1. Measuring teamwork and safety culture (climate) across 3 adult intensive care units of a single hospital cluster in Hong Kong
Sammei Tam
18 Oct 2009

2. Why study this topic?
Patient safety is an important component in health care quality
Many errors are potentially preventable
Communication breakdown is a common cause of serious adverse events
Encourage to improve patient safety culture and promote team functioning in current healthcare practice
(Institute of Medicine Report 1999)

3. Overseas experience Huang, et al., Critical Care Medicine (2007)
Significant safety culture variation existed across ICUs of a single institution
Nurses had lower mean scores than Doctors

4. Overseas experience Kaissi, et al., Nursing Economics (2003)
Measured teamwork and patient safety attitudes in high-risk areas
No significant difference between 4 hospitals
Nurses favoured team approach, but
Teamwork in departments not very advanced
Problematic communication with some key team members

5. Overseas experience Thomas, et al., Critical Care Medicine (2003)
Discrepancy in attitudes on teamwork amongst critical care nurses and physicians
Physicians: more satisfied with physician-nurse collaboration than nurses
Nurses: difficulty in speaking up, disagreements not appropriately resolved
Individuals ranking lower in a hierarchy: often not being asked for comments or information in relation to patient safety

6. This Study Aims and Objectives
Primary objective : to determine whether teamwork and safety culture (climate) vary between different units in the NTEC cluster
Ultimate aim : to improve team work and patient safety in ICUs
A self-completed structured questionnaire with a few semi-structured questions
Anonymous, voluntary
Subjects and Target Population
All doctors and nurses working in the 3 ICUs
ICU Doctors n = 25
Nurses n = 184

7. Methodology – Questionnaire Design
Adapted from …Original SAQ-ICU…included 64 items and assessed six safety culture factors. (Sexton, et al., 2006)
For this study purposes, only the teamwork climate and safety climate factors were used
Each factor is made up of a set of individual questions (10 items in a set for safety and 10 items in a set for teamwork)
When taken together, they comprised a respondent’s perception of the factor
Some of the SAQ-ICU items were rewritten to suit the Chinese language

8. Methodology – Questionnaire Design
Factor
Definition
Example Items
Teamwork Climate
Perceived quality of collaboration between ICU Doctors and ICU Nurses
I have the support I need from other staff to care for patients
Safety
Climate
Perceptions of strong and proactive organizational commitment to patient safety
This unit is putting effort to ensure patient safety
Modified from Sexton, et al., .BMC Health Services Research, (2006)

9. Methodology – Questionnaire Design
Final questionnaire contained 30 items
Section A : 2 demographic questions
Section B : 20 Likert scale questions for Culture Factors
Section C : 2 Likert scale questions for impression of collaboration and communication
Section D : 3 multiple-choice (yes or no) questions for incident reporting
Section E : 3 open-ended questions for other comments

10. Pilot study
5 senior nurses were asked to participate in a content validity exercise to rank the questionnaire in terms of comprehension and appropriateness, and whether the questionnaire retained original meanings

11. Methodology
Ethical Approval from the Joint CUHK-NTEC Clinical Research Ethics Committee
Approval obtained from CCE and senior hospital management
Questionnaire distributed and collected between January and February 2008

12. Methodology
Analysis
Descriptive analysis to determine the frequency of response for each survey item
Compare mean factor scores by ANOVA
Compare percent-favourable scores by Chi-square
between each unit and between doctors and nurses
Mean factor score provides a rough point estimate about the factor score of the relevant group
Percent-favourable score is a measure of the % of respondents that gave positive response, i.e. mean score of higher or equal than 75

13. Results Response Rates 209 questionnaires handed out
A total of 135 questionnaires were received
One questionnaire was excluded because more than half of the data missing
Total valid questionnaires were then counted as 134
An overall response rate was 64.11%
Response Rates
Respondents
Doctors
Nurses
Unit
Rec.
(n)
Adm. % A 71
104
68.27 5
10**
50.00 66 94
70.21 B 53 69
76.81 7 11
63.64 46 58
79.31 C 10 36
27.78 1 4
25.00 9 32
28.13
All
134*
209
64.11 13 25
52.00
121
184
65.76
*One subject was excluded because of over 50% of missing items. **Only full time, core ICU staff were administrated the questionnaire.

14. Results Differences of Perception across ICUs
The safety factor scores among the three ICUs were very close to each other and also the teamwork factors scores
ICUs did not uniformly have high factor scores or low factor scores
The percentages of staff members of a given group with favourable scores > 75 on safety and teamwork factors were less than half
Mean Score
% favourable Score
Safety
Teamwork
Unit A
69.86
63.63
38.03
14.08
Unit B
68.87
63.00
32.08
22.64
Unit C
68.51
65.00
40.00
10.00
P value
0.836
0.921
0.978
0.269

15. Results Differences of Perception between Staff Groups
Discrepancies in perceptions between doctors and nurses
Doctors tended to perceive the factors more positively than nurses
Ratings for safety factor by all nurses and doctors were higher than for teamwork factor
Mean Score
% favourable Score
Safety
Teamwork
All Doctors
72.31
70.39
46.15
30.77
All Nurses
69.05
62.87
34.71
13.43
P value
0.276
0.032*
0.588
0.496
*Statistically significant

16. *Statistically significant
Results
Differences of Perception between Staff Groups for individual ICUs
Significant differences found in Unit A & Unit C; Dr perceived more positively
Nurses at Unit B had a higher rating on safety factor than doctors; Highest % on Teamwork among nurses
None of the nurses in Unit C responded favourably towards teamwork
Mean Score
% favourable Score
Safety
Teamwork
Unit A
Doctor
79.50
76.50
60.00
40.00
Nurse
69.13
62.65
36.40
12.12
P value
0.018*
0.014*
0.049*
0.125
Unit B
67.15
63.93
28.57
69.29
63.21
32.61
21.74
0.493
0.887
0.656
0.569
Unit C
80.00
85.00
100.0
67.22
62.28
33.33
0.00
0.137
0.017*
0.046* -
*Statistically significant

17. Results Response to Incidents Reporting
Only 130 out of 134 respondents had answered
52 (Nurse n=47, Dr n=5) out of 130 have involved in patient safety related incidents
14 out of 52 did not report incidents provided reasons:
may not be blame free
not anonymous
near miss incidents and immediately corrected by colleagues

18. Results Perceptions on Communications
Discrepant attitudes about collaboration and communication between doctors and nurses
Doctors perceived more satisfactory in communication than nurses
All differences reported were not statistically significant

19. Patient Safety Comments (n=135)
Results
Summary of comments on patient safety
Patient Safety Comments (n=135)
Received
Procedure guidelines & practice issues 40
29.6%
Education, supervision, empowerment 28
20.7%
Duty arrangement, workload, day off & staffing 25
18.5%
Communication, morale, relationship 23
17.0%
System, culture change, incident reporting, fairness 11
8.1%
Resources, equipment, space 8
5.9%
Total
135
100%　

20. Teamwork Comments (n=119)
Results
Summary of comments on teamwork
Teamwork Comments (n=119)
Received
Communication, regular meeting 32
26.9%
Leadership style, culture, morale 26
21.8%
Workload, working condition, fairness
Relationship, mutual respect, polite, no blame 23
19.3%
Social function, staff welfare, team building activities 12
10.1%
Total
119
100%

21. Conclusions
Minimal differences on safety and teamwork climate exist across the ICUs within the cluster
Doctors were more positive in their perceptions of safety and teamwork than nurses in their working units
Doctors perceived communication more satisfactory than nurses
Findings were consistent with previous studies using SAQ in ICU
Reluctance to report incidents to supervisors

22. Recommendations Repeat survey periodically to monitor culture change
Efforts should better direct to team-based training
Promote a positive working environment, result in good teamwork, enhance job satisfaction and improve nurse morale
Provide a starting point for understanding patient safety culture issues to leaderships in future planning of improvement programme

23. Acknowledgement
All ICU doctors and nurses in NTEC for their participation and support.
THANK YOU!

24. Questionnaire (2 pages double sided)

25. Questionnaire