|
Article Excerpt
Despite substantial efforts by many health care organizations, medical errors remain too common and continue to generate significant personal and financial burdens (Institute of Medicine 2006). Researchers who study organizations that face hazardous and turbulent task conditions, yet demonstrate sustained superior safety performance, attribute their achievement in large part to their culture of safety (Roberts 1990; Weick and Sutcliffe 2001). These organizations, often termed high-reliability organizations (HROs), are "systems operating in hazardous conditions that have fewer than their share of adverse events" (Reason 2000) and include aircraft carriers, air traffic control systems, and nuclear power plants. The main distinguishing feature of HROs is their ability to perform demanding activities with low incident rates and an almost complete absence of catastrophic failures over several years. Based on evidence from HROs, policy makers interested in improving health care delivery have called upon health care organizations to strengthen their safety culture to reduce adverse events (Institute of Medicine 2001).
In this study, the safety culture of an organization is viewed as the values shared among organization members about what is important, their beliefs about how things operate in the organization, and the interaction of these with work unit and organizational structures and systems, which together produce behavioral norms in the organization that promote safety. Although this definition is similar to definitions of organizational culture more generally (Schein 1992), it is specific to the safety culture of an organization and highlights the role of interpersonal, work unit, and organizational contributions in forming shared basic assumptions that individuals working in organizations develop over time. Like others, we adopt the view that culture is difficult to measure, and that it is more feasible to track a related construct called safety climate (Zohar 1980; Griffin and Neal 2000), the perceptions and attitudes of the organization's workforce about surface features of the culture of safety in hospitals at a given point in time (Flin 2007).
While most presume that better safety climate in hospitals will be associated with fewer errors and better outcomes, quantitative evidence establishing this link is limited. Anticipated benefits would stem from the ability of organizations with strong safety climates to cultivate behaviors that enhance collective learning by addressing unproductive beliefs and attitudes about errors, their cause and cure. Obtaining better information about the relationship between hospital safety climate and safety performance would be beneficial. By highlighting the importance of safety climate, such information would facilitate the development of benchmarks and initiatives to improve it. Further recognition of safety climate's importance would promote collaboration within and among organizations to compare the measures of safety climate and share useful approaches. Such information would also help hospital managers and clinicians target approaches to safety improvement of greatest potential value.
In this study, we examined the relationship between hospital safety climate and measures of hospital performance on selected indicators of patient safety. We combined data from a survey that measured safety climate among personnel in a national sample of hospitals, with indicators of potential safety events from the Agency for Healthcare Research and Quality's Patient Safety Indicators (AHRQ PSIs).
BACKGROUND
Hospitals with strong safety climates prioritize safety and integrate it into the daily functioning of the organization and the routines of individuals and teams that work within it. They also empower workers and provide psychological safety (i.e., comfort to take interpersonal risks), which enables personnel to prevent, solve, and learn collectively from problems that occur at the frontlines of care delivery (Edmondson 1999).
A number of surveys produce quantitative measures of hospital safety climate (see Singla et al. 2006). Differences in measurement approaches reflect divergent opinions regarding open questions. One question concerns the level of aggregation at which climate should be measured (Gaba, Singer, and Rosen 2007). In this study, we focus on institution-level measures. Assessing the overall level of climate of an organization is valuable, because many kinds of outcomes, especially those assessable using administrative data, result from patient care in multiple work units. We also study some measures for individuals in specific job types on an organization-wide basis, capturing all individuals in a hospital in the same job category.
Another measurement question concerns the components of climate. Our survey instrument identifies three groups of dimensions that include important components of an overall climate of safety. First, some aspects of safety climate reflect features of an entire organization, such as the allocation of organizational resources and engagement of organizations' senior managers. Second, dimensions reveal normative features of work units, including norms of socially acceptable behavior and use of patient safety standards in unit operations. Finally, dimensions reflect interpersonal dynamics among individuals who work in the unit, such as their willingness to take interpersonal risks for the sake of safety.
Ultimately, safety climate in a hospital is determined by the internalized values and beliefs of hospital personnel, which evidence themselves in their behaviors. Daily activities and experiences at work heavily influence workers through acculturation. Peers and managers in a work unit and within a professional discipline in a unit strongly influence individual attitudes and behaviors toward safety and establish an identifiable climate of work processes. The hospital represents an aggregation of the interacting subcultures of its work units. Senior executives, and the decisions and resources they control, strongly influence the safety climate that individuals and work units express. The instrument used in this paper explicitly assesses factors that reflect contributions by all three levels.
Prior Research Regarding the Relationship of Safety Climate and Safety Performance
Prior research has demonstrated a link between organizational culture or climate and organizational outcomes, including financial (Kotter and Heskett 1992), quality (Carman et al. 1996), and safety (Clarke et al. 2002; Brewer 2006; Stone and Gershon 2006) performance. Evidence more closely related to safety climate has come from case studies of HROs, which have attributed their safety records to strong safety culture, and from accident investigations, which have identified the absence of important aspects of safety culture as a major cause (see, e.g., Vaughan 1996). In addition, relationships between safety performance and many of the specific dimensions typically considered part of safety culture also have been suggested on theoretical grounds (see Appendix SA2).
Work from other industries has linked rates of injuries and accidents with safety climate and related dimensions (Clarke 2006). Within health care, four studies (Katz-Navon, Naveh, and Stern 2005; Hofmann and Mark 2006; Neal and Griffin 2006; Vogus and Sutcliffe 2007) report a link between numbers of medication errors and other outcomes with measures of selected safety behaviors and contextual factors in hospital units. In addition, one study found that better safety climate corresponded to lower rates of incident reports for four hospitals (Weingart et al. 2004). However, careful analyses of the link between hospital safety climate and patient safety outcomes at the organizational level of analysis have not been conducted.
Prior studies used measures that assumed safety climate is one-dimensional or captured only selected dimensions. In addition, all but one (Hofmann and Mark 2006) used perceptual measures or self-reported estimates of clinical impact rather than objectively derived measures of clinical quality. These indicators may be poorly associated with actual error rates and may...
|
