Is There a Relationship Between Hospital Safety Culture and Safety Outcomes in VA Hospitals? Amy K. Rosen, Ph.D. 1,2, Sara Singer, Ph.D. 3,Christine Hartmann, Ph.D. 1,2, Priti Shokeen, M.S. 1, Shibei Zhao, M.P.H. 1, Alyson Falwell, M.P.H. 4, David Gaba, M.D. 4,5 1 Center for Health Quality, Outcomes, and Economic Research (VA Center of Excellence), 2 Boston University School of Public Health, Health Policy and Management, 3 Harvard University School of Public Health, Health Policy and Management, 4 Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, 5 Patient Safety Culture Institute, VA Palo Alto Healthcare System. Financial support for this study provided by the VA HSR&D IIR and the Agency for Healthcare Research and Quality RO1 HSO13920 AcademyHealth June 2008

Background Reducing adverse events and improving patient safety is a national priority High reliability organizations (HROs) attribute their strong safety performance to their strong safety culture Strong safety culture is critical to improving safety and reducing adverse events Little empirical research exists on the relationship between safety culture and safety outcomes

Organizational Safety Culture and Safety Performance Dimensions + OrganizationalWork UnitInterpersonal AHRQ Patient Safety Indicators (PSIs) Organizational Safety Performance

Objective and Hypotheses Objective: To examine the relationship between safety culture and hospital safety performance in VA hospitals Hypotheses – (1) Higher levels of hospital safety culture will be associated with lower levels of hospital PSIs – (2) Individual/interpersonal dimensions of safety culture will more strongly influence the relationship between safety culture and hospital performance than other dimensions – (3) Perceptions of safety culture will be more strongly associated with PSIs for frontline workers than for senior managers – (4) Perceptions of safety culture will be more strongly associated with PSIs for workers in surgical units than in non- surgical units

Safety Culture vs. Safety Climate Safety Culture – Shared values and beliefs of individuals, and structures and systems of work areas and organizations, that interact to shape behavioral norms (Singer, 2007) Safety Climate – The surface features of the safety culture discerned from the workforces attitudes and perceptions at a given point in time (Flin et al., 2000) Individual Values & Beliefs + Structures & Work Systems Behavioral Norms

Safety Climate Measurement The Patient Safety Climate in Healthcare Organizations (PSCHO) survey used to measure perceptions of safety climate among personnel in VA hospitals Survey contains 6 demographic questions and 42 safety items that are based on a 5-point Likert scale Responses range from strongly agree to strongly disagree High PPR suggests a poor safety climate – lack of uniform safety climate (Roberts, 1990)

Survey Subscales Survey includes 11 subscales determined by psychometric analyses OrganizationalWork unitInterpersonal Subscales Senior leadership Unit leadershipFear of blame Resources for safety Unit normsPsychological safety Facility characteristics Unit recognition Problem responsiveness Examples of Dimensions

Survey Design and Methodology Mailed survey conducted in 30 VA hospitals between December June 2006 Sample (n=9,309) – 100% of senior managers – 100% hospital-based physicians – 10% random sample of other personnel – At 10 hospitals, 100% of employees working in high hazard units 50% response rate (n=4,629) Survey was anonymous

Data Sources Hospital safety climate – PSCHO survey collected from sample of employees Hospital safety performance – 13 of the AHRQ PSIs calculated from 2006 VA hospital discharge data (AHRQ PSI software version 3.1a) Hospital characteristics – AHA Annual Hospital Survey, VA Decision Support System data (nurse staffing), Area Resource File (location)

Analysis Reported strength of safety climate by hospital (average percent problematic response, PPR), job category, and work area PSIs were risk adjusted, using AHRQ comorbidity software Linear regression models examined the relationship between safety climate overall and 11 dimensions of safety climate with individual PSIs, controlling for hospital teaching status, location, and nurse staffing ratios

Safety Climate in 29 Hospitals Responses weighted for sample size and non-response *Hospital report statistically significantly lower problematic response than the VA average ** Hospital report statistically significantly higher problematic response than the VA average Low response = stronger safety climate

Relationship between PSIs and Safety Climate by Dimensions Note: Observations range from 25 to 28. Any hospitals with PSI denominator less than 2 were excluded from models.

Relationship between PSIs and Safety Climate Dimensions by Job Categories Note: Observations range from 25 to 28. Any hospitals with PSI denominator less than 2 were excluded from models.

Relationship between PSIs and Safety Climate Dimensions by Work Areas Note: Observations range from 25 to 28. Any hospitals with PSI denominator less than 2 were excluded from models.

Conclusions and Implications VA results similar to those from the AHRQ-funded safety culture study Individual/interpersonal dimensions of safety climate most strongly related to individual PSIs Frontline workers perceptions related more to safety performance than senior managers Surgical unit employees perceptions related more to safety performance than non-surgical employees Suggests interventions to improve safety climate

Thank you!