printable versionStudy seeks to measure, improve hospitals’ safety culture
BY SARA SELIS
Executives at Northwest Hospital Center in Baltimore thought they were doing a good job of promoting patient safety and quality care. The 200-bed hospital closely monitors its data on key safety measures, such as patient falls and infections. And it has implemented several initiatives to meet annual patient safety goals.
Still, the hospital's leadership said they also wanted to know how their 295 physicians and 1,500 employees felt about patient safety: Did they have the resources needed to provide the safest possible care? If they saw a co-worker make a mistake, would they report it or keep quiet? Did they believe management understood the problems at their facility that could lead to medical errors?
Like most hospitals, Northwest had few resources to gain such insight. So when the hospital's executives were approached in 2004 by researchers at Stanford's Center for Health Policy/Center for Primary Care and Outcomes Research about participating in a national patient safety study, they signed up. And the experience has led them and other institutions to rethink how they are handling the problem.
"We'd been talking a lot about patient safety, but things hadn't filtered down to the staff as much as we expected," said Candy Hamner, Northwest's vice president of care management, after receiving the study's findings about her hospital. The results "showed us we needed to focus on closing that communication gap and making sure our people knew how much we cared about safety."
The study, led by Laurence Baker, PhD, associate professor of health research and policy, and Sara Singer, a CHP/PCOR senior scholar now based at Harvard, is the largest effort to date to measure and improve hospitals' "safety culture"—a set of attitudes and beliefs about patient safety that pervade an organization, from the CEO to housekeeping staff. The project builds on a decade of research by David Gaba, MD, professor of anesthesia, and Singer.
The concept of safety culture, now increasingly applied to health care, originated in high-risk fields such as naval aviation and nuclear power, in which researchers found that an organizational culture of safety played a key role in fostering an excellent safety record. "It's hard to put your finger on it, because it's not something concrete," Baker explained. "It's basically an attitude that says safety takes precedence over everything else."
The project is aimed at producing a detailed picture of patient-safety culture in U.S. hospitals, determining whether safety culture is associated with patient outcomes and testing whether it can be improved through an intervention that gets hospital executives to interact more with front-line staff.
The 92 participating hospitals include those large and small, for-profit and nonprofit, rural and urban, academic and community-based. In the project's first phase, completed last year, the hospitals sent a "safety climate survey" to senior managers, staff physicians and front-line employees. The questionnaire measured workers' perceptions of various aspects of safety culture, including fear of punishment, organizational support and management's involvement with safety issues.
The CHP/PCOR researchers documented that hospital managers such as the ones at Northwest tend to have a more positive view of their hospital's safety culture than front-line employees. Senior managers gave a "problematic" response on 12 percent of the questions, while staff gave a problematic response on 17 percent. That difference, researchers said, is statistically significant.
"Managers aren't out on the floor with patients, so they're not as aware of the day-to-day problems," said Singer.
The researchers hypothesized that if hospital managers had closer contact with front-line staff, it would narrow the gap, which would strengthen hospitals' safety culture and practices. Building on business theories of "management by walking around," the researchers—with Anita Tucker, assistant professor at the Wharton School—developed an intervention program that requires senior executives at each hospital to participate in a sequence of three activities in several work areas, including the ED, ICU, surgery and pharmacy. Twenty-four of the participating hospitals were randomly selected to implement the intervention last year, including Northwest Hospital Center, where Hamner and three other executives participated.
For the first part of the intervention, dubbed "work-site observations," the executives spend 30-60 minutes shadowing employees in a particular work area. The executives are instructed to observe and ask questions to learn what obstacles may be hindering safe care.
For Hamner, these visits were an eye-opener, showing her the complexities and challenges of providing patient care. On a visit to the emergency department, staff members pointed out that during the night shift, certain medical instruments were kept locked up in a separate room. This caused some procedures to be delayed, as physicians waited for equipment to be retrieved. When she visited the pharmacy, she noticed that the pharmacists were entering medication orders in a noisy area and experienced frequent interruptions. They told Hamner this environment made it difficult to focus on their work—a situation that could lead to medication errors.
"If we'd thought about the best way to organize work on that unit, we wouldn't have designed it that way," Hamner said.
After visiting each work area, the executives hosted a "safety forum" in that area, to discuss employees' concerns about and ideas for improving patient safety. Alyson Falwell, CHP/PCOR project manager for the study, said prompt follow-up is crucial to building a strong safety culture. "If you ask 100 hospital CEOs whether they think patient safety is important, they'll all say yes, but they need to back it up with action. There's a big difference between talking the talk and walking the walk."
To make sure the hospitals "walk the walk," the third part of the intervention requires that soon after an area's safety forum, a team including staff members, area managers and senior executives meets to prioritize the problems identified and develop plans to address them. Management must also send out periodic communications to update staff on their progress.
This fall, all of the hospitals in the study are repeating the safety culture surveys, enabling them and the researchers to track changes in their safety culture. The researchers expect that, compared with a control group, the intervention hospitals will show a greater improvement in safety-culture scores and a smaller difference between managers' and staff's responses.
The researchers are also seeking to show that there is a connection between safety culture and patient outcomes—that hospitals with a stronger safety culture have fewer patient deaths or complications, for example. By comparing the hospitals' first round of survey scores with their data from the national Patient Safety Indicators (measures that track errors and complications) the researchers have found a statistically significant relationship between the safety indicators and dimensions of safety culture.
"Making that link between safety culture and outcomes is important," Baker said. "We need to be able to say to people, 'Culture matters.'"