BACKGROUND/RATIONALE:
Further research is needed in measuring safety climate in VA hospitals and to relating this climate to outcomes of patient care. We have developed the Patient Safety Climate in Hospital Organization (PSCHO) instrument to measure each individual's perceived safety climate by the amount of "problematic response" (responses that are against a safety climate) to survey questions. Our proposed project is a VA hospital companion to an AHRQ-funded project we are conducting on the safety climate in 120 non-VA hospitals nationwide. This study will enable the VA to obtain important information- alone and in comparison to private sector facilities - about the strength and uniformity of its safety climate, its variability across hospitals, work units, and Veterans Integrated Service Networks (VISNs), as well as about the link between safety climate and patient outcomes in VA facilities.
OBJECTIVE(S):
Safety culture/safety climate of hospital personnel is a key component of patient safety. The purpose of the study is to assess the level of safety climate in VA hospitals and improve understanding of the safety culture in VA hospitals using the previously developed and validated Patient Safety Climate in Healthcare Organizations (PSCHO) survey in a nationwide sample of 30 VA hospitals. Our objectives are:
* To assess safety climate in 30 VA hospitals and in a representative sub-sample of work units of high intrinsic hazard using the PSCHO instrument;
* To compare safety climate to selected hospital characteristics, and to compare VA to non-VA facilities;
* To compare PSCHO data to (measured by the Zammuto and Karkower survey) and implementation of quality improvement (QI) practices (measured using Baldrige scales);
* To compare the level of safety climate to measures of patient safety outcomes;
* To compare the level and uniformity of safety climate in VA hospitals to that in high-reliability organizations in other high-hazard industries.
METHODS:
The project will obtain 2006 and 2007 primary data on the safety climate in VA by surveying employees with the PSCHO survey plus either the modified Baldrige survey or the abridged Zammuto and Krakower survey. Survey will be administered twice to examine longitudinal changes in safety climate and to determine if relationships between climate and outcome are stable over time. We will survey 100% of hospital-based physicians & senior managers (defined as department heads and above) and a 10% random sample of staff. In addition, at some hospitals, we will survey 100% staff working in high hazard units. Secondary data (FY2005-2006) will be obtained from a variety of VA and non-VA sources will investigate relationships between safety climate and PSIs & NSQIP outcome data, and hospital characteristics. We will compare safety climate in VA and non-VA hospitals using comparable data being collected by the investigators on 120 non-VA hospitals. We will also compare VA safety climate with the safety climate in non-health care organizations. The PSCHO consists of 42 Likert-scale questions and six demographic questions. For each question, a "problematic response" (PR) suggested a weak safety climate. We calculated average PR rates and 95% confidence intervals (CIs), accounting for sample proportion and patterns of non-response for each question and job-type across all participating hospitals. We applied multi-trait analysis to responses in the derivation sample to create an initial scale structure and confirmed this structure by applying confirmatory factor analysis in the validation sample. We compared results to a companion study that administered the PSCHO survey in 105 non-VA hospitals.
FINDINGS/RESULTS:
The psychometric characteristics of the PSCHO survey have been assessed and as a result, several new questions were added to the survey while a few old ones were deleted. We received 4504 surveys across 29 hospitals (one recruit could not administer the survey). The average overall PR rate across all hospitals and personnel was 18.1%; rates of PR varied widely between institutions, ranging from 4.4% to 49.6%. The questions eliciting the highest and lowest PR rate were "My unit recognizes individual safety achievement through rewards and incentives" and "If I make a mistake that has significant consequences and nobody notices, I do not tell anyone about it," respectively. Physicians and hospital employees had statistically significantly higher PR rates than senior managers (PRs = 17.1, 17.3, and 9.8%, respectively); nurses had the highest PR rates of any job-type (PR=20.8%; CI=17.0%-24.7%). We found empirical support for eleven scales: senior leadership, resources for safety, overall, unit leadership, unit norms, unit recognition, learning, psych safety 1: no retribution, psychological safety 2: protection for initiative, problem solving, and outcomes. Consistent with the private sector, we found that a) perceptions of safety culture differed among hospitals, job-type, and work area, b) senior managers have a more positive perception of safety culture than frontline staff, and c) employees working in high-hazard areas have a more negative perception of safety culture. We found that higher levels of safety climate were significantly associated with hospital metropolitan location, location in South, and higher levels of group and entrepreneurial cultures and higher levels of cultural balance. Higher levels of hierarchical culture were significantly associated with lower levels of safety climate. We did not find a strong association between our culture measure and outcomes as measured by PSIs and NSQIP.
IMPACT:
VA is a leader in the patient safety movement and has instituted a number of programs aimed at reducing preventable deaths or morbidity. Yet, little has been done to address the systematic safety climate of VA's management or front-line workers. Moreover, it is not known how VA compares to the private sector after the efforts and investments in these activities. These comparisons can help determine if VA facilities are indeed leaders in safe care or if they lag behind similar facilities in the private sector. If the former is true, it will reinforce the benefits of existing patient safety programs. If the latter is found, VA may need to re-think its patient safety activities, as they might not be resulting in the outcomes desired.
PUBLICATIONS:
Journal Articles
- Rosen AK, Gaba DM, Meterko M, Shokeen P, Singer S, Zhao S, Labonte A, Falwell A. Recruitment of hospitals for a safety climate study: facilitators and barriers. Joint Commission Journal on Quality and Patient Safety. 2008; 34(5): 275-84.
- Gaba DM, Singer SJ, Rosen AK. Safety culture: is the "unit" the right "unit of analysis"? Critical Care Medicine. 2007; 35(1): 314-6.
- Dutta S, Gaba D, Krummel TM. To simulate or not to simulate: what is the question? Annals of Surgery. 2006; 243(3): 301-3.
- Sowb YA, Howard SK, Raemer DB, Feinstein D, Fish KJ, Gaba DM. Clinicians' recognition of the Ohmeda Modulus II Plus and Ohmeda Excel 210 SE anesthesia machine system mode and function. Simulation in healthcare : journal of the Society for Simulation in Healthcare. 2006; 1(1): 26-31.
- Gaba DM. What makes a "good" anesthesiologist? Anesthesiology. 2004; 101(5): 1061-3.
- Gaba DM. The future vision of simulation in health care. Quality & Safety in Health Care. 2004; 13 Suppl 1: i2-10.
