Examining the Relationship between Patient Safety Climate
Patient Safety Climate and Hospital Readmission
Luke Hansen MD MHS
Luke Hansen, MD, MHS Division of Hospital Medicine, Northwestern University Feinberg School of Medicine
What is culture?
What is culture?
• An academic definition:
“The integrated pattern of human knowledge, belief, g
p
f
g ,
f,
and behavior that depends upon the capacity for g
g
g
learning and transmitting knowledge to succeeding generations.” • An easy definition: “It’s how we do things here.”
What is Safety Culture?
What is Safety Culture?
“The accident can be said to have “Th
id
b
id h
flowed from deficient safety culture, not only at the ,
y
Chernobyl plant, but throughout the Soviet design, operating and regulatory
operating and regulatory organizations for nuclear power that existed at the time.”
‐‐International Atomic Energy Agency (IAEA)
What is Safety Culture?
“BP has harnessed impressive scientific and technological experience…and you have to wonder why they hadn't harnessed similar science and a essed s a sc e ce a d
technology to anticipate failure, to install redundancy to prevent failure [they] cast doubt on
failure…[they] cast doubt on whether the company has the commitment to the practice and the culture of safety
and the culture of safety necessary to protect the public.”
Rep. James L. Oberstar (D‐
Minn.), chairman of the House Transportation and p
Infrastructure Committee
Culture and Behavior
Culture and Behavior
Process
Knowledge
Safe Action
Culture
Regulatory emphasis
Regulatory emphasis
• To Err is Human
• Joint Commission
Joint Commission
– Mark Chassin (President, Joint Commission): Health care leaders are directly responsible for care leaders are directly responsible for
“Health
establishing a culture of safety.”
• CMS
– Medicare QIO program includes “organizational p g
g
safety culture assessment” in QIO scope of work
Limited evidence of patient outcome associations
• Improvement in safety climate associated with shorter ICU LOS, fewer medication errors, ,
,
lower ventilator associated pneumonia rates, lower bloodstream infection lower risk‐
lower bloodstream infection, lower risk
adjusted mortality rates (Pronovost, 2005)
• Specific aspects of safety climate associated f
f f
with fewer adverse patient safety events (Singer, 2009)
Safety Culture and Safety Climate
Safety Culture
and Safety Climate
Safety Climate
Safety Culture
“The surface features of the safety culture discerned from the
workforce's attitudes and perceptions at a given point in time.”
(Flin et al. 2000)
Research aims
Research aims
• To measure the relationship between hospital p
patient safety climate and heart failure (HF), y
( ),
acute myocardial infarction (AMI) and pneumonia readmission
pneumonia readmission
• To investigate which organizational level (unit, individual, job role) demonstrated the closest )
associations between safety climate and readmission
Survey instrument: Patient Safety Climate in Healthcare Organizations Survey
lh
i i
• 45 items measuring safety climate with Likert‐
type response scale
yp
p
• Data from 2006‐2007 survey of hospital personnel (36 375 individuals from 74 US
personnel (36,375 individuals from 74 US hospitals [38.52% response rate])
• Hospitals selected from stratified random sample based on size and region
sample based on size and region
Method: Domains of safety climate ( i
(primary independent variables)
i d
d t i bl )
• Derived from principle components analysis
Unit
Organization
• Senior manager engagement (α=0.877)
• Organizational resources (α=0.757)
y
• Overall safety emphasis (α=0.695)
•Unit safety norms ((α=0.727))
•Unit recognition and support (α=0.736)
•Unit manager
•Unit manager support (α=0.706)
•Psychological safety (α=0.758)
•Collective learning (α=0.787)
•Responsiveness ( 0 791)
(α=0.791)
Interpersonal
• Fear of shame ((α=0.708))
• Fear of blame (α=0.701)
Provision of safe care (α 0 713)
care (α=0.713)
Safety climate survey output:
“P
“Percent Problematic Response” (PPR)
t P bl
ti R
” (PPR)
• For positively worded items (“Senior management has a clear picture of the risk associated with patient care”), PPR is recorded as g
gy
g
p
% with “disagree” or “strongly disagree” response
• FFor negatively
ti l worded items (“If people find out d d it
(“If
l fi d t
that I made a mistake, I will be disciplined”), PPR i
is recorded as % with “agree” or “strongly agree” d d % i h“
” “
l
”
response
Analysis
• Independent Variables
Independent Variables
– Percent problematic response for twelve safety culture y
domains and summary measure
• Dependent Variables:
– Risk standardized measures of 30 day readmission for heart failure acute myocardial infarction and
heart failure, acute myocardial infarction and pneumonia obtained from CMS Hospital Compare
• Multiple robust linear regression
p
g
• All results are presented as β coefficients with associated significance testing.
– Results can be interpreted as a the % problematic l
b i
d
h %
bl
i
response change required to alter % readmission equally.
Indiv.
Unit
Organization
Multiple regression models: All Staff
Multiple regression models: All Staff
Senior Management Engagement
Organizational Resources
O
Overall Emphasis on Safety
ll E h i
S f t
Problem Responsiveness
Unit Safety Norms
y
Unit Recognition and Support
Unit Manager Support
Collective Learning
Psychological Safety
Fear of Shame
Fear of Shame
Fear of Blame
Provision of Safe Care
Summary Measure
AMI
HF
0.0804*
0.0744
0.0642
0.0705
0.0968**
0.1130**
0.0853*
0.0903
0.1860**
0.1860
0.2590**
0.2590
0.0345
0.0599
0.0506
0.0344
0.116*
0.160**
0.0644
0.0602
0 0126
0.0126
‐0 0827
‐0.0827
0.051
0.106**
‐0.0138
0.0067
0.123*
0.160*
**p<0.01, *p<.05, Regression models include region, hospital tax status, nurse staffing ratios
Multiple regression models: S i
Senior managers vs
f tli
frontline staff
t ff
AMI
Indivv.
Unit
Organizattion
Mgmt
Staff
HF
Mgmt
Senior Management Engagement
Organizational Resources
Overall Emphasis on Safety
Problem Responsiveness
Unit Safety Norms
Unit Recognition and Support
Unit Manager Support
Unit Manager Support
Collective Learning
Psychological Safety
F
Fear of Shame
f Sh
Fear of Blame
Provision of Safe Care
0.0074
‐0.0182
0.0311
0.0441
0.0262
0.0001
0 0372
0.0372
‐0.0070
0.0009
0 0283
0.0283
0.0524
‐0.0233
Summary
0.0144 0.128** 0.0646 0.163**
**p<0.01, *p<.05
0.0873**
0.0754**
0.0881**
0.0798*
0.124**
0.0428
0 0478
0.0478
0.113**
0.0715
0 0147
0.0147
0.0415
0.00919
0.0422
0.0123
0.0718**
0.0719*
0.0655**
0.0304
0 0513
0.0513
0.0378
0.0343
0 0334
0.0334
0.0498
‐0.0237
Staff
0.0831*
0.0732*
0.105**
0.0938*
0.200**
0.0497
0 0331
0.0331
0.127**
0.0719
0 0317
0.0317
0.0961**
0.00575
Multiple regression models: MD vs RN
Multiple regression models: MD vs
Ind
div.
Unit
Organizzation
AMI
Senior Management Engagement
Organizational Resources
g
Overall Emphasis on Safety
Problem Responsiveness
Unit Safety Norms
Unit Safety Norms
Unit Recognition and Support
Unit Manager Support
Collective Learning
Psychological Safety
Fear of Shame
Fear of Blame
Provision of Safe Care
MD
0.0626**
0.0374
0.0540**
0.0429*
0 0800**
0.0800**
0.0317
0.0524**
0.0682**
0.0191
0.0388
‐0.0024
‐0.0107
Summary
0 0829** 0.0407
0.0829**
0 0407 0.0652
0 0652 0.0832*
0 0832*
**p<0.01, *p<.05,
RN
0.0247
0.0267
0.0272
0.021
0 0828
0.0828
0.0050
0.0195
0.0299
‐0.0199
‐0.0845
0.036
‐0.0179
HF
MD
0.0443
0.0379
0.0401
0.0403
0 027
0.027
0.0429
0.0377
0.0341
‐0.0103
0.0699*
0.0196
‐0.0071
RN
0.0368
0.0414
0.0583**
0.0348
0 155**
0.155**
0.0484
0.0097
0.0761*
0.0179
‐0.160
0.0569**
0.0279
Conclusions
• Associations exist between safety climate and readmissions readmissions
• Frontline staff > senior management perceptions
• MD
MD’ss perceptions perceptions ≈ AMI readmission
AMI readmission
• Nurses’ perceptions ≈ HF readmission
Room for Improvement?
Room for Improvement?
% Proble
ematic Ressponse
(mean of 16 items)
25
20
One US hospital from a sample of 97 performed b tt th th
better than the naval l
aviation average
15
10
5
0
US hospitals and Naval aviation average (orange line)
Singer, et al. Safety climate in naval aviation and hospitals: Implications for improving patient safety
Implications
• Why would nurses’ perceptions be more tied to readmission for HF patients while MD’s p
perceptions are more tied to AMI patients?
– HF as chronic disease vs
HF as chronic disease vs AMI as acute illness
AMI as acute illness
• And what about pneumonia?
A d h t b t
i ?
Acknowledgments:
Acknowledgments: Sara Singer, PhD, MBA
Assistant Professor Harvard University
Assistant Professor, Harvard University
Mark Williams, MD
Professor, Northwestern University
f
h
i
i
Questions?
Additional Materials
Why readmission?
Why readmission?
• Of patients admitted for CHF (Krumholz, 2009):
– ½ are readmitted within 6 months
– ¼ are readmitted within 30 days
– 20% are readmitted within 2 weeks
20% are readmitted within 2 weeks
• MedPAC estimates annual cost of avoidable readmission $16 Billion
readmission $16 Billion
• Readmission rates are modifiable and can be reduced by an intervention peri‐discharge (Phillips, JAMA, 2004)
Data collection
Data collection
• 100% of senior managers and staff physicians, 10% random sample of remaining staff, were p
g
,
surveyed
In
ndiv.
Uniit
Organ
nization
Primary independent variables: D
Domains of safety climate
i
f f t li t
Senior Management Engagement
Organizational Resources
Overall Emphasis on Safety
Problem Responsiveness
Unit Safety Norms
Unit Recognition and Support
Unit Manager Support
Collective Learning
Psychological Safety
Fear of Shame
Fear of Blame
f l
Provision of Safe Care
Derived from principle components analysis
Safety climate survey output:
“P
“Percent Problematic Response” (PPR)
t P bl
ti R
” (PPR)
• For positively worded items (“Senior management has a clear picture of the risk associated with patient care”), PPR is recorded as g
gy
g
p
% with “disagree” or “strongly disagree” response
• FFor negatively
ti l worded items (“If people find out d d it
(“If
l fi d t
that I made a mistake, I will be disciplined”), PPR i
is recorded as % with “agree” or “strongly agree” d d % i h“
” “
l
”
response
2
Multiple regression models (w/R ):
All Staff
ll ff
Indiv..
Un
nit
Organizatiion
Safety Climate Domain
Senior Management Engagement
Organizational Resources
Overall Emphasis on Safety
p
Problem Responsiveness
Unit Safety Norms
Unit Recognition and Support
Unit Manager Support
Unit Manager Support
Collective Learning
Psychological Safety
Fear of Shame
Fear of Blame
Provision of Safe Care
Summary Measure
Admission Diagnosis, parameter estimate (Adjusted
ti t (Adj t d R2)
AMI
CHF
0.0804* (.035)
0.0744
0.0642
0.0705
0.0968** (.075) 0.113** (.199)
0.0853* (.021)
0.0853
(.021)
0.0903
0.186** (.094)
0.259** (.249)
0.0345
0.0599
0 0506
0.0506
0 0344
0.0344
0.116* (.022)
0.160** (.185)
0.0644
0.0602
0.0126
‐0.0827
0.051
0.106**(.220)
‐0.0138
0.0067
0.123* (.02)
**p<0.01, *p<.05, Regression models include region, hospital tax status
0.160* (.173)
Limitations
• Study hospitals were more likely to be academic centers and located in the South and Midwest compared to national averages.
• Response rate was low (38.52%), largely as a result of low physician responsiveness, but was similar to that observed in previous published surveys of safety climate.