Assessing and improving safety climate in a large cohort of intensive care units*

Objectives:To evaluate the impact of a comprehensive unit-based safety program on safety climate in a large cohort of intensive care units participating in the Keystone intensive care unit project. Design/Setting:A prospective cohort collaborative study to improve quality of care and safety culture by implementing and evaluating patient safety interventions in intensive care units predominantly in the state of Michigan. Interventions:The comprehensive unit-based safety program was the first intervention implemented by every intensive care unit participating in the collaborative. It is specifically designed to improve the various elements of a unit's safety culture, such as teamwork and safety climate. We administered the validated Safety Attitudes Questionnaire at baseline (2004) and after 2 yrs of exposure to the safety program (2006) to assess improvement. The safety climate domain on the survey includes seven items. Measurements and Main Results:Post-safety climate scores for intensive care units. To interpret results, a score of <60% was in the “needs improvement” zone and a ≥10-point discrepancy in pre-post scores was needed to describe a difference. Hospital bed size, teaching status, and faith-based status were included in our analyses. Seventy-one intensive care units returned surveys in 2004 and 2006 with 71% and 73% response rates, respectively. Overall mean safety climate scores significantly improved from 42.5% (2004) to 52.2% (2006), t = −6.21, p < .001, with scores higher in faith-based intensive care units and smaller-bed-size hospitals. In 2004, 87% of intensive care units were in the “needs improvement” range and in 2006, 47% were in this range or did not score ≥10 points or higher. Five of seven safety climate items significantly improved from 2004 to 2006. Conclusions:A patient safety program designed to improve teamwork and culture was associated with significant improvements in overall mean safety climate scores in a large cohort of 71 intensive care units. Research linking improved climate scores and clinical outcomes is a critical next step.

[1]  Stephen J. Gerras,et al.  Climate as a moderator of the relationship between leader-member exchange and content specific citizenship: safety climate as an exemplar. , 2003, The Journal of applied psychology.

[2]  Peter J Pronovost,et al.  A practical tool to learn from defects in patient care. , 2006, Joint Commission journal on quality and patient safety.

[3]  Torsten B Neilands,et al.  The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research , 2006, BMC Health Services Research.

[4]  M D Cooper,et al.  Exploratory analysis of the safety climate and safety behavior relationship. , 2013, Journal of safety research.

[5]  David A. Hofmann,et al.  A CROSS-LEVEL INVESTIGATION OF FACTORS INFLUENCING UNSAFE BEHAVIORS AND ACCIDENTS , 1996 .

[6]  B. Sexton,et al.  Revealing and resolving patient safety defects: the impact of leadership WalkRounds on frontline caregiver assessments of patient safety. , 2008, Health services research.

[7]  John S. Carroll.  Safety culture as an ongoing process: Culture surveys as opportunities for enquiry and change , 1998 .

[8]  D. Zohar.  A group-level model of safety climate: testing the effect of group climate on microaccidents in manufacturing jobs. , 2000, The Journal of applied psychology.

[9]  D. Hofoss,et al.  Psychometric properties of the Norwegian version of the Safety Attitudes Questionnaire (SAQ), Generic version (Short Form 2006) , 2008, BMC health services research.

[10]  Toivo Niskanen,et al.  Safety climate in the road administration , 1994 .

[11]  P. Pronovost,et al.  Harnessing the Potential of Health Care Collaboratives: Lessons from the Keystone ICU Project , 2008 .

[12]  Peter J Pronovost,et al.  Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study , 2010, BMJ : British Medical Journal.

[13]  Sharon Clarke.  Safety culture on the UK railway network , 1998 .

[14]  Richard L. Griffith,et al.  Senior executive adopt-a-work unit: a model for safety improvement. , 2004, Joint Commission journal on quality and safety.

[15]  J. Defontes,et al.  Preoperative Safety Briefing Project. , 2004, The Permanente journal.

[16]  Paula S Kent,et al.  Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit. , 2010, Joint Commission journal on quality and patient safety.

[17]  W. Weeks,et al.  Measuring patient safety climate: a review of surveys , 2005, Quality and Safety in Health Care.

[18]  D. Zohar.  Safety climate in industrial organizations: theoretical and applied implications. , 1980, The Journal of applied psychology.

[19]  W. D. Compton,et al.  The Context of Care and the Patient Care Team: The Safety Attitudes Questionnaire , 2005 .

[20]  Peter J Pronovost,et al.  Improving care for the ventilated patient. , 2004, Joint Commission journal on quality and safety.

[21]  P. Pronovost,et al.  Improving communication in the ICU using daily goals. , 2003, Journal of critical care.

[22]  Peter J Pronovost,et al.  Improving patient safety in intensive care units in Michigan. , 2008, Journal of critical care.

[23]  P. Pronovost,et al.  An intervention to decrease catheter-related bloodstream infections in the ICU. , 2006, The New England journal of medicine.

[24]  C. Holzmueller,et al.  Variation in caregiver perceptions of teamwork climate in labor and delivery units , 2006, Journal of Perinatology.

[25]  David V. Canter,et al.  Employee attitudes and safety in the chemical industry , 1994 .

[26]  Torsten B Neilands,et al.  The effect of executive walk rounds on nurse safety climate attitudes: A randomized trial of clinical units , 2005, BMC health services research.

[27]  Alistair Cheyne,et al.  Modelling safety climate in the prediction of levels of safety activity , 1998 .

[28]  C. Holzmueller,et al.  View the world through a different lens: shadowing another provider. , 2008, Joint Commission journal on quality and patient safety.

[29]  Behaviors that undermine a culture of safety. , 2008, Sentinel event alert.

[30]  François Béland,et al.  A safety climate measure for construction sites , 1991 .

[31]  E. Kelloway,et al.  Development and test of a model linking safety-specific transformational leadership and occupational safety. , 2002, The Journal of applied psychology.

[32]  M. Makary,et al.  Teamwork in the Operating Room: Frontline Perspectives among Hospitals and Operating Room Personnel , 2006, Anesthesiology.

[33]  C. Holzmueller,et al.  Implementing and Validating a Comprehensive Unit-Based Safety Program , 2005 .

[34]  J. Sexton,et al.  Measuring Safety Culture in the Ambulatory Setting: The Safety Attitudes Questionnaire—Ambulatory Version , 2007, Journal of General Internal Medicine.

[35]  E. Norwitz,et al.  Impact of a comprehensive patient safety strategy on obstetric adverse events. , 2009, American journal of obstetrics and gynecology.

[36]  W. Hendee.  To Err is Human: Building a Safer Health System , 2001 .

[37]  Peter J Pronovost,et al.  Eliminating catheter-related bloodstream infections in the intensive care unit* , 2004, Critical care medicine.

[38]  Y. Donchin,et al.  Healthcare climate: A framework for measuring and improving patient safety* , 2007, Critical care medicine.

[39]  C. Holzmueller,et al.  A morning briefing: setting the stage for a clinically and operationally good day. , 2005, Joint Commission journal on quality and patient safety.

[40]  L. Kohn,et al.  Creating Safety Systems in Health Care Organizations , 2000 .

[41]  P. Pronovost,et al.  Assessing safety culture: guidelines and recommendations , 2005, Quality and Safety in Health Care.