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What is a 'safety culture'?
Submit responseDear Editor
We welcome Singer and colleague’s contribution to developing the concept of a safety culture.[1] Policy-makers, managers and clinicians are slowly realising that patient safety will not be improved solely by counting adverse events or by introducing technical innovations. History tells us that when these initiatives are evaluated the results will probably show a marginal impact on patient safety, and one that is likely to be poorly sustained. In order to maximise their impact we need to understand the shared attitudes, beliefs, values and assumptions that underlie how people perceive and act upon safety issues within their organisations. This is what is commonly called the ‘safety culture’ of an organisation.
The problem with the approach adopted in this paper is that it fails to get to the heart of the hospital’s culture. What they have done is to use a blunt survey instrument to assess the opinions of individual members of staff to a series of statements about safety. The responses represent the most superficial evaluation of the ‘climate’ of the organisations in which they work. These opinions are likely to be influenced by a wide range of factors that have little to do with the organisation’s culture. Furthermore, the relationship between these opinions and the shared values that underlie them is largely unknown.
If we really want to understand the safety culture of an organisation we need to use more sophisticated approaches.[2] These should draw on a wide range of methods – participant observation, in-depth and semi- structured interviews and focus groups, alongside attitudinal surveys and the use of new and established culture-measurement tools.[3] Developmental or action research approaches might provide additional insights into the complexity of the organisations. The aim should be not only to understand and assess the concept of safety culture but also to examine ways of improving it and integrating it with the broader field of organisational culture. This presents a significant challenge to health service researchers. Singer and colleagues have made a start but there is a long way to go before we know how, or indeed whether it is possible, to change the safety culture of our hospitals and primary care centres.
References
(1) Singer S et al. The culture of safety: results of an organization-wide survey in 15 California hospitals. Quality and Safety in Health Care, 2003. 12: p. 112-118.
(2) Mannion R, Davies H, Marshall M. Cultures for performance in healthcare: evidence on the relationships between organisational culture and organisational performance in the NHS. Centre for Health Economics: York, 2003.
(3) Scott J et al. The quantitative measurement of organisational culture in health care: A review of the available instruments. Health Services Researcher, in press.
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Re Article: Qual Saf Health Care 2003; 12 : 112-118
Submit responseDear Editor
Congratulations to the authors for this wonderful comprehensive survey undertaken across 15 hospitals regarding safety cultures. The results of an overall response rate of only 47.4%, was largely due to the poor response for physicians (33%) . Efforts need to be taken to increase the response rate for a more reliable study result. The majority of participants in the survey responded in ways which indicated a culture of safety. However it will be interesting to determine the safety culture among hospitals which do not come under the ‘hospitals participating in the California Patient Safety Consortium’ group. It is noted that higher responses are attributable to shorter survey questions. People generally do not get interested if they have to go through a large format. Clinicians, as expected are more critical about the patient care safety and thus scored more “problematic responses”. Survey sample noted that a total of 6312 eligible individuals participated. As a matter of fact, that figure is actually 6332 individuals (initial mailing list of 6909 names minus 347 duplicates minus 227 undeliverable = 6332).
The high percentage of non respondents an overall figure of 53% could possibly still lead to non response bias. A survey on the non responders will be interesting.
Senior managers gave fewer problematic responses than frontline workers. Generally speaking all senior managers will want to give a high opinion regarding their own organization/institution. Also it could that the patient care problems may not have been briefed to them.
Going by the High Reliability Organization’s (HRO) standards of a cut off point of 10% problematic attitudes the results of an overall problematic response of 13% is worrying. Generally speaking, it can be assumed that we still need to improve and to internalize the culture of safety in healthcare settings among all levels of healthcare workers.
Culture of safety should be cultivated into all health care workers from our undergraduate student days itself if it is to be internalized within ourselves. The article on “Finding safety in medical Education” [1]- Importance of a ‘Safety Culture’ in Medical Education” emphasises that “Improving health and health care begins with the focus on improving medical education”.
Another point for consideration is “Bringing issues of quality and safety out of the shadows can remove some of the sting associated with improvement."[2] Who can doubt that the real agenda in the controversy currently raging over mandatory reporting of medical errors is the fear of being ashamed? The results of this study also supports this as stated: problematic responses were higher for questions that were phrased as hypothetical or impersonal, and lower to questions that were personal or time delimited. Having said all that, it would be good to adapt and conduct a similar survey on the cultures of safety in our very own healthcare setup, compared to the established results of this article as a baseline measure.
References:
(1) Stevens D P. Finding safety in medical education. Qual Saf Health Care 2002; 11:109-110
(2) Davidoff F. Shame: the elephant in the room. Qual Saf Health Care 2002; 11:2-3.
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