Rosen AK (Bedford VAMC), Zhao S
(Bedford VAMC), Meterko M
(Jamaica Plain VA), Shokeen P
(Bedford VAMC), Gaba DM
(Palo Alto VA)
Improving the safety climate of hospitals could enhance patient safety. Little evidence exists regarding the relationship between hospital characteristics and safety climate. Some hospital characteristics are nearly immutable (size, teaching status) while others may be modifiable. This study identifies those characteristics associated with higher levels of safety climate in 30 VA hospitals.
We administered the Patient Safety Climate in Healthcare Organizations (PSCHO) survey to 100% of hospital-based physicians, 100% of senior managers, and a 10% random sample of all other employees between December 2005 and June 2006 (total n=9,309). A random one-third of these employees also received the Zammuto and Krakower survey, which measures organizational culture in four domains: group, entrepreneurial, hierarchical, and rational.
The survey had an overall response rate of 50% (responses = 4,629). A number of significantly strong and consistent associations were found between hospital characteristics and safety climate. Lower levels of safety climate were significantly associated with higher nurse staffing ratios and larger hospital size. Stronger group and entrepreneurial culture were significantly associated with higher levels of safety climate, while stronger hierarchical culture was associated with lower levels of safety climate. Models explained up to 67% of the variation in safety climate.
Both structural and organizational culture characteristics are important in predicting higher levels of safety climate. Contrary to expectations, higher levels of nurse staffing were associated with lower levels of safety climate; possibly because nurse staffing served as a proxy for patient acuity or some aspect of intensity of care that was not captured by our models. Organizational culture findings were consistent with the literature. Stronger group and entrepreneurial cultures may promote patient safety because these types of organizational culture facilitate group learning around problem solving. Stronger hierarchical culture may emphasize conformity with standard operating procedures and deference to rank, creating an environment in which workers are reluctant to raise safety issues.
Organizational culture characteristics are potentially mutable and have an impact on safety climate. Hospitals should devote greater attention to activities that promote stronger group and entrepreneurial cultures and reduce hierarchy within their institutions.