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IIR 03-303 – HSR&D Study

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IIR 03-303
Improving Safety Culture and Outcomes in VA Hospitals
David M. Gaba MD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: July 2005 - December 2008

BACKGROUND/RATIONALE:
Further research is needed in measuring safety climate in VA hospitals and to relating this climate to outcomes of patient care. We have developed the Patient Safety Climate in Hospital Organization (PSCHO) instrument to measure each individual's perceived safety climate by the amount of "problematic response" (responses that are against a safety climate) to survey questions. Our proposed project is a VA hospital companion to an AHRQ-funded project we are conducting on the safety climate in 120 non-VA hospitals nationwide. This study will enable the VA to obtain important information- alone and in comparison to private sector facilities - about the strength and uniformity of its safety climate, its variability across hospitals, work units, and Veterans Integrated Service Networks (VISNs), as well as about the link between safety climate and patient outcomes in VA facilities.

OBJECTIVE(S):
Safety culture/safety climate of hospital personnel is a key component of patient safety. The purpose of the study is to assess the level of safety climate in VA hospitals and improve understanding of the safety culture in VA hospitals using the previously developed and validated Patient Safety Climate in Healthcare Organizations (PSCHO) survey in a nationwide sample of 30 VA hospitals. Our objectives are:
* To assess safety climate in 30 VA hospitals and in a representative sub-sample of work units of high intrinsic hazard using the PSCHO instrument;
* To compare safety climate to selected hospital characteristics, and to compare VA to non-VA facilities;
* To compare PSCHO data to (measured by the Zammuto and Karkower survey) and implementation of quality improvement (QI) practices (measured using Baldrige scales);
* To compare the level of safety climate to measures of patient safety outcomes;
* To compare the level and uniformity of safety climate in VA hospitals to that in high-reliability organizations in other high-hazard industries.

METHODS:
The project obtained 2006 and 2007 primary data on the safety climate in VA by surveying employees with the PSCHO survey plus either the modified Baldrige survey or the abridged Zammuto and Krakower survey. Survey was administered twice to examine longitudinal changes in safety climate and to determine if relationships between climate and outcome are stable over time. We surveyed 100% of hospital-based physicians & senior managers (defined as department heads and above) and a 10% random sample of staff. In addition, at some hospitals, we surveyed 100% staff working in high hazard units. Secondary data (FY2005-2006) were obtained from a variety of VA and non-VA sources will investigate relationships between safety climate and PSIs & NSQIP outcome data, and hospital characteristics. We compared safety climate in VA and non-VA hospitals using comparable data being collected by the investigators on 120 non-VA hospitals. We will also compared VA safety climate with the safety climate in a non-health care organization (Naval aviators). The PSCHO consists of 42 Likert-scale questions and six demographic questions. For each question, a "problematic response" (PR) suggested a weak safety climate. We calculated average PR rates and 95% confidence intervals (CIs), accounting for sample proportion and patterns of non-response for each question and job-type across all participating hospitals. We applied multi-trait analysis to responses in the derivation sample to create an initial scale structure and confirmed this structure by applying confirmatory factor analysis in the validation sample. We compared results to a companion study that administered the PSCHO survey in 105 non-VA hospitals.

FINDINGS/RESULTS:
The response rate for both the 1st and 2nd survey administrations was 50%. The average overall PR rate across all hospitals and personnel for administrations 1 and 2 was 18.1% and 17.7%, respectively. Rates of PR varied widely between institutions, ranging from 4.4% to 49.6% and 4.9% to 46.2% during administration 1 and 2, respectively. The questions eliciting the highest and lowest PR rate for both administrations were "My unit recognizes individual safety achievement through rewards and incentives" and "If I make a mistake that has significant consequences and nobody notices, I do not tell anyone about it," respectively. For both administrations, we found that physicians and hospital employees had higher PR rates than senior managers (PRs for administration #1= 17.1, 17.3, and 9.8%, respectively); nurses had the highest PR rates of any job-type (PR for administration #1=20.8%; CI=17.0%-24.7%). In our psychometric analysis, we found empirical support for eleven scales: senior leadership, resources for safety, overall, unit leadership, unit norms, unit recognition, learning, psych safety 1: no retribution, psychological safety 2: protection for initiative, problem solving, and outcomes. Consistent with the private sector, we found that a) perceptions of safety culture differed among hospitals, job-type, and work area, b) senior managers had a more positive perception of safety culture than frontline staff, and c) employees working in high-hazard areas had a more negative perception of safety culture. For administration #1 data, we found that higher levels of safety climate were associated with hospital metropolitan location, location in South, and higher levels of group and entrepreneurial organizational culture and higher levels of organizational cultural balance. Higher levels of hierarchical culture were significantly associated with lower levels of safety climate. We found no significant association between overall hospital safety climate and rates of PSIs or NSQIP data. Although there was substantial overlap among the two groups, the range in safety climate among individual non-VA hospitals was larger than among VA hospitals. Safety climate was better on average in non-VA hospitals than in VA hospitals on 10 of 12 safety climate dimensions. Nevertheless, specific results suggest that neither non-VA nor VA hospitals has achieved superior safety climate as a group.

IMPACT:
This is the first systematic study of patient safety climate in VA hospitals. Findings indicate an overall positive safety climate across the VA, but there is room for improvement. Hospitals may wish to conduct specific interventions aimed at improving safety climate.

PUBLICATIONS:

Journal Articles

  1. Rosen AK, Singer S, Shibei Zhao, Shokeen P, Meterko M, Gaba D. Hospital safety climate and safety outcomes: is there a relationship in the VA? Medical care research and review : MCRR. 2010 Oct 1; 67(5):590-608.
  2. Singer SJ, Rosen A, Zhao S, Ciavarelli AP, Gaba DM. Comparing safety climate in naval aviation and hospitals: implications for improving patient safety. Health care management review. 2010 Apr 1; 35(2):134-46.
  3. Singer SJ, Falwell A, Gaba DM, Meterko M, Rosen A, Hartmann CW, Baker L. Identifying organizational cultures that promote patient safety. Health care management review. 2009 Oct 1; 34(4):300-11.
  4. Singer SJ, Hartmann CW, Hanchate A, Zhao S, Meterko M, Shokeen P, Lin S, Gaba DM, Rosen AK. Comparing safety climate between two populations of hospitals in the United States. Health services research. 2009 Oct 1; 44(5 Pt 1):1563-83.
  5. Kaafarani HM, Itani KM, Rosen AK, Zhao S, Hartmann CW, Gaba DM. How does patient safety culture in the operating room and post-anesthesia care unit compare to the rest of the hospital? American journal of surgery. 2009 Jul 1; 198(1):70-5.
  6. Hartmann CW, Meterko M, Rosen AK, Shibei Zhao, Shokeen P, Singer S, Gaba DM. Relationship of hospital organizational culture to patient safety climate in the Veterans Health Administration. Medical care research and review : MCRR. 2009 Jun 1; 66(3):320-38.
  7. Singer S, Lin S, Falwell A, Gaba D, Baker L. Relationship of safety climate and safety performance in hospitals. Health services research. 2009 Apr 1; 44(2 Pt 1):399-421.
  8. Singer SJ, Gaba DM, Falwell A, Lin S, Hayes J, Baker L. Patient safety climate in 92 US hospitals: differences by work area and discipline. Medical care. 2009 Jan 1; 47(1):23-31.
  9. Singer SJ, Falwell A, Gaba DM, Baker LC. Patient safety climate in US hospitals: variation by management level. Medical care. 2008 Nov 1; 46(11):1149-56.
  10. Hartmann CW, Rosen AK, Meterko M, Shokeen P, Zhao S, Singer S, Falwell A, Gaba DM. An overview of patient safety climate in the VA. Health services research. 2008 Aug 1; 43(4):1263-84.
  11. Rosen AK, Gaba DM, Meterko M, Shokeen P, Singer S, Zhao S, Labonte A, Falwell A. Recruitment of hospitals for a safety climate study: facilitators and barriers. Joint Commission Journal on Quality and Patient Safety. 2008 May 1; 34(5):275-84.
  12. Singer S, Meterko M, Baker L, Gaba D, Falwell A, Rosen AK. Workforce perceptions of hospital safety culture: development and validation of the patient safety climate in healthcare organizations survey. Health services research. 2007 Oct 1; 42(5):1999-2021.
  13. Gaba DM, Singer SJ, Rosen AK. Safety culture: is the "unit" the right "unit of analysis"? Critical care medicine. 2007 Jan 1; 35(1):314-6.
  14. Gaba DM, Singer SJ, Sinaiko AD, Bowen JD, Ciavarelli AP. Differences in safety climate between hospital personnel and naval aviators. Human Factors. 2003 Apr 1; 45(2):173-85.
  15. Singer SJ, Gaba DM, Geppert JJ, Sinaiko AD, Howard SK, Park KC. The culture of safety: results of an organization-wide survey in 15 California hospitals. Quality & Safety in Health Care. 2003 Apr 1; 12(2):112-8.
Book Chapters

  1. Rall M, Gaba DM. Human performance and patient safety. In: Miller R, editor. Anesthesia. 7 ed. New York, NY: Elsevier; 2009. Chapter 6. 93-150 p.
  2. Rall M, Gaba DM. Patient simulators. In: Miller R, editor. Anesthesia. 7 ed. New York, NY: Elsevier; 2009. Chapter 7. 151-192 p.
Conference Presentations

  1. Stolzman KL, Meterko MM, Baker EH, Hendricks AM, Iverson KM, Krengel MH, Charns MP, Pogoda TK, Lew HL. Association Between Neurobehavioral Symptoms and Post injury Employment Status Among OEF/OIF Veterans Who Screen Positive for Traumatic Brain Injury. Poster session presented at: AcademyHealth Annual Research Meeting; 2011 Dec 14; Seattle, WA.
  2. Benzer JK, Young GJ, Charns MP, Mohr D. Organizational climates for task direction and relational support: A contingency-based framework. Presented at: Academy of Management Annual Meeting; 2011 Aug 12; San Antonio, TX.
  3. Hartmann CW, Rosen AK, Zhao S, Hanchate AD, Singer SJ, Meterko MM, Shokeen PV, Gaba DM. Comparing Safety Climate between Different Settings of Care: Methodological Considerations. Poster session presented at: VA HSR&D National Meeting; 2009 Feb 13; Baltimore, MD.
  4. Hartmann CW, Rosen AK, Shao S, Meterko M, Shokeen P, Gaba D. Organizational culture and safety climate in U.S. Veterans Administration hospitals. Presented at: International Union of Psychological Science Annual Congress; 2008 Jul 20; Berlin, Germany.
  5. Rosen AK, Singer S, Hartmann CW, Shokeen P, Zhao S, Falwell A, Gaba D. Is There a Relationship between Hospital Safety Culture and Safety Outcomes in VA Hospitals? Presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC.
  6. Hartmann CW, Rosen AK, Zhao S, Meterko M, Shokeen P, Gaba D. Relationship of hospital characteristics to patient safety in the VA. Presented at: AcademyHealth Annual Research Meeting; 2008 Jun 6; Washington, DC.
  7. Kaafarani HMA, Itani KMF, Rosen AK, Zhoa S, Hartmann CW, Gaba DM. How does patient safety culture compare in the operating room and post anesthesia care unit to the rest of the hospital? Presented at: American College of Surgeons Spring Meeting; 2008 May 4; Dallas, TX.
  8. Rosen AK, Zhao S, Meterko M, Shokeen P, Gaba DM, Hartmann CW. Hospital characteristics and safety climate in the VA. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD.
  9. Hartmann C, Rosen AK, Shokeen P, Zhao S, Meterko M, Singer S, Falwell A, Gaba D. Safety culture in VA hospitals. Poster session presented at: AcademyHealth Annual Research Meeting; 2007 Jun 3; Orlando, FL.
  10. Shokeen P, Rosen AK, Zhao S, Meterko M, Falwell A, Gaba DM. Safety culture in VA hospitals. Paper presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.


DRA: Health Systems
DRE: none
Keywords: Safety
MeSH Terms: none