Exploring the Relationship Between Hospital Patient Safety Culture and Performance on Measures of Hospital-Acquired Conditions

OBJECTIVE

The aim of the study is to examine the relationship between hospital perceptions of patient safety culture and the incidence of hospital-acquired conditions (HACs) included in Medicare's HAC Reduction Program utilizing updated and standardized metrics.

METHODS

The pooled cross-sectional study design utilized the 2018 and 2021 datasets from (1) the Agency for Healthcare Research and Quality's Hospital Survey on Patient Safety Culture (HSOPS), (2) the American Hospital Association's annual survey, and (3) the Center for Medicare and Medicaid's Hospital Compare dataset. The final analytic sample included 131 acute care, nonfederal, U.S. facilities. Multivariable linear regression models were used to compare the HSOPS domains of patient safety culture to CMS's HAC metrics.

RESULTS

Controlling for hospital structural and patient-mix characteristics, hospitals with higher staff-reported ratings of overall patient safety culture ('overall perceptions of patient safety' and 'patient safety grade') had significantly lower rates of HACs, including total HAC rate, catheter-associated urinary tract infections, and central line-associated blood stream infections (P's < 0.000-0.044). Higher HSOPS domain scores were variably associated with lower HAC rates, with consistently significant associations found for domains related to nonpunitive, open communication (P's < 0.05).

CONCLUSIONS

Our relatively robust results suggest that while patient safety culture may not be the only strategy necessary to improve HAC rates, it needs to be aligned with other efforts to improve quality and safety. This underscores the importance of cultivating a culture of psychological safety that promotes open feedback and communication about errors.

The relationship between hospital patient safety culture and performance on Centers for Medicare & Medicaid Services value-based purchasing metrics

BACKGROUND

Despite the intense policy focus on reducing health-care-associated conditions, adverse events in health care settings persist. Therefore, evaluating patient safety efforts and related health policy initiatives remains critical.

PURPOSE

The aim of this study was to explore the relationship between hospital patient safety culture and hospital performance on Centers for Medicare & Medicaid Services (CMS) Hospital Value-Based Purchasing (HVBP) metrics.

METHODOLOGY/APPROACH

A pooled cross-sectional study design was used utilizing three secondary datasets from 2018 and 2021: the Hospital Survey on Patient Safety Culture, the American Hospital Association annual survey, and the Hospital Compare data from CMS. We used two multivariable linear regression models to examine the relationship between organizational patient safety culture and hospital performance. The dependent variables included the overall CMS total performance score (TPS) and the four individual TPS domain scores. Hospital patient safety culture, the independent variable, was operationalized using two measures from the Hospital Survey on Patient Safety Culture: (a) the domain score of overall perceptions of patient safety and (b) the patient safety grade.

RESULTS

We observed positive and significant associations between hospital patient safety culture and a hospital's overall TPS and the "patient and community engagement" and "safety" domains.

CONCLUSION

Findings suggest that building a strong patient safety culture has the potential to lead health care organizations to achieve high performance on HVBP metrics.

PRACTICE IMPLICATIONS

Our findings have important policy implications for both the future of CMS HVBP as a motivator of patient safety and how health care managers integrate culture change into programs to meet external quality metrics.

Revisiting organizational culture in healthcare: Heterogeneity as a resource

Aligning culture to be similar across work units is a common organizational tactic, but its appropriateness for the multidisciplinary context of healthcare is far from certain. Variation in perceptions of culture across large health systems may serve a functional purpose in delivering high quality care and ameliorating job stress; however, past research in healthcare has focused on culture as the average set of values and norms (i.e., cultural content) rather than on (dis)agreement about values and norms among organizational members (i.e., cultural structure). This survey-based study examines both cultural content (averages among individuals) and structure (distances between individuals) in departments of a large U.S. healthcare organization (total sample = 26,314 workers, response rate = 84%). We used linear models to associate four commonly used culture measures with outcome measures (perceived care quality, intent to stay, and manageable job stress). We found substantial heterogeneity in perceptions for multiple culture types. We found curvilinear relationships between heterogeneity for all culture types and outcomes, suggesting that heterogeneity promotes positive outcomes up to a certain point after which the positive effect declines. For research, our findings point to the importance of studying culture in healthcare with greater focus on heterogeneity; for practice, this study highlights how culturally-focused efforts to improve care quality and worker experience in healthcare should be more precise about balancing cultural alignment and heterogeneity.

Safe Surgery Checklist Implementation: Associations of Management Practice and Safety Culture Change

Designing and developing safe systems has been a persistent challenge in health care, and in surgical settings in particular. In efforts to promote safety, safety culture, i.e., shared values regarding safety management, is considered a key driver of high-quality, safe healthcare delivery. However, changing organizational culture so that it emphasizes and promotes safety is often an elusive goal. The Safe Surgery Checklist is an innovative tool for improving safety culture and surgical care safety, but evidence about Safe Surgery Checklist effectiveness is mixed. We examined the relationship between changes in management practices and changes in perceived safety culture during implementation of safe surgery checklists. Using a pre-posttest design and survey methods, we evaluated Safe Surgery Checklist implementation in a national sample of 42 general acute care hospitals in a leading hospital network. We measured perceived management practices among managers (n = 99) using the World Management Survey. We measured perceived preoperative safety and safety culture among clinical operating room personnel (N = 2,380 (2016); N = 1,433 (2017)) using the Safe Surgical Practice Survey. We collected data in two consecutive years. Multivariable linear regression analysis demonstrated a significant relationship between changes in management practices and overall safety culture and perceived teamwork following Safe Surgery Checklist implementation.

Voice is not enough: A multilevel model of how frontline voice can reach implementation

ISSUE

When frontline employees' voice is not heard and their ideas are not implemented, patient care is negatively impacted, and frontline employees are more likely to experience burnout and less likely to engage in subsequent change efforts.

CRITICAL THEORETICAL ANALYSIS

Theory about what happens to voiced ideas during the critical stage after employees voice and before performance outcomes are measured is nascent. We draw on research from organizational behavior, human resource management, and health care management to develop a multilevel model encompassing practices and processes at the individual, team, managerial, and organizational levels that, together, provide a nuanced picture of how voiced ideas reach implementation.

INSIGHT/ADVANCE

We offer a multilevel understanding of the practices and processes through which voice leads to implementation; illuminate the importance of thinking temporally about voice to better understand the complex dynamics required for voiced ideas to reach implementation; and highlight factors that help ideas reach implementation, including voicers' personal and interpersonal tactics with colleagues and managers, as well as senior leaders modeling and explaining norms and making voice-related processes and practices transparent.

PRACTICE IMPLICATIONS

Our model provides evidence-based strategies for bolstering rejected or ignored ideas, including how voicers (re)articulate ideas, whom they enlist to advance ideas, how they engage peers and managers to improve conditions for intentional experimentation, and how they take advantage of listening structures and other formal mechanisms for voice. Our model also highlights how senior leaders can make change processes and priorities explicit and transparent.

Managing safety in perioperative settings: Strategies of meso-level nurse leaders

BACKGROUND

Perioperative nursing units are described as one of the most challenging practice environments, characterized by a distinct hierarchal culture and rapid pace. These dynamics create challenges for creating a culture of safety, where meso-level nurse leaders (MLNLs) must operate in the space between the micro level of direct patient care and the macro-level administrative priorities.

PURPOSE

Guided by complexity leadership theory, we sought to understand the strategies MLNLs used to facilitate a culture of safety in perioperative settings.

METHODOLOGY

A qualitative descriptive study with semistructured interviews was conducted. Inductive thematic analysis was used to analyze content from the interviews, and several techniques (audit trail, reflexivity, peer debriefing) were used to ensure rigor.

RESULTS

Seventeen MLNLs completed an interview, and analysis identified four strategies that MLNLs reported to foster safety as meso-leaders in perioperative environments: (a) recognizing the unique perioperative management environment, (b) learning not to take interactions personally, (c) developing "super meso-level nurse leader" skills, and (d) appealing to policies and patient safety.

CONCLUSION

Perioperative environments require MLNLs to use multifaceted strategies to keep the peace among many stakeholders and foster patient safety.

PRACTICE IMPLICATIONS

Our study shows how clear organizational policies and procedures can serve as a vital tool-moving attention away from a feeling of individual "policing" and toward joint discussion about shared patient safety goals-and ultimately support MLNLs in challenging perioperative work environments. Perioperative environments create unique challenges, and organizations should consider perioperative-specific leadership training to prepare MLNLs for these roles.

Testing the association between the enabling and enacting factors of patient safety culture and patient safety: structural equation modelling

BACKGROUND

Despite evidence linking a safety culture with patient safety, the processes by which aspect of safety culture influences patient safety are not yet well understood. Thus, this study aimed to test a theoretical model of the relationships between three enabling factors (supervisor/clinical leader support for patient safety, hospital management support for patient safety, and psychological safety), and four enacting factors of patient safety culture (handoffs and information exchange, teamwork, error reporting intention, and withholding voice) with nurse assessments of patient safety.

METHODS

A cross-sectional, descriptive correlational study design was used. Between May and June 2020, 526 nurses who provided direct care to patients in medical surgical units in three Korean hospitals completed an online survey that included four standardized scales or subscales. Structural equation modelling was used to test the hypothesized model.

RESULTS

Among the three enabling factors, psychological safety was associated with all four enacting factors, and all enacting factors were associated with overall patient safety. Hospital management support was associated with all enacting factors except teamwork, but supervisor/clinical leader support was associated with only handoffs and information exchange, and withholding voice. Thus, teamwork was influenced only by psychological safety. Findings demonstrate overall support for the theoretical model of safety culture wherein enabling factors influence enacting factors which, in turn, lead to patient safety outcomes, but emphasize the critical nature of psychological safety among nursing staff.

CONCLUSION

This study provides further insight into the importance of support from hospital management and unit supervisors/clinical leaders for patient safety to motivate and enable hospital nurses to enact behaviours necessary for patient safety. However, such support must also take the form of enhancing psychological safety for nursing staff.

Patient Safety Culture in Latin American Hospitals: A Systematic Review with Meta-Analysis

INTRODUCTION

Adverse events in hospitals are prevented through risk reduction and reliable processes. Highly reliable hospitals are grounded by a robust patient safety culture with effective communication, leadership, teamwork, error reporting, continuous improvement, and organizational learning. Although hospitals regularly measure their patient safety culture for strengths and weaknesses, there have been no systematic reviews with meta-analyses reported from Latin America.

PURPOSE

Our systematic review aims to produce evidence about the status of patient safety culture in Latin American hospitals from studies using the Hospital Survey on Patient Safety Culture (HSOPSC).

METHODS

This systematic review was guided by the JBI guidelines for evidence synthesis. Four databases were systematically searched for studies from 2011 to 2021 originating in Latin America. Studies identified for inclusion were assessed for methodological quality and risk of bias. Descriptive and inferential statistics, including meta-analysis for professional subgroups and meta-regression for subgroup effect, were calculated.

RESULTS

In total, 30 studies from five countries-Argentina (1), Brazil (22), Colombia (3), Mexico (3), and Peru (1)-were included in the review, with 10,915 participants, consisting primarily of nursing staff (93%). The HSOPSC dimensions most positive for patient safety culture were "organizational learning: continuous improvement" and "teamwork within units", while the least positive were "nonpunitive response to error" and "staffing". Overall, there was a low positive perception (48%) of patient safety culture as a global measure (95% CI, 44.53-51.60), and a significant difference was observed for physicians who had a higher positive perception than nurses (59.84; 95% CI, 56.02-63.66).

CONCLUSIONS

Patient safety culture is a relatively unknown or unmeasured concept in most Latin American countries. Health professional programs need to build patient safety content into curriculums with an emphasis on developing skills in communication, leadership, and teamwork. Despite international accreditation penetration in the region, there were surprisingly few studies from countries with accredited hospitals. Patient safety culture needs to be a priority for hospitals in Latin America through health policies requiring annual assessments to identify weaknesses for quality improvement initiatives.

Safety management in times of crisis: Lessons learned from a nationwide status-analysis on German intensive care units during the COVID-19 pandemic

Background

The status of Safety Management is highly relevant to evaluate an organization's ability to deal with unexpected events or errors, especially in times of crisis. However, it remains unclear to what extent Safety Management was developed and sufficiently implemented within the healthcare system during the COVID-19 pandemic. Providing insights of potential for improvement is expected to be directional for ongoing Safety Management efforts, in times of crisis and beyond.

Method

A nationwide survey study was conducted among healthcare professionals and auxiliary staff on German Intensive Care Units (ICUs) evaluating their experiences during the first wave of the COVID-19 pandemic. Error Management and Patient Safety Culture (PSC) measures served to operationalize Safety Management. Data were analyzed descriptively and by using quantitative content analysis (QCA).

Results

Results for n = 588 participants from 53 hospitals show that there is a gap between errors occurred, reported, documented, and addressed. QCA revealed that low quality of safety culture (27.8%) was the most mentioned reason for errors not being addressed. Overall, ratings of PSC ranged from 26.7 to 57.9% positive response with Staffing being the worst and Teamwork Within Units being the best rated dimension. While assessments showed a similar pattern, medical staff rated PSC on ICUs more positively in comparison to nursing staff.

Conclusion

The status-analysis of Safety Management in times of crisis revealed relevant potential for improvement. Human Factor plays a crucial role in the occurrence and the way errors are dealt with on ICUs, but systemic factors should not be underestimated. Further intensified efforts specifically in the fields of staffing and error reporting, documentation and communication are needed to improve Safety Management on ICUs. These findings might also be applicable across nations and sectors beyond the medical field.

Assessing managerial patient safety practices that influence adverse events reporting among nurses in the Savannah Region, Ghana

Introduction

Patient safety is a global concern for both health professionals and the public. Studies show that evaluating patient safety culture can help improve patient safety outcomes. Nursing care strategically places nurses at the centre of patient safety promotion and their proximity to patients makes them the drivers of patient safety. Managerial decisions regarding patient safety impact greatly on patient safety outcomes in the healthcare organization. This study aimed to assess the managerial patient safety practices that influence adverse event reporting in three hospitals in the Savannah Region of Ghana.

Methods

A quantitative cross-sectional design was used to collect data from 210 participants in three hospitals. Data were analysed using descriptive, Pearson's correlation and linear regression.

Results

It was found that patient safety practices with good positive rating scores were management support (56.6%), managers' expectations (62.8%) and feedback about errors (56.2%). Areas with weak patient safety practices were staffing levels (42.4%), open communication (40.2%) and non-punitive response to errors (36.7%). Again, nurses' attitude towards adverse events reporting was generally low (37.3%). Managerial patient safety practices that had significant associations with adverse events reporting were management support ( r = .18, p < .001), open communication ( r = .19, p < .001), non-punitive to errors ( r = .21, p < .001) and feedback about errors ( r = .37, p < .001). Again, the significant predictors of adverse events reporting were feedback about errors ( β  =  .36, p < .001) and non-punitive response to errors ( β  =  .21, p  < .01).

Conclusion

Nurses perceived patient safety culture in their units to be good. Although nurses' attitude towards adverse events reporting was low, the significant predictors of adverse events reporting were feedback about errors and non-punitive response to errors. Therefore, healthcare managers should continually strengthen patient safety to ensure optimal care outcomes.

Implications for nursing practice

Feedback on errors and non-punitive response to errors had a great influence on adverse events reporting, managerial failure to provide feedback and a non-punitive work environment could result in under-reporting of adverse events. This can be a major threat to patient safety; hence clinical practice should be aware of this and put in strategies to appropriately address them.

The Perception of the Patient Safety Climate by Health Professionals during the COVID-19 Pandemic-International Research

The patient safety climate is a key element of quality in healthcare. It should be a priority in the healthcare systems of all countries in the world. The goal of patient safety programs is to prevent errors and reduce the potential harm to patients when using healthcare services. A safety climate is also necessary to ensure a safe working environment for healthcare professionals. The attitudes of healthcare workers toward patient safety in various aspects of work, organization and functioning of the ward are important elements of the organization’s safety culture. The aim of this study was to determine the perception of the patient safety climate by healthcare workers during the COVID-19 pandemic. Methods: The study was conducted in five European countries. The Safety Attitude Questionnaire (SAQ) short version was used for the study. A total of 1061 healthcare workers: physicians, nurses and paramedics, participated in this study. Results: All groups received the highest mean results on the stress recognition subscale (SR): nurses 98.77, paramedics 96.39 and physician 98.28. Nurses and physicians evaluated work conditions (WC) to be the lowest (47.19 and 44.99), while paramedics evaluated perceptions of management (PM) as the worst (46.44). Paramedics achieved statistically significantly lower scores compared to nurses and physicians in job satisfaction (JS), stress recognition (SR) and perception of management (PM) (p < 0.0001). Paramedics compared to nurses and physicians rank better in working conditions (WC) in relation to patient safety (16.21%). Most often, persons of lower seniority scored higher in all subscales (p = 0.001). In Poland, Spain, France, Turkey, and Greece, healthcare workers scored highest in stress recognition (SR). In Poland, Spain, France, and Turkey, they assessed working conditions (WC) as the worst, while in Greece, the perception of management (PM) had the lowest result. Conclusion: Participant perceptions about the patient safety climate were not at a particularly satisfactory level, and there is still a need for the development of patient safety culture in healthcare in Europe. Overall, positive working conditions, good management and effective teamwork can contribute to improving employees’ attitudes toward patient safety. This study was carried out during the COVID-19 pandemic and should be repeated after its completion, and comparative studies will allow for a more precise determination of the safety climate in the assessment of employees.

Impact on Patient Safety Culture by the Intervention of Multidisciplinary Medical Teams

OBJECTIVE

To provide comprehensive patient-centered care, we need multidisciplinary teams to face challenges of advanced and complex care. The Taichung Veterans General Hospital has had a ward-based multidisciplinary team system in each ward for 10 years. This study aimed to investigate whether better team performance results in a more positive response in patient safety culture (PSC).

DESIGN/SETTING

From 2014 to 2017, there were 21 ward-based multidisciplinary teams. We organized an evaluation panel to assess the performance of the teams. Those teams were divided into 3 groups: high, medium, and low according to their annual performance scores. The Taichung Veterans General Hospital used annual Safety Attitude Questionnaire-based surveys concerning patient safety issues. We used the generalized estimating equation to analyze the dataset over 4 years. All analyses were carried out using SAS Version 9.4 (SAS Institute, Cary, NC).

RESULTS

Taking the trend effects from 2014 to 2017 into account, we found that teamwork climate, safety climate, and perception of management were significantly better in the high and medium groups of the ward-based multidisciplinary teams. There was no significant difference in the dimensions of job satisfaction, stress recognition, and working conditions, which suggests that all staff had the same degree of stress or work loading.

CONCLUSIONS

Our ward-based multidisciplinary team system had a positive effect on PSC, which demonstrates the following: when team performance is better, patient safety climate is also better. We should keep the ward-based multidisciplinary team system, improve its performance, and maximize positive attitudes about PSC among our staff.

Safety culture and incident learning systems in radiation oncology: Staff perceptions across Australia and New Zealand

INTRODUCTION

Radiation therapy has a highly complex pathway and uses detailed quality assurance protocols and incident learning systems (ILSs) to mitigate risk; however, errors can still occur. The safety culture (SC) in a department influences its commitment and effectiveness in maintaining patient safety.

METHODS

Perceptions of SC and knowledge and understanding of ILSs and their use were evaluated for radiation oncology staff across Australia and New Zealand (ANZ). A validated healthcare survey tool (the Hospital Survey on Patient Safety Culture) was used, with additional specialty-focussed supporting questions. A total of 220 radiation oncologists, radiation therapists and radiation oncology medical physicists participated.

RESULTS

An overall positive SC was indicated, with strength in teamwork (83.7%), supervisor/manager/leader support (83.3%) and reporting events (77.1%). The weakest areas related to communication about error (63.9%), hospital-level management support (60.5%) and handovers and information exchange (58.0%). Barriers to ILS use included 'it takes too long' and that many respondents must use multiple reporting systems, including mandatory hospital-level systems. These are generally not optimal for specific radiation oncology needs. Varied understanding was indicated of what and when to report.

CONCLUSION

The findings report the ANZ perspective on ILS and SC, highlighting weaknesses, barriers and areas for further investigation. Differences observed in some areas suggest that a unified state, national or bi-national ILS specific to radiation oncology might eliminate multiple reporting systems and reduce reporting time. It could also provide more consistent and robust approaches to incident reporting, information sharing and analysis.

Effect of after action review on safety culture and second victim experience and its implementation in an Irish hospital: A mixed methods study protocol

Background

After Action Review is a form of facilitated team learning and review of events. The methodology originated in the United States Army and forms part of the Incident Management Framework in the Irish Health Services. After Action Review has been hypothesized to improve safety culture and the effect of patient safety events on staff (second victim experience) in health care settings. Yet little direct evidence exists to support this and its implementation has not been studied.

Aim

To investigate the effect of After Action Review on safety culture and second victim experience and to examine After Action Review implementation in a hospital setting.

Methods

A mixed methods study will be conducted at an Irish hospital. To assess the effect on safety culture and second victim experience, hospital staff will complete surveys before and twelve months after the introduction of After Action Review to the hospital (Hospital Survey on Safety Culture 2.0 and Second Victim Experience and Support Tool). Approximately one in twelve staff will be trained as After Action Review Facilitators using a simulation based training programme. Six months after the After Action Review training, focus groups will be conducted with a stratified random sample of the trained facilitators. These will explore enablers and barriers to implementation using the Theoretical Domains Framework. At twelve months, information will be collected from the trained facilitators and the hospital to establish the quality and resource implications of implementing After Action Review.

Discussion

The results of the study will directly inform local hospital decision-making and national and international approaches to incorporating After Action Review in hospitals and other healthcare settings.

Effectiveness of customised safety intervention programmes to increase the safety culture of hospital staff

The aim of this study was to investigate the effectiveness of customised safety interventions in improving the safety cultures of both clinical and non-clinical hospital staff. This was assessed using the Safety Attitude Questionnaire-Chinese at baseline, 2 years and 4 years after the implementation of safety interventions with a high response rate ranging from 80.5% to 87.2% and excellent internal consistency (Cronbach’s alpha=0.93). The baseline survey revealed a relatively low positive attitude response in the Safety Climate (SC) domain. Both SC and Working Conditions (WC) domains were shown to have increased positive attitude responses in the second survey, while only the Management Perception domain had gained 3.8% in the last survey. In addition, safety dimensions related to collaboration with doctors and service delays due to communication breakdown were significantly improved after customised intervention was applied. Safety dimensions related to safety training, reporting and safety awareness had a high positive response in the initial survey; however, the effect was difficult to sustain subsequently. Multilevel analysis further illustrated that non-clinical staff were shown to have a more positive attitude than clinical staff, while female staff had a higher positive attitude percentage in job satisfaction than male staff. The results showed some improvements in various safety domains and dimensions, but also revealed inconsistent changes in subsequent surveys. The change in positive safety culture over the years and its sustainability need to be further explored. It is suggested that hospital management should continuously monitor and evaluate their strategies while delivering multifaceted interventions to be more specifically focused and to motivate staff to be enthusiastic in sustaining patient safety culture.

Changing safety culture

Safety culture, an aspect of organizational culture, that reflects work place norms toward safety, is foundational to high-quality care. Improvements in safety culture are associated with improved operational and clinical outcomes. In the neonatal intensive care unit (NICU), where fragile infants receive complex, coordinated care over prolonged time periods, it is critically important that unit norms reflect the high priority placed on safety. Changing the safety culture of the NICU involves a systematic process of measurement, identifying strengths and weaknesses, deploying targeted interventions, and learning from the results, to set the stage for an iterative process of improvement. Successful change efforts require: effective partnerships with key stakeholders including management, clinicians, staff, and families; using data to make the case for improvement; and leadership actions that motivate change, channel resources, and support active problem- solving. Sustainable change requires buy-in from NICU staff and management, resources, and long-term institutional commitment.

Strategies and interventions for improving safety culture in Australian Emergency Departments: A modified Delphi study

BACKGROUND

Patient safety and safety culture are critical for quality healthcare delivery in general and in Emergency Departments (EDs) in particular. The aim of this study is to identify strategies that may contribute to the improvement and maintenance of patient safety culture and which are considered most feasible in the ED environment.

METHODS

A two-step modified Delphi method with 11 experts' panel was performed to establish consensus. A list of potential expert participants with a background in patient safety culture in EDs was compiled through the professional networks of the supervisory team. Snowball sampling was used to identify additional possible participants. The expert panel included key leaders in the emergency medicine community in Queensland, Australia: patient safety experts and researchers, patient safety directors, and healthcare providers in an Australian ED The study ran from September 2018 to December 2018. The tool used in Round 1 in this study was developed through triangulating the outcomes of a review of literature, results from a survey of ED staff and findings from semi-structured interviews with key stakeholders in ED. The results from Round 1 informed the development of the Round 2 tool. The responses from the Delphi Round 1 tool were analysed as both qualitative data and quantitative data. The responses from the Delphi Round 2 tool were treated as quantitative data and analysed with the SPSS software. Consensus was calculated based on more than 80% agreement in collapsed categories 1 and 2 (or 4 and 5) of the five-point Likert scale.

RESULTS

Only six strategies out of 17 (35%) achieved consensus for both importance and feasibility. These strategies may therefore be considered the most important and feasible key strategies for improving safety culture in EDs. Seven strategies (41.1%) achieved consensus for importance, but not for feasibility and four strategies (23.55%) did not achieve consensus for either importance or feasibility.

CONCLUSIONS

This study offers practical solutions for safety culture improvement in the ED context. Six key strategies were seen as both important and feasible and these grouped into three main themes; leadership through agenda setting, operational management approaches to reinforce the agenda and commitment, and systems and structures to reinforce the agenda and monitor progress.

Leapfrog Hospital Safety Score, Magnet Designation, and Healthcare-Associated Infections in United States Hospitals

OBJECTIVE

Healthcare-associated infections (HAIs) pose a challenge to patient safety. Although studies have explored individual level, few have focused on organizational factors such as a hospital's safety infrastructure (indicated by Leapfrog Hospital Safety Score) or workplace quality (Magnet recognition). The aim of the study was to determine whether Magnet and hospitals with better Leapfrog Hospital Safety Scores have fewer HAIs.

METHODS

Ordered probit regression analyses tested associations between Safety Score, Magnet status, and standardized infection ratios, depicting whether a hospital had a Clostridium difficile infection (CDI) and methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection standardized infection ratio that was "better," "no different," or "worse" than a National Benchmark as per Centers for Disease Control and Prevention's National Healthcare Safety Network definitions.

RESULTS

Accounting for confounders, relative to "A" hospitals, "B" and "C" hospitals had significant and negative relationships with CDI (-0.16, P < 0.01, and -0.14, P < 0.05, respectively) but not MRSA bacteremia. Magnet hospitals had a significant and positive relationship with MRSA bloodstream infections (0.74, P < 0.001) but a significant negative relationship with CDI (-0.21, P < 0.01) compared with non-Magnet.

CONCLUSIONS

A hospitals performed better on CDI but not MRSA bloodstream infections. In contrast, Magnet designation was associated with fewer than expected MRSA infections but more than expected CDIs. These mixed results indicate that hospital global assessments of safety and workplace quality differentially and imperfectly predict its level of HAIs, suggesting the need for more precise organizational measures of safety and more nuanced approaches to infection prevention and reduction.

Acute care nurses' perceptions of leadership, teamwork, turnover intention and patient safety - a mixed methods study

BACKGROUND

This study contributes to a small but growing body of literature on how context influences perceptions of patient safety in healthcare settings. We examine the impact of senior leadership support for safety, supervisory leadership support for safety, teamwork, and turnover intention on overall patient safety grade. Interaction effects of predictors on perceptions of patient safety are also examined.

METHODS

In this mixed methods study, cross-sectional survey data (N = 185) were collected from nurses and non-physician healthcare professionals. Semi-structured interview data (N = 15) were collected from nurses. The study participants worked in intensive care, general medicine, mental health, or the emergency department of a large community hospital in Southern Ontario.

RESULTS

Hierarchical regression analyses showed that staff perceptions of senior leadership (p < 0.001), teamwork (p < 0.01), and turnover intention (p < 0.01) were significantly associated with overall patient safety grade. The interactive effect of teamwork and turnover intention on overall patient safety grade was also found to be significant (p < 0.05). The qualitative findings corroborated the survey results but also helped expand the characteristics of the study's key concepts (e.g., teamwork within and across professional boundaries) and why certain statistical relationships were found to be non-significant (e.g., nurse interviewees perceived the safety specific responsibilities of frontline supervisors much more broadly compared to the narrower conceptualization of the construct in the survey).

CONCLUSIONS

The results of the current study suggest that senior leadership, teamwork, and turnover intention significantly impact nursing staff perceptions of patient safety. Leadership is a modifiable contextual factor and resources should be dedicated to strengthen relational competencies of healthcare leaders. Healthcare organizations must also proactively foster inter and intra-professional collaboration by providing teamwork educational workshops or other on-site learning opportunities (e.g., simulation training). Healthcare organizations would benefit by considering the interactive effect of contextual factors as another lever for patient safety improvement, e.g., lowering staff turnover intentions would maximize the positive impact of teamwork improvement initiatives on patient safety.

How Can Implementation of a Large-Scale Patient Safety Program Strengthen Hospital Safety Culture? Lessons From a Qualitative Study of National Patient Safety Program Implementation in Two Public Hospitals in Brazil

Large-scale (e.g., national) programs could strengthen safety culture, which is foundational to patient safety, yet we know little about how to optimize this potential. In 2013, Brazil's Ministry of Health launched the National Patient Safety Program, involving hospital-level safety teams and targeted safety protocols. We conducted in-depth qualitative case studies of National Patient Safety Program implementation in two hospitals, with different readiness, to understand how program implementation affected enabling, enacting, and elaborating processes that produce and sustain safety culture. For both hospitals, external mandates were insufficient for enabling hospital-level action. Internal enabling failures (e.g., little safety-relevant senior leadership) hindered enactment (e.g., safety teams unable to institute plans). Limited enactment and weak elaboration processes (e.g., bureaucratic monitoring) failed to institutionalize protocol use and undermined safety culture. Optimizing the safety culture impact of large-scale programs requires effective multi-level enabling and capitalizing on the productive potential of interacting national- and local-level influences.

Soft Factors, Smooth Transport? The role of safety climate and team processes in reducing adverse events during intrahospital transport in intensive care

BACKGROUND

Intrahospital patient transports (IHTs) in intensive care involve an appreciable risk of adverse events (AEs). Research on determinants of AE occurrence during IHT has hitherto focused on patient, transport, and intensive care unit (ICU) characteristics. By contrast, the role of "soft" factors, although arguably relevant for IHTs and a topic of interest in general health care settings, has not yet been explored.

PURPOSE

The study aims at examining the effect of safety climate and team processes on the occurrence of AE during IHT and whether team processes mediate the effect of safety climate.

METHODOLOGY/APPROACH

Data stem from a noninterventional, observational multicenter study in 33 ICUs (from 12 European countries), with 858 transports overall recorded during 28 days. AEs include medication errors, dislodgments, equipment failures, and delays. Safety climate scales were taken from the "Patient Safety Climate in Healthcare Organizations" (short version), team processes scales from the "Leiden Operating Theatre and Intensive Care Safety" questionnaire. Patient condition was assessed with NEMS (Nine Equivalents of Nursing Manpower Use Score). All other variables could be directly observed. Hypothesis testing and assessment of effects rely on bivariate correlations and binomial logistic multilevel models (with ICU as random effect).

FINDINGS

Both safety climate and team processes are comparatively important determinants of AE occurrence, also when controlling for transport-, staff-, and ICU-related variables. Team processes partially mediate the effect of safety climate. Patient condition and transport duration are consistently related with AE occurrence, too.

PRACTICE IMPLICATIONS

Unlike most patient, transport, and ICU characteristics, safety climate and team processes are basically amenable to managerial interventions. Coupled with their considerable effect on AE occurrence, this makes pertinent endeavors a potentially promising approach for improving patient safety during IHT. Although literature suggests that safety climate is slow and hard to change (also compared to team processes), efforts to improve safety climate should not be forgone.

Nurses' Views Highlight a Need for the Systematic Development of Patient Safety Culture in Forensic Psychiatry Nursing

BACKGROUND

Although forensic nurses work with the most challenging psychiatric patients and manifest a safety culture in their interactions with patients, there have been few studies on patient safety culture in forensic psychiatric nursing.

OBJECTIVES

The aim of this qualitative study was to describe nurses' views of patient safety culture in their working unit and daily hospital work in 2 forensic hospitals in Finland.

METHODS

Data were collected over a period of 1 month by inviting nurses to answer an open-ended question in an anonymous Web-based questionnaire. A qualitative inductive analysis was performed on nurses' (n = 72) written descriptions of patient safety culture in state-owned forensic hospitals where most Finnish forensic patients are treated.

RESULTS

Six main themes were identified: "systematization of an open and trusting communication culture," "visible and close interaction between managers and staff," "nonpunitive responses to errors, learning and developing," "balancing staff and patient perspectives on safety culture," "operational safety guidelines," and "adequate human resources to ensure safety."

CONCLUSIONS

The findings highlight the influence of the prevailing culture on safety behaviors and outcomes for both healthcare workers and patients. Additionally, they underline the importance of an open culture with open communication and protocols.

Building an Ambulatory Safety Program at an Academic Health System

BACKGROUND

Patient safety has traditionally focused on the inpatient setting; however, there is an increased awareness of ambulatory safety risk. However, successful strategies and programs to mitigate risk in the ambulatory setting are lacking.

PROGRAM

In 2012, we started building a multidisciplinary ambulatory safety program at an academic health system. Our team was composed of clinical, administrative, and patient safety membership. Based on organizational needs, our program initially focused on the following: (1) safety reporting, (2) safety culture measurement, (3) medication safety, and (4) test result management.

WHAT WE DID

We were able to develop initiatives around safety reporting, safety culture survey administration, and medication safety and begin to work on test result management. Internal metrics were developed to measure performance and to drive improvement.

SAFETY REPORTING

When evaluating our ambulatory safety reports, we discovered that less than one-third of staff filing safety reports requested feedback. From 2013 to 2018, we tested various strategies to increase the rates of feedback to staff and ultimately found that a decentralized process that was supported by the ambulatory safety program could achieve rates of feedback of 90%.

SAFETY CULTURE MEASUREMENT

We administered the Agency for Healthcare Research and Quality Medical Office Survey in 2012, 2014, and 2016, achieving a more than 70% response rate across 70 unique ambulatory areas. Data from these surveys were shared with senior hospital leadership, local departmental directors, and managers and ultimately with frontline staff focusing on two key survey areas: communication openness and communication about error.

MEDICATION SAFETY

From 2012 to 2014, our rates of ambulatory medication reconciliation increased to more than 90% in both primary care and specialty practices in our homegrown electronic medical record system. From 2015 to 2016, rates of ambulatory medication reconciliation in our new vendor-based electronic medical record were 73% as of August 2017.

CONCLUSIONS

We were able to build an infrastructure to focus and support ambulatory safety efforts on safety reporting, safety culture change, and medication reconciliation with a team dedicated to ambulatory-focused safety risks and encountered many challenges along the way. Currently, we are expanding our program to concentrate on test result follow-up to prevent missed and delayed diagnosis and medication error reduction.

Safety culture and systems thinking for predicting safety competence and safety performance among registered nurses in Saudi Arabia: a cross-sectional study

BACKGROUND

Medical errors are a worldwide concern and the contribution of nurses' safety competence and performance to these errors is a high priority. It has been over 20 years since the first report of the need to address medical errors. New approaches are needed for enhancing safety competence and performance.

AIMS

This study explored the relationships among systems thinking, educational level, safety culture, safety competence and safety performance among registered nurses working in medical and surgical units in Saudi Arabia.

METHODS

A correlational cross-sectional design with a convenience sample of 84 registered nurses was used.

RESULTS

Systems thinking predicted 16% of safety knowledge (F[2, 81] = 7.61, P = 0.001), while safety culture, baccalaureate education and completion of safety training predicted 19% of safety skill (F[3, 78] = 2.80, P = 0.001). A safety culture that promoted learning from mistakes predicted 15% of safety performance measured based on nurses' self-report of the number of errors in the past 3 months (F[3, 75] = 2.86, P = 0.008).

CONCLUSIONS

Professional development including systems thinking and safety training are the necessary next steps for nurses. In addition, policy changes facilitating organisations to support learning from mistakes will contribute to reducing medical errors.

Patient safety. Factors for and perceived consequences of nursing errors by nursing staff in home care services

AIM

To identify factors for and perceived consequences of nursing errors by nursing staff in home care services in correlation with qualification, work experience, working hours and trainings.

BACKGROUND

Patient safety has increasingly been brought into focus of politics and care practices over the past few years. However, little evidence has been provided yet on nursing errors in out-of-hospital settings.

DESIGN

A cross-sectional study.

METHODS

Randomized sample of 107 home care services and 656 nurses and nursing assistants recruited from all 16 federal states in Germany.

RESULTS

Missing trainings on error management within the past 2 years were identified to be an important factor for mistakes regarding hygienic measures and medication administration. However, most errors arose in documentation without any significant differences in qualification, work experience, training and working hours.

CONCLUSION

Findings indicate that insufficient hygiene and medication administration might be reduced by implementing error management trainings on a regular basis in home care services.

Safety Culture: An Integration of Existing Models and a Framework for Understanding Its Development

OBJECTIVE

This study reviews theoretical models of organizational safety culture to uncover key factors in safety culture development.

BACKGROUND

Research supports the important role of safety culture in organizations, but theoretical progress has been stunted by a disjointed literature base. It is currently unclear how different elements of an organizational system function to influence safety culture, limiting the practical utility of important research findings.

METHOD

We reviewed existing models of safety culture and categorized model dimensions by the proposed function they serve in safety culture development. We advance a framework grounded in theory on organizational culture, social identity, and social learning to facilitate convergence toward a unified approach to studying and supporting safety culture.

RESULTS

Safety culture is a relatively stable social construct, gradually shaped over time by multilevel influences. We identify seven enabling factors that create conditions allowing employees to adopt safety culture values, assumptions, and norms; and four behaviors used to enact them. The consequences of these enacting behaviors provide feedback that may reinforce or revise held values, assumptions, and norms.

CONCLUSION

This framework synthesizes information across fragmented conceptualizations to clearly depict the dynamic nature of safety culture and specific drivers of its development. We suggest that safety culture development may depend on employee learning from behavioral outcomes, conducive enabling factors, and consistency over time.

APPLICATION

This framework guides efforts to understand and develop safety culture in practice and lends researchers a foundation for advancing theory on the complex, dynamic processes involved in safety culture development.

Improving patient safety during intrahospital transportation of mechanically ventilated patients with critical illness

Aim

Intrahospital transportation (IHT) of patients under mechanical ventilation (MV) significantly increases the risk of patient harm. A structured process performed by a well-prepared team with adequate communication among team members plays a vital role in enhancing patient safety during transportation.

Design and implementation

We conducted this quality improvement programme at the intensive care units of a university-affiliated medical centre, focusing on the care of patients under MV who received IHT for CT or MRI examinations. With the interventions based on the analysis finding of the IHT process by healthcare failure mode and effects analysis, we developed and implemented strategies to improve this process, including standardisation of the transportation process, enhancing equipment maintenance and strengthening the teamwork among the transportation teammates. In a subsequent cycle, we developed and implemented a new process with the practice of reminder-assisted briefing. The reminders were printed on cards with mnemonics including ‘VITAL’ (Vital signs, Infusions, Tubes, Alarms and Leave) attached to the transportation monitors for the intensive care unit nurses, ‘STOP’ (Secretions, Tubes, Oxygen and Power) attached to the transportation ventilators for the respiratory therapists and ‘STOP’ (Speak-out, Tubes, Others and Position) attached to the examination equipment for the radiology technicians. We compared the incidence of adverse events and completeness and correctness of the tasks deemed to be essential for effective teamwork before and after implementing the programme.

Results

The implementation of the programme significantly reduced the number and incidence of adverse events (1.08% vs 0.23%, p=0.01). Audits also showed improved teamwork during transportation as the team members showed increased completeness and correctness of the essential IHT tasks (80.8% vs 96.5%, p<0.001).

Conclusion

The implementation of reminder-assisted briefings significantly enhanced patient safety and teamwork behaviours during the IHT of mechanically ventilated patients with critical illness.

Culture of Safety: Impact on Improvement in Infection Prevention Process and Outcomes

Purpose

Safety culture is known to be related to a wide range of outcomes, and measurement of safety culture is now required for many hospitals in the U.S.A. In previous reviews, the association with outcomes has been limited by the research design and strength of the evidence. The goal of this review was to examine recent literature on the relationship between safety culture and infection prevention and control-related (IPC) processes and healthcare-associated infections (HAIs) in U.S. healthcare organizations. We also sought to quantitatively characterize the challenges to empirically establishing these relationships and limitations of current research.

Recent Findings

A PubMed search for U.S. articles published 2009–2019 on the topics of infection prevention, HAIs, and safety culture yielded 448 abstracts. After screening, 55 articles were abstracted for information on purpose, measurement, analysis, and conclusions drawn about the role of safety culture in the outcome. Approximately ½ were quality improvement (QI) initiatives and ½ were research studies. Overall, 51 (92.7%) concluded there was an association between safety culture and IPC processes or HAIs. However, only 39 studies measured safety culture and 26 statistically analyzed safety culture data for associations. Though fewer QI initiatives analyzed associations, a higher proportion concluded an association exists than among research studies.

Summary

Despite limited empirical evidence and methodologic challenges to establishing associations, most articles supported a positive relationship between safety culture, improvement in IPC processes, and decreases in HAIs. Authors frequently reported experiencing improvements in safety culture when not directly measured. The findings suggest that associations between improvement and safety culture may be bi-directional such that positive safety culture contributes to successful interventions and implementing effective interventions drives improvements in culture. Greater attention to article purpose, design, and analysis is needed to confirm these presumptive relationships.

When a Family Seeks to Exclude Residents From Their Child's Care

A primary goal of our medical education system is to produce physicians qualified to promote health, prevent and treat disease, and relieve suffering. Although some aspects of the practice of medicine can be learned in classrooms, from textbooks, or with simulators, other aspects can only be learned through the direct provision of patient care. Residency programs therefore offer essential educational experiences that support residents' acquisition of knowledge, skills, and professional judgment through the assumption of progressive responsibility under an appropriate level of supervision. Yet, ethical questions can arise when medical education is integrated with patient care. How should we balance the educational needs of residents and the social benefits of medical education against obligations to patients and families? In this article, we present the case of a child whose family requests that residents not be allowed to perform any procedures on their child and then ask experts (a pediatric residency program director, a pediatrics resident, and an ethicist) to comment.

Arabic version of pharmacy survey on patient safety culture: Hospital pharmacy settings

Objective:

The objective was to assess the validity and reliability of a translated Arabic language version of the pharmacy survey on patient safety culture released by the United States Agency for Healthcare Research and Quality in 2012 and to utilize this to assess staff attitudes and perceptions of the patient safety culture in hospital pharmacies of Kuwait.

Methods:

This study used a cross-sectional timeframe. Data were gained from three of the largest public hospital pharmacies and three of the largest private hospital pharmacies in Kuwait. The primary and secondary outcome measures were descriptive statistics, internal consistency, construct validity, model fit, and calculation of the positive response rate for all composites and items.

Results:

The results demonstrated that 9 of the 11 composites had a Cronbach’s alpha (α) of >0.7, and all composites had factor loadings above 0.6. The standardized root mean residual score appropriately fitted the data with a value of 0.072. The intercorrelations among the patient safety composites ranged from 0.29 to 0.83. The proportion of pharmacy staff who categorized the grade of patient safety as “Good,” Very good,” or “Excellent” was 93%.

Conclusion:

The Arabic version of the pharmacy survey on patient safety culture questionnaire indicated suitable levels of reliability and validity. Also, the results demonstrated that the pharmacy staff surveyed in Kuwait have a positive perception of patient safety culture in their organizations.

The Enabling, Enacting, and Elaborating Factors of Safety Culture Associated With Patient Safety: A Multilevel Analysis

PURPOSE

Worldwide, 1 in 10 hospital patients is harmed while receiving care. Despite evidence that a culture of safety is associated with greater patient safety, these effects and the processes by which safety culture impacts patient safety are not yet clearly understood. Therefore, the purpose of this study was to examine the effects of various safety culture factors on nurses' perceptions of patient safety using an innovative theoretical model.

DESIGN

This descriptive, correlational study drew on deidentified, publicly available data from the 2018 Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture. The study sample included 34,514 nurses who provided direct care to patients in medical and surgical units in 535 hospitals in the United States.

METHODS

Multilevel linear regression was used to examine the effects of 11 safety culture factors on nurses' overall perceptions of patient safety. The 11 safety culture factors were grouped as enabling, enacting, and elaborating processes, and entered in separate blocks.

FINDINGS

All 11 safety culture factors were associated with nurse-perceived patient safety, and all but two of the 11 factors uniquely predicted nurse-perceived patient safety. Staffing adequacy was the strongest predictor of nurse-perceived patient safety, followed by hospital management support for patient safety (both enabling processes), and continuous organizational learning and improvement (an elaborating process).

CONCLUSIONS

Hospital administrators and managers play a key role in promoting a safety culture and patient safety in healthcare organizations through enabling and elaborating processes.

CLINICAL RELEVANCE

Organizational efforts should be made to provide sufficient staffing and hospital-wide support for patient safety. However, all staff, administrators, and managers have a role to play in patient safety.

Occupational stress and cognitive failure of nurses and associations with self-reported adverse events: A national cross-sectional survey

AIM

To determine correlations for nurse self-reported occupational stress, prevalence of cognitive failure (CF), and adverse events.

DESIGN

Cross-sectional nationwide survey.

METHODS

Tertiary-level public hospitals (N = 115) from 13 provinces in Iran were recruited and 2,895 nurses surveyed (August 2016-December 2017). Participants' self-reported demographic information, occupational stress, CF, and frequency of adverse events were analysed using chi-square, t tests, and binary logistic regression.

RESULTS

This study showed that 29.1% of nurses had experienced adverse events in the past six months. Significant predictors for reported adverse events from logistic regression were 'Role stressors', 'Interpersonal relations stressors', and 'Action', while 'Working environment stressors' was protective for reported adverse events. Demographic predictors of adverse events were longer work hours and male gender, while those working in critical care units, general wards, and other wards had higher reported adverse events than for emergency wards.

CONCLUSIONS

Occupational stress and CF are associated with the reporting of adverse events. Further research is needed to assess interventions to address occupational stress and CF to reduce adverse events.

IMPACT

Adverse events compromise patient safety, lead to increased healthcare costs, and impact nursing staff. Higher self-reported adverse events were associated with higher reported stressors and CF. Understanding the factors that influence occupational stress, CF, and adverse events will support quality patient care and safety.

Relating Medical Errors to Medical Specialties: A Mixed Analysis Based on Litigation Documents and Qualitative Data

BACKGROUND

We know a great deal about types, causes, and prevention of medical errors, as well as the risks of each medical specialties. Although we know something about medical errors, much remains to be done in this area particularly around effective prevention. However, little is known about whether medical errors are related to medical specialties. Our objective was to categorize and map the distribution of medical errors and analyze their relationships with medical specialties.

METHODS

First, public cases of medical disputes were searched on "China Judgment Online" according to the key words including medical errors. Second, we set up a database with 5237 medical litigations. After removing unrelated judgment documents, we used systematic random sampling to extract half of these. Then, we hired two frontline physicians with M.D. to review the litigation documents and independently determine the medical errors and the departments in which they took place. A third physician further reviewed the divergent results. After the descriptive statistical analysis and mind map analysis, semi-structured interviews were further conducted with 63 doctors to reveal the relationships mentioned above.

RESULTS

More than 97.8% of medical errors occurred in clinical departments. The insufficient implementation of informed consent obligations is the top medical error in all medical departments [internal medical departments (12.86%, N=36), surgical departments (14.57%, N=106), specialist departments (13.16%, N=86)]. The types of medical errors in diverse medical departments might be associated with therapeutic means used by physicians. Errors related to surgical operations were common in surgical departments, errors related to diagnoses were common in internal medicine departments, and errors related to therapy were common in specialist departments. A lack of clinical experience and undesirable work system design have contributed to the occurrence of medical errors. Inadequate human resources and unreasonable shift systems have increased the workload of staff members and this has in turn increased the incidence rate of medical errors.

CONCLUSION

Medical departments are facing medical errors both in humanity and technology. Medical institutions should be alert to the harm caused by medical humanity (mainly including insufficient communication between physicians and patients, insufficient implementation of infringement of informed consent, infringement of patient's privacy and overtreatment). Improving the clinical skill and vigilance of medical staff is a top priority. Medical institutions should also improve undesirable system designs.

Toward a Corporate Culture of Health: Results of a National Survey

Policy Points The private sector has large potential influence over social determinants of health, but we have limited information about how businesses perceive or engage in actions to promote health and well-being. We conducted a national survey of more than 1,000 businesses of varying sizes and industries to benchmark private sector engagement in employee, environmental, consumer, and community health, which we collectively refer to as a corporate culture of health. Overall, the private sector is taking steps to foster health and well-being but still has substantial opportunity for growth.

CONTEXT

The private sector has a large potential role in advancing health and well-being, but attention to corporate practices around health tends to focus on a narrow range of issues and on large businesses. Systematically describing private sector engagement in health and well-being is a necessary step toward understanding the current state of the field and developing an agenda for businesses going forward.

METHODS

We conducted a national survey of 1,017 private sector organizations to assess current levels of engagement in what we term a culture of health (CoH). We measured corporate CoH along four dimensions, which assess the extent to which businesses promote employee, environmental, consumer, and community health and well-being. We also explored potential explanations for the number of health-related actions taken in each dimension.

FINDINGS

On average, businesses took 38% of health-related actions included in our survey. For each dimension, we found variation among businesses in the number of actions taken (on average, there were almost fourfold differences between the bottom and top quartiles of businesses in terms of actions taken). Mentioning health and well-being in the corporate mission, having a strategic plan for CoH, and perceiving a positive return on CoH investments were all associated with businesses' actions taken. Fewer than half of businesses, however, perceived a positive return on their CoH investments.

CONCLUSIONS

Overall, the private sector is taking steps to foster health and well-being. However, there remains substantial variation among businesses and opportunity for growth, even among those currently taking the most action. Strengthening the business case for a corporate CoH may increase private sector investments in health and well-being. Actions taken by individual businesses, business groups, industries, and regulators have the potential to improve corporate engagement and impact.

Safety climate, safety climate strength, and length of stay in the NICU

Background

Safety climate is an important marker of patient safety attitudes within health care units, but the significance of intra-unit variation of safety climate perceptions (safety climate strength) is poorly understood. This study sought to examine the standard safety climate measure (percent positive response (PPR)) and safety climate strength in relation to length of stay (LOS) of very low birth weight (VLBW) infants within California neonatal intensive care units (NICUs).

Methods

Observational study of safety climate from 2073 health care providers in 44 NICUs. Consistent perceptions among a NICU’s respondents, i.e., safety climate strength, was determined via intra-unit standard deviation of safety climate scores. The relation between safety climate PPR, safety climate strength, and LOS among VLBW (< 1500 g) infants was evaluated using log-linear regression. Secondary outcomes were infections, chronic lung disease, and mortality.

Results

NICUs had safety climate PPRs of 66 ± 12%, intra-unit standard deviations 11 (strongest) to 23 (weakest), and median LOS 60 days. NICUs with stronger climates had LOS 4 days shorter than those with weaker climates. In interaction modeling, NICUs with weak climates and low PPR had the longest LOS, NICUs with strong climates and low PPR had the shortest LOS, and NICUs with high PPR (both strong and weak) had intermediate LOS. Stronger climates were associated with lower odds of infections, but not with other secondary outcomes.

Conclusions

Safety climate strength is independently associated with LOS and moderates the association between PPR and LOS among VLBW infants. Strength and PPR together provided better prediction than PPR alone, capturing variance in outcomes missed by PPR. Evaluations of NICU safety climate consider both positivity (PPR) and consistency of responses (strength) across individuals.

Hospital Survey on Patient Safety Culture (HSPSC): a systematic review of the psychometric properties of 62 international studies

OBJECTIVE

To carry out a systematic review of the psychometric properties of international studies that have used the Hospital Survey on Patient Safety Culture (HSPSC).

DESIGN

Literature review and an analysis framework to review studies.

SETTING

Hospitals and other healthcare settings in North and South America, Europe, the Near East, the Middle East and the Far East.

DATA SOURCES

A total of 62 studies and 67 datasets made up of journal papers, book chapters and PhD theses were included in the review.

PRIMARY AND SECONDARY OUTCOME MEASURES

Psychometric properties (eg, internal consistency) and sample characteristics (eg, country of use, participant job roles and changes made to the original version of the HSPSC).

RESULTS

Just over half (52%) of the studies in our sample reported internal reliabilities lower than 0.7 for at least six HSPSC dimensions. The dimensions 'staffing', 'communication openness', 'non-punitive response to error', 'organisational learning' and 'overall perceptions of safety' resulted in low internal consistencies in a majority of studies. The outcomes from assessing construct validity were reported in 60% of the studies. Most studies took place in a hospital setting (84%); the majority of survey participants (62%) were drawn from nursing and technical staff. Forty-two per cent of the studies did not state what modifications, if any, were made to the original US version of the instrument.

CONCLUSIONS

While there is evidence of a growing worldwide trend in the use of the HSPSC, particularly within Europe and the Near/Middle East, our review underlines the need for caution in using the instrument. Future use of the HSPSC needs to be sensitive to the demands of care settings, the target population and other aspects of the national and local healthcare contexts. There is a need to develop guidelines covering procedures for using, adapting and translating the HSPSC, as well as reporting findings based on its use.

Patient safety culture among European cancer nurses-An exploratory, cross-sectional survey comparing data from Estonia, Germany, Netherlands, and United Kingdom

Aim

To explore the differences in perceived patient safety culture in cancer nurses working in Estonia, Germany, the Netherlands, and the United Kingdom.

Design

An exploratory cross‐sectional survey.

Methods

In 2018, 393 cancer nurses completed the 12 dimensions of the Hospital Survey on Patient Safety Culture.

Results

The mean score for the overall patient safety grade was 61.3. The highest rated dimension was “teamwork within units” while “staffing” was the lowest in all four countries. Nurses in the Netherlands and in the United Kingdom, scored higher on “communication openness”, the “frequency of events reported”, and “non‐punitive response to errors”, than nurses from Estonia or Germany. We found statistically significant differences between the countries for the association between five of the 12 dimensions with the overall patient safety grade: overall perception of patient safety, communication openness, staffing, handoffs and transitions and non‐punitive response to errors.

Conclusion

Patient safety culture, as reported by cancer nurses, varies between European countries and contextual factors, such as recognition of the nursing role and education have an impact on it. Cancer nurses’ role in promoting patient safety is a key concern and requires better recognition on a European and global level.

Impact

Cancer Nursing Societies in any country can use these data as an indication on how to improve patient care in their country. Recognition of cancer nursing as a distinct specialty in nursing will help to improve patient safety.

Factors Influencing the Implementation of a Hospitalwide Intervention to Promote Professionalism and Build a Safety Culture: A Qualitative Study

BACKGROUND

There is widespread recognition that creating a safety culture supports high-quality health care. However, the complex factors affecting cultural change interventions are not well understood. This study examines factors influencing the implementation of an intervention to promote professionalism and build a safety culture at an Australian hospital.

METHODS

The study was completed midway into the three-year intervention and involved collecting qualitative data from two sources. First, face-to-face interviews were conducted pre- and mid-intervention with a purposely selected sample. Second, a survey with three open-ended questions was completed one year into the intervention by clinical and patient support staff. Data from interviews and survey questions were analyzed using a combination of inductive and deductive approaches.

RESULTS

A total of 25 participants completed preintervention interviews, and 24 took part mid-intervention. Of the 2,047 staff who completed the survey (61% response rate), 59.1% of respondents answered at least one open-ended question. Multiple interrelated factors were identified as enhancing intervention implementation. These include sustaining a favorable implementation climate, leaders consistently demonstrating behaviors that support a safety culture, increasing compatibility of working conditions with intervention aims, building confidence in systems to address unprofessional behaviors, and responding to evolving needs.

CONCLUSION

Strengthening safety culture remains an enduring challenge, but this study yields valuable insights into factors influencing implementation of a multifaceted behavior change intervention. The findings provide a basis for practical strategies that health care leaders seeking cultural improvements can employ to enhance the delivery of similar interventions and address potential impediments to success.

Turnover intention of hospital staff in Ontario, Canada: exploring the role of frontline supervisors, teamwork, and mindful organizing

BACKGROUND

This study contributes to a small but growing body of literature on how context influences employee turnover intention. We examine the impact of staff perceptions of supervisory leadership support for safety, teamwork, and mindful organizing on turnover intention. Interaction effects of safety-specific constructs on turnover intention are also examined.

METHODS

Cross-sectional survey data were collected from nurses, allied health professionals, and unit clerks working in intensive care, general medicine, mental health, or the emergency department of a large community hospital in Southern Ontario.

RESULTS

Hierarchical regression analyses showed that staff perceptions of teamwork were significantly associated with turnover intention (p < 0.001). Direct associations of supervisory leadership support for safety and mindful organizing with turnover intention were non-significant; however, when staff perceived lower levels of mindful organizing at the frontlines, the positive effect of supervisory leadership on turnover intention was significant (p < 0.01).

CONCLUSIONS

Our results suggest that, in addition to teamwork perceptions positively affecting turnover intentions, safety-conscious supportive supervisors can help alleviate the negative impact of poor mindful organizing on frontline staff turnover intention. Healthcare organizations should recruit and retain individuals in supervisory roles who prioritize safety and possess adequate relational competencies. They should further dedicate resources to build and strengthen the relational capacities of their supervisory leadership. Moreover, it is important to provide on-site workshops on topics (e.g., conflict management) that can improve the quality of teamwork and consequently reduce employees' intention to leave their unit/organization.

Improving Resident-To-Attending Communication: Implementing a Tool to Facilitate Attending Notification of Critical Patient Events at a Single Academic Institution

Ineffective communication between surgical trainees and attending surgeons is a significant contributor to patient harm. The aim of this study was to evaluate a tool to improve resident-to-attending communication regarding changes in patient clinical status. Ten critical patient events were compiled into a list of triggers for direct attending surgeon notification at a single academic institution. Residents and faculty were surveyed to assess communication before and after implementation of the list. Institution of the triggers list was associated with a nonstatistically significant increase in resident-to-attending notification regarding 7 of 10 critical patient events. There was no reported change in frequency of calls associated with the list's implementation. Most residents felt that the list improved patient care and increased their comfort with calling attending surgeons. Comments were generally positive; however, both groups expressed concern that the list could negatively impact resident autonomy and supervision. Implementing a list of triggers for attending notification of critical patient events subjectively improved resident-to-attending communication in an environment with high baseline levels of communication.

Applying the American Nurses Association Credentialing Center Accreditation Program in the Setting of Registered Nurse Remediation

The objective of this project was to use and evaluate the American Nurses Credentialing Center (ANCC) accreditation program in the context of registered nurse practice remediation using Just Culture. The quality improvement project intervention was aimed at educating nursing professional development educators about the accreditation program for registered nurse remedial education and implementing this program for remediation. It compared pre- and postintervention data for nurse educators using the nine key elements.