Timothy J. Vogus

The Safety Organizing Scale Development and Validation of a Behavioral Measure of Safety Culture in Hospital Nursing Units

Background:Evidence that medical error is a systemic problem requiring systemic solutions continues to expand. Developing a “safety culture” is one potential strategy toward improving patient safety. A reliable and valid self-report measure of safety culture is needed that is both grounded in concrete behaviors and is positively related to patient safety. Objective:We sought to develop and test a self-report measure of safety organizing that captures the behaviors theorized to underlie a safety culture and demonstrates use for potentially improving patient safety as evidenced by fewer reported medication errors and patient falls. Subjects:A total of 1685 registered nurses from 125 nursing units in 13 hospitals in California, Indiana, Iowa, Maryland, Michigan, and Ohio completed questionnaires between December 2003 and June 2004. Research Design:The authors conducted a cross-sectional assessment of factor structure, dimensionality, and construct validity. Results:The Safety Organizing Scale (SOS), a 9-item unidimensional measure of self-reported behaviors enabling a safety culture, was found to have high internal reliability and reflect theoretically derived and empirically observed content domains. The measure was shown to discriminate between related concepts like organizational commitment and trust, vary significantly within hospitals, and was negatively associated with reported medication errors and patient falls in the subsequent 6-month period. Conclusions:The SOS not only provides meaningful, behavioral insight into the enactment of a safety culture, but because of the association between SOS scores and reported medication errors and patient falls, it also provides information that may be useful to registered nurses, nurse managers, hospital administrators, and governmental agencies.

Organizational resilience: Towards a theory and research agenda

In this paper we outline the contours of a theory of organizational resilience as well as a research agenda. First, we identify how the notion of resilience has become increasingly important to all organizations and argue that organization theory currently does not reflect its importance. Second we reconcile varying definitions of resilience to create a definition of organizational resilience. Third, we identify the affective, cognitive, relational, and structural mechanisms constitutive of organizational resilience. Fourth, we develop research questions regarding the antecedents and mechanisms of resilience.

Doing No Harm: Enabling, Enacting, and Elaborating a Culture of Safety in Health Care

Executive Overview Medical error has reached epidemic proportions, and researchers have developed insufficiently sophisticated models of safety culture to match the complexity of the challenge of safety in health care. This has left providers and researchers with an inadequate conceptual toolkit for improving safety. To rectify the resulting crisis we consolidate fragments of management research into a comprehensive and integrative framework of how patient safety is produced and sustained through safety culture. Safety culture involves actions that single out and focus safety-relevant premises and cultural practices that reduce harm. This entails (a) enabling, which consolidates the premises for a safety culture; (b) enacting, which translates consolidated premises into concrete practices that prioritize safety; and (c) elaborating, which enlarges and refines the consolidation and translation. We close by discussing the implications of our framework for future research on key issues such as efficiency-safety trade-offs, interactions among components of the framework, and feedback loops.

Sensemaking and emotion in organizations

Emotion is a critical but relatively unexplored dimension of sensemaking in organizations. Existing models of sensemaking tend to ignore the role of emotion or portray it as an impediment. To address this problem, we explore the role that felt emotion plays in three stages of individual sensemaking in organizations. First, we examine emotion’s role in mediating the relationship between unexpected events and the onset of sensemaking processes. We argue that emotion signals the need for and provides the energy that fuels sensemaking, and that different kinds of emotions are more and less likely to play these roles. Second, we explore the role of emotion in shaping sensemaking processes, focusing on how emotions make sensemaking a more solitary or more interpersonal process, and a more generative or more integrative process. Third, we argue that sensemakers’ felt emotion plays an important role in concluding sensemaking, particularly through its effect on the plausibility of sensemaking accounts.

Reducing Hospital Errors: Interventions that Build Safety Culture

Hospital errors are a seemingly intractable problem and continuing threat to public health. Errors resist intervention because too often the interventions deployed fail to address the fundamental source of errors: weak organizational safety culture. This review applies and extends a theoretical model of safety culture that suggests it is a function of interrelated processes of enabling, enacting, and elaborating that can reduce hospital errors over time. In this model, enabling activities help shape perceptions of safety climate, which promotes enactment of safety culture. We then classify a broad array of interventions as enabling, enacting, or elaborating a culture of safety. Our analysis, which is intended to guide future attempts to both study and more effectively create and sustain a safety culture, emphasizes that isolated interventions are unlikely to reduce the underlying causes of hospital errors. Instead, reducing errors requires systemic interventions that address the interrelated processes of safety culture in a balanced manner.

Safety climate research: taking stock and looking forward

Though long a subject of scholarly interest outside of healthcare,1 ,2 attention to safety climate within healthcare began in earnest following the report by the Institute of Medicine: To Err is Human . Accomplishments of the growing body of literature on safety climate in healthcare include developing and validating a number of comprehensive measures of safety climate3–5; linking safety climate to a wide range of patient outcomes, such as patient safety indicators,6 ,7 rates of hospital readmission,8 and medication and other errors9 ,10; and identifying leader and organisational practices that influence safety climate, such as Leadership WalkRounds11 and multifaceted interventions.12 This body of research has also impacted practice. For example, bolstered by a Joint Commission accreditation requirement, most hospitals now participate in regular efforts to survey and benchmark their safety climate.13 The two papers on safety climate in this issue represent additional contributions to this literature.14 ,15 At the same time, they provide an opportunity to reflect on the nature of safety climate research, what scholars have already accomplished, and what additional research is needed now, in light of the chasm yet to be crossed.16 ,17 In this commentary, we describe what we see as the key contributions of these papers and use them as an occasion to take stock of the state of safety climate research. We then identify lingering conceptual and empirical challenges and suggest several strategies for resolving them and advancing the field. The review of safety climate interventions by Morello and colleagues14 highlights that present enthusiasm for interventions outstrips the evidence supporting them. These authors found minimal effects from the interventions they studied. Moreover, very few studies examined interventions in comparison with a control group. These findings highlight …

Safety in numbers: the development of Leapfrog's composite patient safety score for U.S. hospitals.

Objective To develop a composite patient safety score that provides patients, health-care providers, and health-care purchasers with a standardized method to evaluate patient safety in general acute care hospitals in the United States. Methods The Leapfrog Group sought guidance from a panel of national patient safety experts to develop the composite score. Candidate patient safety performance measures for inclusion in the score were identified from publicly reported national sources. Hospital performance on each measure was converted into a “z-score” and then aggregated using measure-specific weights. A reference mean score was set at 3, with scores interpreted in terms of standard deviations above or below the mean, with above reflecting better than average performance. Results Twenty-six measures were included in the score. The mean composite score for 2652 general acute care hospitals in the United States was 2.97 (range by hospital, 0.46–3.94). Safety scores were slightly lower for hospitals that were publicly owned, rural in location, or had a larger percentage of patients with Medicaid as their primary insurance. Conclusions The Leapfrog patient safety composite provides a standardized method to evaluate patient safety in general acute care hospitals in the United States. While constrained by available data and publicly reported scores on patient safety measures, the composite score reflects the best available evidence regarding a hospital’s efforts and outcomes in patient safety. Additional analyses are needed, but the score did not seem to have a strong bias against hospitals with specific characteristics. The composite score will continue to be refined over time as measures of patient safety evolve.

Compassion Practices and HCAHPS: Does Rewarding and Supporting Workplace Compassion Influence Patient Perceptions?

OBJECTIVE To examine the benefits of compassion practices on two indicators of patient perceptions of care quality-the Hospital Consumer Assessment of Healthcare Providers and systems (HCAHPS) overall hospital rating and likelihood of recommending. STUDY SETTING Two hundred sixty-nine nonfederal acute care U.S. hospitals. STUDY DESIGN Cross-sectional study. DATA COLLECTION Surveys collected from top-level hospital executives. Publicly reported HCAHPS data from October 2012 release. PRINCIPAL FINDINGS Compassion practices, a measure of the extent to which a hospital rewards compassionate acts and compassionately supports its employees (e.g., compassionate employee awards, pastoral care for employees), is significantly and positively associated with hospital ratings and likelihood of recommending. CONCLUSIONS Our findings illustrate the benefits for patients of specific and actionable organizational practices that provide and reinforce compassion.

The underappreciated role of habit in highly reliable healthcare

We are what we repeatedly do. Excellence then, is not an act, but a habit.1 Healthcare leaders,2 ,3 academics4–7 and regulators,8 ,9 continue to push healthcare organisations to emulate high-reliability organisations (HROs) like aircraft carrier flight decks and nuclear power control rooms10 to solve long-standing quality and safety problems in healthcare delivery. The nearly error-free performance of HROs in trying circumstances is a function of mindful organising—a set of behavioural and cognitive processes by which their members discern latent and manifest threats to reliability and act swiftly to resolve them.11 ,12 Emerging evidence suggests that processes of mindful organising are associated with lower error rates,13–15 more reliable service performance16 and even lower turnover.17 Yet despite persistent calls by influential leaders and promising empirical evidence, there is little indication of highly reliable performance in healthcare generally.8 ,9 ,18 In other words, the pursuit of highly reliable healthcare through mindful organising has become a problematic improvement to the problem of medical error.19 We ask, ‘why does high reliability remain so elusive?’ Fostering improvement often starts with looking at what successful people and organisations consistently do as evidenced by the continuing popularity of Steven Coveys 7 Habits of Highly Effective People 20 or Charles Duhiggs The Power of Habit .21 Similarly, we argue that the continued unreliability of healthcare delivery results from the failure to turn periodic mindful practice into consistent, enduring habit. In other words, we focus on healthcare organisations that either aspire to be highly reliable and/or have attempted to pursue it in some manner but have not achieved reliable performance. For example, hospital executives may consistently emphasise a zero harm goal and frequently talking with frontline care providers about safety (ie, WalkRounds), yet …

Creating highly reliable health care

Hospitals are increasingly looking to new work practices and processes to reduce the epidemic of medical errors. The authors examine one such innovative approach emulating high-reliability organizations (e.g., nuclear power plants) that use a combination of specific work practices and behavioral processes to detect and adapt to unexpected events to operate in a nearly error-free manner. They explore whether and how reliability-enhancing work practices (REWPs) help enable such processes and improve performance (i.e., reduce errors). Using survey and archival data from 1,685 registered nurses and 95 nurse managers in 95 hospital nursing units, the authors examine how REWPs affect a set of attitudinal (affective commitment and organizational citizenship behavior) and discursive (respectful interaction and mindful organizing) processes and, in turn, patient safety. They find the greater use of REWPs are directly and indirectly (through respectful interaction and mindful organizing) associated with fewer medication errors and patient falls. In contrast, organizational citizenship behavior was associated with more medication errors and patient falls.