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...safety systems, terms of both extent of systems and progress over time?
To answer this question, a survey was administered to 107 hospitals at two points in time. Data were consolidated into seven latent variables measuring progress in specific areas. Using the overall measure, Joint Commission-accredited hospitals showed statistically significant improvement, as reflected in the sum score (p = .01); nonaccredited hospitals did not show statistically significant improvement (p = .21). Joint Commission accreditation was the key predictor of patient safety system implementation. Management type and urban/rural status were secondary predictors.
Several factors may account for the strong association between accreditation and patient safety system implementation. In 2003, the Joint Commission began tying accreditation to patient safety goals. Also, Joint Commission data are now widely available to the public and may stimulate hospitals to address safety issues. Healthcare executives, hospital trustees, regulators, and policymakers should encourage Joint Commission accreditation and reward hospital efforts toward meeting Joint Commission standards. The Joint Commission should continually strive to maintain evidence-based and state-of-the-art standards that advance the aim of providing the best possible care for hospitalized patients.
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Seven years ago, the Institute of Medicine (IOM) reported that at least 44,000, and perhaps as many as 98,000, deaths annually could be attributed to medical errors and that such preventable adverse events cost the United States an estimated $17 billion to $29 billion (Chassin and Galvin 1998; Kohn, Corrigan, and Donaldson 2000). The IOM not only urged hospitals and healthcare professionals to improve patient safety practices, but it also called on Congress and other policymakers, regulators, private and public purchasers, and patients to work together toward redesigning a national health system that is safe, effective, patient centered, timely, efficient, and equitable (Committee on Quality Health Care in America 2001). Yet concerns about patient safety continue to be raised. Senators Hillary Rodham Clinton (DNY) and Barack Obama (D-IL) recently added their voices to others, calling for improvements in patient safety, along with open disclosure when errors occur, as a "centerpiece" in addressing the nation's medical liability crisis (Clinton and Obama 2006; Hattie and Sheridan 2003; Rao et al. 2006). Critics have cited IOM findings that more than 90 percent of deaths from medical errors are the result of failed systems and procedures, rather than physician negligence (Kohn, Corrigan, and Donaldson 2000), as well as the conclusions of other studies and commentaries indicating that medical malpractice lawsuits more often stem from ineffective communication between patients and providers than from adverse medical outcomes in themselves (Sage 2003; Vincent, Young, and Phillips 1994). Although different databases and methods were used, other researchers have reached similar conclusions (AHRQ 2004; AHRQ 2005; Altman, Clancy, and Blendon 2004; Galvin et al. 2005; Leape and Berwick 2005; Wachter 2004). According to Longo and colleagues (2005), "The current status of hospital patient safety systems is not close to meeting IOM recommendations.... System progress is slow and is a cause for great concern" (2858). Others have pointed out the need for a comprehensive systems approach to patient safety and the challenge of identifying appropriate measurement methods (Stryer 2004; Thomas and Petersen 2003). Yet, as Longo and colleagues (2005) point out, patient safety systems are not being developed consistently. In this study, we examined characteristics of those hospitals that are (1) likely to have more extensive patient safety systems than others and (2) likely to have made more progress in implementing such programs over time.
METHODS
We used a two-factor (states--Utah and Missouri; survey time) quasi-experimental design with repeated measures on one factor (surveys were conducted twice, approximately 18 months apart). Data were obtained from a 91-question survey using dichotomous (yes/no) and seven-level ordinal measurement questions. For this study we used data from the cohort of hospitals that responded to the survey at both points in time (n = 107, response rate = 65.2 percent). In a previous study (Longo et al. 2005), given the large number of variables, seven latent variables were constructed from the ordinal-level questions to summarize data and identify key aspects of patient safety (Table 1). We developed a measure of the overall level of system implementation that permits us to address a fundamental question previously unanswered: What organizational characteristics are associated with better performance in implementing patient safety systems? The concept of systems and their applicability to patient safety, as well as the generalizability of findings, were discussed in a previous article (Longo et al. 2005). We developed a latent variable summary measure that was consistent with established methods (Fox 1970; Johnson and Wichern 1992) and resulted in a coefficient [alpha] of 0.85. We correlated the sum with each of the seven-level questions. All correlations were positive, and all but one were highly significant; 47 of them had p values <.0001 (Table 2). These tests support the summary measure as an excellent method to capture system implementation.
Hospitals completing both surveys (n = 107) were included in our analyses. We considered bed size as both a quantitative and a dichotomous variable to make the best possible use of all bed-size information. A plot of the latent variable sum against bed size (Figure 1) was used to group hospitals by size; bed size of 0-99 was in one group and bed size [greater than or equal to] 100 was in the other. Other organizational characteristics of interest included management type, rural or urban location, and Joint Commission accreditation status. These were the type of variables considered in previous empirical investigations of the relationship of hospital organizational structure to various outcomes (Ayanian and Weissman 2002; Flood and Scott 1987; Griffith, Knutzen, and Alexander 2002; Kovner and Neuhauser 1990; Scott 1990; Shortell, Morrison, and Robbins 1990; Sloan et al. 2003; Thomas, Orav, and Brennan 2000). We examined means, medians, and standard deviations for quantitative variables and frequencies for categoric variables. The Wilcoxon rank sum test or Kruskal-Wallis test was used to determine if quantitative variables differed across categories. The Wilcoxon signed rank test identified differences from survey 1 to survey 2. It was also critical to determine if changes were different for different groups. Because potential to change is often determined by the initial value, we compared groups using the survey 2 value as the outcome variable and the survey 1 value as the covariate. To determine which characteristics were predictive of the latent variables, multiple regression models were constructed using the latent variables as dependent variables and the characteristics as independent variables. We used the dichotomous bed-size variable (bed size 0-99; bed size [greater than or equal to]...
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