Patient Safety Culture
Measurement and Improvement
Mark Fleming
Saint Mary’s University
Mark.fleming@smu.ca
Objectives

•
Understand the nature and importance of culture and
relationship with patient safety
Evaluate current culture
–
•
•
Measure, track, monitor culture
Develop a strategic plan for safety culture
measurement and improvement
Implement culture improvement strategies
–
Identify barriers to improvement
We can't solve problems by using the same kind of thinking
we used when we created them
Albert Einstein
Importance of culture
•
“Health care organizations must develop a culture of
safety such that an organization's care processes and
workforce are focused on improving the reliability and
safety of care for patients.” (p. 14; IOM, 1999)
•
“The biggest challenge to moving toward a safer health
system is changing the culture from one of blaming
individuals for errors to one in which errors are treated
not as personal failures, but as opportunities to improve
the system and prevent harm.” (p. 79; Crossing the
Quality Chasm, 2001)
Culture and patient safety
Patient
Safety Culture
Norms and
Behaviour
Enabler/
Barrier
Patient
Safety
Patient Safety
Interventions
Patient safety culture

A culture of safety can be defined as an
integrated pattern of individual and
organizational behaviour, based upon shared
beliefs and values, that continuously seeks to
minimize patient harm that may result from
the processes of care delivery (Kizer, 1999).
Patient safety culture elements

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Leadership commitment to safety
Organizational resources for patient safety
Priority of safety versus production
Effectiveness and openness of communication
Openness about problems and errors
Organizational learning
Frequency of unsafe acts
(Singer et al. 2003)
Measurement and Improvement

Organizational level

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Major system wide change process requiring significant
resources
Step change in patient safety outcomes
Unit level

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Focused intervention
Incremental improvement
1. Investigate

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Build expertise in safety culture
Form small assessment and improvement team
Select appropriate instrument

Agency for Health Care Research and Quality

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Safety Attitudes Questionnaire

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Hospital survey on patient safety (79 items) (Sorra & Nieva, 2004)
SAQ (60 items) (Sexton & Thomas 2003)
York University

Modified Stanford (32 items) (Ginsburg et al, 2009)
York University Modified Stanford

Based on PSCI and Capital Health questionnaire
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Organizational leadership for safety
Unit leadership for safety
Perceived state of safety
Shame and repercussions
Learning
Good psychometrics (alpha’s .66-.86)
Currently used by Accreditation Canada
Large Canadian data set
2. Initiate

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Obtain Informed senior leadership support
Involve health care staff

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Planning and implementation of assessment
Keep staff informed about progress
3. Implement

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Collect data
Interpret results
Feedback results to staff
Overall average for each factor
5.0
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
5.0
Organisational leadership Items
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
Q1. Patient safety
Q2. Good
Q4. Senior
Q7. Senior
Q12. Senior
Q29. My
Q30. I work in an
decisions are made communication management has a
management
management
organization
environment where
at the proper level flow exists up the clear picture of the provides a climate considers patient effectively balances patient safety is a
by the most
chain of command risk associated with that promotes
safety when
the need for
high priority
qualified people regarding patient
patient care
patient safety
program changes patient safety and
safety issues
are discussed
the need for
productivity
Comparsion between units
5.0
4.5
4.0
Oncology
Cardiac surgery
3.5
Gynecology
Day surgery
ICU
3.0
ENT
Emergency
2.5
Orthopedics
CCU
Diagnostic Imaging
2.0
Overall
1.5
1.0
Organisational
leadership
Unit leadership
Perceived state of
safety
Shame and
repercussions
Learning
Organisational leadership by Unit
5.0
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
Unit level assessment and improvement
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Conduct safety culture survey (e.g. MSI )
Group exercise
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Representative group of frontline caregivers
30 – 60 minutes to complete
Helps to make sense out of culture survey results and
create actions for improvement
Normalizes patient safety culture conversations
Organisational leadership items for Emergency dept
5.0
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
Q1. Patient safety
decisions are made at
the proper level by
the most qualified
people
Q2. Good
Q4. Senior
Q7. Senior
Q12. Senior
communication flow management has a management provides
management
exists up the chain of clear picture of the
a climate that
considers patient
command regarding risk associated with
promotes patient safety when program
patient safety issues
patient care
safety
changes are discussed
Q29. My organization Q30. I work in an
effectively balances environment where
the need for patient patient safety is a high
safety and the need
priority
for productivity
4. Improve

Involve cross section of staff in development of
improvement plan
Implement an improvement plan
Monitor the implementation of plan
Evaluate effectiveness of plan

Assess change in culture
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Patient Safety Culture Improvement
Tool (PSCIT)
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Perceptions are based in reality
 i.e. perceptions of leadership commitment reflect their
interactions with leaders
Organisations and units with different cultures have different
practices
Safety culture improvement involves system change
 e.g. perceptions of leader commitment is improved through
training and evaluating safety leadership practices
Patient safety culture elements

Leadership
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Senior Manager
Clinical Manager
Physician
Risk analysis
Workload management
Sharing and learning
Resource management
Example element
How to use the audit

Self assessment of systems supporting the safety culture

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Completed by unit or department to assist in identifying
opportunities to improve
Completed by senior management team to form basis for
improvement workshop
Improving patient safety culture



Leadership
 Judged by actions not words
Solution focused approach
 Assess current culture
 Work at team level to develop local action plan
 Implement changes
 Reassess culture
Health care specific challenges
 Unclear management control
 Limited acceptance of need to change
Taking Action
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Culture is shared by group members
Groups consist of individuals
Culture change requires individuals to change their values,
beliefs and behaviour
Cultural change can begin at the:
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Organizational level
Unit level
Individual level
So what are you going to do to change the culture?
Summary
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Creating a culture of patient safety is crucial
The culture determines what behaviours are acceptable
and unacceptable
Patient safety culture consists of a number of dimensions
It is important to understand the current culture before
trying to change it
Cultural change can be conducted at the organisational or
unit level
References
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Kizer, K. W. 1999. Large system change and a culture of safety. In: Enhancing
Patient Safety and Reducing Errors in Health Care. Chicago, IL: National Patient
Safety Foundation
Ginsburg L, Gilin D, Tregunno D, Norton P G, Flemons W. and Fleming M
(2009) Advancing measurement of patient safety culture Health Services
Research Vol 44 no 1 pp205-223
Sexton JB, Paine LA, Manfuso J, Holzmueller CG, Martinez EA, Moore D,
Hunt DG, & Pronovost PJ.(2007) A check-up for safety culture in "my
patient care area". Joint Commission journal on quality and patient safety.
Nov;33(11):699-703, 645
Fleming, M. and Wentzell, N. (2008) Patient Safety culture improvement tool:
development and guidelines for use. Healthcare Quarterly Volume 11
Special issue pp10-15
Jackson, J. Sarac, C. and Flin R. (2010) Hospital safety climate surveys:
measurement issues Current Opinion in Critical Care , 16:632–638