Jason M. Etchegaray

Comparing two safety culture surveys: Safety Attitudes Questionnaire and Hospital Survey on Patient Safety

Objective To examine the reliability and predictive validity of two patient safety culture surveys—Safety Attitudes Questionnaire (SAQ) and Hospital Survey on Patient Safety Culture (HSOPS)—when administered to the same participants. Also to determine the ability to convert HSOPS scores to SAQ scores. Method Employees working in intensive care units in 12 hospitals within a large hospital system in the southern United States were invited to anonymously complete both safety culture surveys electronically. Results All safety culture dimensions from both surveys (with the exception of HSOPSs Staffing) had adequate levels of reliability. Three of HSOPSs outcomes—frequency of event reporting, overall perceptions of patient safety, and overall patient safety grade—were significantly correlated with SAQ and HSOPS dimensions of culture at the individual level, with correlations ranging from r=0.41 to 0.65 for the SAQ dimensions and from r=0.22 to 0.72 for the HSOPS dimensions. Neither the SAQ dimensions nor the HSOPS dimensions predicted the fourth HSOPS outcome—number of events reported within the last 12 months. Regression analyses indicated that HSOPS safety culture dimensions were the best predictors of frequency of event reporting and overall perceptions of patient safety while SAQ and HSOPS dimensions both predicted patient safety grade. Unit-level analyses were not conducted because indices did not indicate that aggregation was appropriate. Scores were converted between the surveys, although much variance remained unexplained. Conclusions Given that the SAQ and HSOPS had similar reliability and predictive validity, investigators and quality and safety leaders should consider survey length, content, sensitivity to change and the ability to benchmark when selecting a patient safety culture survey.

The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU

Background Neonatal intensive care unit (NICU) safety culture, as measured by the Safety Attitudes Questionnaire (SAQ), varies widely. Associations with clinical outcomes in the adult intensive care unit setting make the SAQ an attractive tool for comparing clinical performance between hospitals. Little information is available on the use of the SAQ for this purpose in the NICU setting. Objectives To determine whether the dimensions of safety culture measured by the SAQ give consistent results when used as a NICU performance measure. Methods Cross-sectional survey of caregivers in 12 NICUs, using the six scales of the SAQ: teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management and working conditions. NICUs were ranked by quantifying their contribution to overall risk-adjusted variation across the scales. Spearman rank correlation coefficients were used to test for consistency in scale performance. The authors then examined whether performance in the top four NICUs in one scale predicted top four performance in others. Results There were 547 respondents in 12 NICUs. Of 15 NICU-level correlations in performance ranking, two were >0.7, seven were between 0.4 and 0.69, and the six remaining were <0.4. The authors found a trend towards significance in comparing the distribution of performance in the top four NICUs across domains with a binomial distribution p=0.051, indicating generally consistent performance across dimensions of safety culture. Conclusion A culture of safety permeates many aspects of patient care and organisational functioning. The SAQ may be a useful tool for comparative performance assessments among NICUs.

Neonatal intensive care unit safety culture varies widely.

Background Variation in healthcare delivery and outcomes in neonatal intensive care units (NICUs) may be partly explained by differences in safety culture. Objective To describe NICU care giver assessments of safety culture, explore variability within and between NICUs on safety culture domains, and test for association with care giver characteristics. Methods NICU care givers in 12 hospitals were surveyed using the Safety Attitudes Questionnaire (SAQ), which has six scales: teamwork climate, safety climate, job satisfaction, stress recognition, perception of management and working conditions. Scale means, SDs and percent positives (percent agreement) were calculated for each NICU. Results There was substantial variation in safety culture domains among NICUs. Composite mean score across the six domains ranged from 56.3 to 77.8 on a 100-point scale and NICUs in the top four NICUs were significantly different from the bottom four (p<0.001). Across the six domains, respondent assessments varied widely, but were least positive on perceptions of management (3%–80% positive; mean 33.3%) and stress recognition (18%–61% positive; mean 41.3%). Comparisons of SAQ scale scores between NICUs and a previously published adult ICU cohort generally revealed higher scores for NICUs. Composite scores for physicians were 8.2 (p=0.04) and 9.5 (p=0.02) points higher than for nurses and ancillary personnel. Conclusion There is significant variation and scope for improvement in safety culture among these NICUs. The NICU variation was similar to variation in adult ICUs, but NICU scores were generally higher. Future studies should validate whether safety culture measured with the SAQ correlates with clinical and operational outcomes in NICUs.

Error disclosure: a new domain for safety culture assessment

Objective To (1) develop and test survey items that measure error disclosure culture, (2) examine relationships among error disclosure culture, teamwork culture and safety culture and (3) establish predictive validity for survey items measuring error disclosure culture. Method All clinical faculty from six health institutions (four medical schools, one cancer centre and one health science centre) in The University of Texas System were invited to anonymously complete an electronic survey containing questions about safety culture and error disclosure. Results The authors found two factors to measure error disclosure culture: one factor is focused on the general culture of error disclosure and the second factor is focused on trust. Both error disclosure culture factors were unique from safety culture and teamwork culture (correlations were less than r=0.85). Also, error disclosure general culture and error disclosure trust culture predicted intent to disclose a hypothetical error to a patient (r=0.25, p<0.001 and r=0.16, p<0.001, respectively) while teamwork and safety culture did not predict such an intent (r=0.09, p=NS and r=0.12, p=NS). Those who received prior error disclosure training reported significantly higher levels of error disclosure general culture (t=3.7, p<0.05) and error disclosure trust culture (t=2.9, p<0.05). Conclusions The authors created and validated a new measure of error disclosure culture that predicts intent to disclose an error better than other measures of healthcare culture. This measure fills an existing gap in organisational assessments by assessing transparent communication after medical error, an important aspect of culture.

Structural social support predicts functional social support in an online weight loss programme

Background  Online weight loss programmes allow members to use social media tools to give and receive social support for weight loss. However, little is known about the relationship between the use of social media tools and the perception of specific types of support.

Assessing medical students' perceptions of patient safety: The medical student safety attitudes and professionalism survey

Purpose To develop and test the psychometric properties of a survey to measure students’ perceptions about patient safety as observed on clinical rotations. Method In 2012, the authors surveyed 367 graduating fourth-year medical students at three U.S. MD-granting medical schools. They assessed the survey’s reliability and construct and concurrent validity. They examined correlations between students’ perceptions of organizational cultural factors, organizational patient safety measures, and students’ intended safety behaviors. They also calculated percent positive scores for cultural factors. Results Two hundred twenty-eight students (62%) responded. Analyses identified five cultural factors (teamwork culture, safety culture, error disclosure culture, experiences with professionalism, and comfort expressing professional concerns) that had construct validity, concurrent validity, and good reliability (Cronbach alphas > 0.70). Across schools, percent positive scores for safety culture ranged from 28% (95% confidence interval [CI], 13%–43%) to 64% (30%–98%), while those for teamwork culture ranged from 47% (32%–62%) to 74% (66%–81%). They were low for error disclosure culture (range: 10% [0%–20%] to 27% [20%–35%]), experiences with professionalism (range: 7% [0%–15%] to 23% [16%–30%]), and comfort expressing professional concerns (range: 17% [5%–29%] to 38% [8%–69%]). Each cultural factor correlated positively with perceptions of overall patient safety as observed in clinical rotations (r = 0.37–0.69, P < .05) and at least one safety behavioral intent item. Conclusions This study provided initial evidence for the survey’s reliability and validity and illustrated its applicability for determining whether students’ clinical experiences exemplify positive patient safety environments.

Measures and measurement of high-performance work systems in health care settings: Propositions for improvement

Background: Given that non-health care research has demonstrated many positive outcomes for organizations using high-performance work systems (HPWSs), a closer examination of HPWSs in health care settings is warranted. Purposes: We conducted a narrative review of the literature to understand how previous researchers have measured HPWSs in health care settings and what relationships exist between HPWSs and outcomes. Methodology/Approach: Articles that examined HPWSs in health care settings were identified and summarized. Key discrepancies and agreements in the existing HPWS research, including definitional, conceptual, and analytical areas of interest to health services researchers, are included. Findings: The findings demonstrate that although HPWSs might be a valuable predictor of health care-related outcomes, opportunities exist for improving HPWS measurement in health care settings. Practice Implication: Suggestions are provided to help guide future health services researchers in conducting research on HPWSs. Practice implications are provided for health care managers.

Engaging Employees: The Importance of High-Performance Work Systems for Patient Safety.

Objectives To develop and test survey items that measure high-performance work systems (HPWSs), report psychometric characteristics of the survey, and examine associations between HPWSs and teamwork culture, safety culture, and overall patient safety grade. Method We reviewed literature to determine dimensions of HPWSs and then asked executives to tell us which dimensions they viewed as most important for safety and quality. We then created a HPWSs survey to measure the most important HPWSs dimensions. We administered an anonymous, electronic survey to employees with direct patient care working at a large hospital system in the Southern United States and looked for linkages between HPWSs, culture, and outcomes. Results Similarities existed for the HPWS practices viewed as most important by previous researchers and health-care executives. The HPWSs survey was found to be reliable, distinct from safety culture and teamwork culture based on a confirmatory factor analysis, and was the strongest predictor of the extent to which employees felt comfortable speaking up about patient safety problems as well as patient safety grade. Conclusions We used information from a literature review and executive input to create a reliable and valid HPWSs survey. Future research needs to examine whether HPWSs is associated with additional safety and quality outcomes.

Differentiating close calls from errors: A multidisciplinary perspective

Objectives: To investigate the ability of health care providers to correctly identify close calls and errors and to examine the role of close call and error definitions on such identification. Methods: Sixty-eight health care providers from a large, academic medical center institution participated (22 physicians, 23 nurses, 13 pharmacists, and 10 physician assistants). Five hypothetical errors and 5 close call scenarios were developed based upon actual errors and close calls from the institution. Each participant was provided with all 10 scenarios to evaluate. Additionally, to determine the importance of including a definition of a close call or error, participants were randomly assigned to 1 of 2 groups: group 1 received definitions of errors and close calls before reading each scenario, whereas group 2 did not receive these definitions. After reading each scenario, providers classified the scenarios as errors, close calls, or neither. Results: The majority of participants correctly identified close call and error scenarios. The percentage of scenarios categorized correctly by profession for close calls and errors, respectively, was: 67.8% and 74.8% for nurses, 73.8% and 78.5% for pharmacists, 74% and 80% for physician assistants, and 67.6% and 78.2% for physicians. Participants with definitions of close calls were significantly more likely to identify them correctly than participants without definitions (t(65) = 2.303, P < 0.05). The same finding was not replicated for error scenarios (t(66) = 0.149, P > 0.05). Conclusions: The rate of incorrectly identifying close calls, although relatively low, suggests that close call reporting systems might be underutilized due to provider knowledge about these medical situations. The findings provide support for the need to educate providers about close calls to maximize the likelihood of receiving close call reports.

Job Satisfaction Ratings: Measurement Equivalence Across Nurses and Physicians

The measurement equivalence of job satisfaction ratings from physicians and nurses working in intensive care units was tested in the present study. Seventy-two nurses and 72 physicians completed the Safety Attitudes Questionnaire, which contains five items about job satisfaction. Measurement equivalence across nurses and physicians of the job satisfaction ratings was examined via multiple-group confirmatory factor analysis. The results indicated that physicians and nurses use the same metric when providing ratings for this job satisfaction measure. The primary implication from the present study is that nurses and physicians conceptualize job satisfaction in a similar manner. This implication needs to be extended to other survey measures of interest to health services researchers. Future areas of research are discussed.