One way to positively influence patient safety is to improve the safety and teamwork climate of a clinical area. Research shows that patient safety WalkRounds (WRs) are an appropriate and common method to improve safety culture. The aim of this study was to combine WRs with observations of specific patient safety dimensions and to measure the safety and teamwork climate.

METHODS

In this observational study, WRs took place in eight work settings across a 770-bed university hospital in Switzerland. During rounds, health care workers (HCWs) were observed in relation to defined patient safety dimensions. In addition, HCWs were surveyed using safety and teamwork climate scales before the initial WRs and six to nine months later, and implementation of planned improvement actions following the WRs was evaluated.

RESULTS

During WRs, 810 activities of HCWs were observed, of which 85.4% met the requirements for safe care. Safety and teamwork climate did not change significantly after nine months. A total of 36 action plan items were planned to address safety deficits that surfaced during WRs, but only 40.7% of the action items had been implemented after nine months.

CONCLUSION

WRs with structured in-person observations identified safe care practices and deficits in patient safety. Improvement action plans to address safety deficits were not fully implemented nine months later, and there were no significant changes in the safety and teamwork climate at that time.

Open organisational culture: what does it entail? Healthcare stakeholders reaching consensus by means of a Delphi technique

OBJECTIVES

Open organisational culture in hospitals is important, yet it remains unclear what it entails other than its referral to 'open communication' in the context of patient safety. This study aims to identify the elements of an open hospital culture.

METHODS

In this group consensus study with a Delphi technique, statements were constructed based on the existing patient safety literature and input of 11 healthcare professionals from different backgrounds. A final framework consisting of 36 statements was reviewed on inclusion and exclusion, in multiple rounds by 32 experts and professionals working in healthcare. The feedback was analysed and shared with the panel after the group reached consensus on statements (>70% agreement).

RESULTS

The procedure resulted in 37 statements representing tangible (ie, leadership, organisational structures and processes, communication systems, employee attitudes, training and development, and patient orientation) and intangible themes (ie, psychological safety, open communication, cohesion, power, blame and shame, morals and ethics, and support and trust). The culture themes' teamwork and commitment were not specific for an open culture, contradicting the patient safety literature. Thereby, an open mind was shown to be a novel characteristic.

CONCLUSIONS

Open culture entails an open mind-set and attitude of professionals beyond the scope of patient safety in which there is mutual awareness of each other's (un)conscious biases, focus on team relationships and professional well-being and a transparent system with supervisors/leaders being role models and patients being involved. Although it is generally acknowledged that microlevel social processes necessary to enact patient safety deserve more attention, research has largely emphasised system-level structures and processes. This study provides practical enablers for addressing system and microlevel social processes to work towards an open culture in and across teams.

Overcoming Obstacles to Develop High-Performance Teams Involving Physician in Health Care Organizations

Many health care organizations struggle and often do not succeed to be high-performance organizations that are not only efficient and effective but also enjoyable places to work. This review focuses on the physician and organizational roles in limiting achievement of a high-performance team in health care organizations. Ten dimensions were constructed and a number of competencies and metrics were highlighted to overcome the failures to: (i) Ensure that the goals, purpose, mission and vision are clearly defined; (ii) establish a supportive organizational structure that encourages high performance of teams; (iii) ensure outstanding physician leadership, performance, goal attainment; and (iv) recognize that medical team leaders are vulnerable to the abuses of personal power or may create a culture of intimidation/fear and a toxic work culture; (v) select a good team and team members—team members who like to work in teams or are willing and able to learn how to work in a team and ensure a well-balanced team composition; (vi) establish optimal team composition, individual roles and dynamics, and clear roles for members of the team; (vii) establish psychological safe environment for team members; (viii) address and resolve interpersonal conflicts in teams; (xi) ensure good health and well-being of the medical staff; (x) ensure physician engagement with the organization. Addressing each of these dimensions with the specific solutions outlined should overcome the constraints to achieving high-performance teams for physicians in health care organizations.

Towards developing a comprehensive conceptual understanding of positive hospital culture and approaches to healthcare organisational culture change in Australia

PURPOSE

The key aim of this narrative literature review, therefore, is to identify the key conceptual categories that inform the construction of positive person-centred culture within hospitals, and how these frameworks are brought to bear upon organisational culture within healthcare systems in Australia.

DESIGN/METHODOLOGY/APPROACH

This narrative review presents a thematic synthesis of literature identified through a systematic search protocol undertaken across 19 academic databases and Google Scholar as an additional search tool. Thematic qualitative analysis was performed on the research results to determine the common themes within the diverse literature presented within this study.

FINDINGS

Culture change interventions in hospitals attempt to address the problem of widespread unprofessional behaviour within healthcare systems. However, diverse definitions and seemingly fragmented approaches to understanding and enacting organisational culture change present a significant hurdle in achieving cohesive and sustainable healthcare reform. This narrative literature review offers a comprehensive conceptual view of the key approaches that inform positive person-centred culture within hospital settings. In total, three primary dimensions, belonging, behaving and being, aligned against organisational goals, individual behaviours and worker as well as organisational identity were identified. Other individual and group interactional dynamics that give rise to negative organisational culture are further analysed to understand the fault lines along which existing culture change interventions are typically operationalised.

RESEARCH LIMITATIONS/IMPLICATIONS

This review is not exhaustive and is limited in its methodological scope. The central values and themes identified within the literature are integral to designing humanised healthcare systems. However, owing to the qualitative nature and contextual variability of these factors, these themes do not lend themselves to replicable quantification.

SOCIAL IMPLICATIONS

This analysis contributes to foundational research efforts towards transforming healthcare practice to be more aligned with humanised and equitable values within increasingly complex healthcare organisational settings. Designing culture change interventions that align more suitably with the values-driven categories identified in this literature review may increase the effectiveness and sustainability of these interventions and reform efforts at organisational and systemic levels.

ORIGINALITY/VALUE

This article presents a comprehensive framework to approach healthcare organisational reform through shared and equitable models of operation, management and governance rather than continuing to promote narrowly defined outcomes derived from commodified models of healthcare practice.