# Presentation: 875271

## Kerry Bommarito, M.P.H.

June 7 , 2005

- June 7 , 2005

**Techniques for institutionalizing a safety culture**

## Safety Culture

*“**Few phrases occur more frequently in discussions about hazardous technologies than **safety culture**.  Few things are so sought after and yet so little understood.”*
- 						- Reason, 1997

## What is Safety Culture?

-  The shared beliefs and values of staff working in an organization that determine the commitment to and quality of an organization’s health and safety management
- 					OR
-  The way we do things around here

## What is Safety Culture?

- Concept of safety culture originated in the nuclear industry as a result of Chernobyl accident
- Organization’s culture can have a significant impact on the occurrence, reporting and addressing of errors and mistakes

## Components of a Safety Culture

- Financial investment in safe practice
- Open communication about safety issues encouraged
- Commitment to safety articulated at highest level
- Safety perceived to be highest priority
- Incentives aligned to promote safe practice
- Unsafe acts rare
- Commitment to org. learning rather than blame

- To Err is Human. IOM, 2000

## Why is Safety Culture So Important??

- Research in other industries has found strong links between safety culture and significant accidents and mistakes, and has also linked it to an organization’s ability to report and learn from such errors

## WUSM/BJC HealthCare AHRQ Study

- Vicky Fraser, MD – PI
- Clay Dunagan, MD – Co-PI
- Tom Burroughs, PhD
- Jane Garbutt, MD
- Kerry Bommarito, MPH
- Supported by AHRQ #HS1189801
- Improving Patient Safety: Health Systems Reporting, Analysis, and Safety Improvement Research Demonstrations

## Survey Development

- Safety culture
- Current knowledge about causes and frequencies of errors
- Behavior and attitudes toward reporting

- Perceptions  about how information about errors is used
- Perceptions about personal consequences of reporting errors
- Perceptions about the safety programs in the facilities

- Focus groups and interviews with nurses, patient care technicians, pharmacists, clinical managers
- 33 questions from the Stanford Patient Safety Climate Inventory survey
- Survey assessed:

## Study Site

- BJC HealthCare is a large nonprofit delivery system in the Midwest comprised of 12 acute care hospitals, 7 long term care facilities, and a home health company
- Serve rural, urban and suburban communities in Missouri and Illinois
- Facilities range in size from <100 to >600 beds and include 1 adult and 1 pediatric academic, 6 community, and 4 rural hospitals

## Study Population

- Current employees of all care delivery units at BJC HealthCare who provide direct patient care
- Clinical manager, RN, LPN, nursing techs, pharmacists, pharmacy techs, surgical techs, EMT/paramedics, radiology and nuclear med technologists and technicians
- At the 4 rural hospitals – 100% employees, at the remaining larger facilities – 50% employees were surveyed
- 5047 eligible employees

## Survey Administration

- Questionnaires were mailed to employees’ homes using a four-wave approach over an eight-month period beginning October 2002
- Initial scannable survey mailed
- Reminder postcard mailed
- Second paper survey mailed to non-responders
- Third paper survey mailed to non-responders at facilities with less than a sixty percent participation rate

## Response Rate

- 91% of Clinical managers
- 58% of RNs
- 42% of LPNs
- 33% of Nursing Techs

- 69% of Pharmacists
- 51% of Pharmacy Techs
- 35% of EMT/Paramedics

- 51.8% (2617 of 5047) eligible employees responded

## Slide 13

| Demographics | Mean | SD |
| --- | --- | --- |
|   Age, years | 41.1 | 10.8 |
|   Years in department | 7.5 | 7.5 |
|   Years at facility | 9.2 | 8.7 |
|   Years in healthcare | 16.9 | 10.1 |
| Gender | Frequency | Percent |
|   Female | 2282 | 88 |
|   Male | 319 | 12 |
| Race |  |  |
|   Caucasian Non-Hispanic | 2210 | 87 |
|   African American | 285 | 11 |
|   Other Race | 55 | 2 |

## Slide 14

| Job Type | Frequency | Percent |
| --- | --- | --- |
|   Nurse/LPN | 1583 | 61 |
|   Nursing Technician | 410 | 16 |
|   Pharmacist | 140 | 5 |
|   Pharmacy Technician | 71 | 3 |
|   Clinical Manager | 190 | 7 |
|   EMT/Paramedic | 43 | 2 |
|   Radiology/Nuclear Med | 93 | 4 |
|   Other | 87 | 3 |
| Hospital Type |  |  |
|   Adult Academic (1) | 799 | 31 |
|   Community (6) | 1030 | 40 |
|   Rural (4) | 290 | 11 |
|   Pediatric Academic (1) | 289 | 11 |
|   Long Term Care (4) | 70 | 3 |
|   Home Care (1) | 137 | 5 |

## Slide 15

| Attitudes Towards Senior Management |  |
| --- | --- |
| Question Text | Overall |
|  | Agree* % |
| Good communication flow exists up the chain of command regarding patient safety issues | 74.0 |
| Senior management has a clear picture of the risks associated with patient care | 58.6 |
| Senior management has a good idea of the kind of mistakes that actually occur in this facility | 59.5 |
| Senior management provides a climate that promotes patient safety | 66.5
 |
| Senior management considers patient safety when program changes are discussed | 58.8 |
| *Percentage includes strongly agree and agree.
**No significant difference among groups |  |

## Slide 16

| Differences Among Departments - Barriers to Reporting |  |  |  |  |
| --- | --- | --- | --- | --- |
| Question Text | Overall | Nursing
n=1967 | Pharmacy
n=227 | P value |
|  | Agree* % | Agree* % | Agree* % |  |
| If people find out I made a mistake, I will be disciplined | 27.2 | 28.5 | 13.7 | .0001 |
| Clinicians who make serious mistakes are usually punished | 24.7 | 26.2 | 8.9 | .0001 |
| Telling others about my mistakes is embarrassing | 42.1 | 42.0 | 43.5 | .701 |
| I feel ashamed when I make a mistake in front of my coworkers | 40.9 | 40.8 | 42.2 | .724 |
| I am rewarded for taking quick action to report a serious mistake | 25.7 | 26.3 | 19.6 | .049 |
| If reporting were anonymous, I would be more willing to report medical errors. | 38.6 | 39.3 | 31.6 | .048 |
| * Percentage includes strongly agree and agree. |  |  |  |  |

## Slide 17

| Differences Among Job/Skill Level - Barriers to Reporting |  |  |  |  |
| --- | --- | --- | --- | --- |
| Question Text | Management
n=138 | Professional
n=1608 | Technician
n=448 | P value |
|  | Agree* % | Agree* % | Agree* % |  |
| If people find out I made a mistake, I will be disciplined | 9.9 | 27.7 | 30.6 | .0001 |
| Clinicians who make serious mistakes are usually punished | 8.5 | 24.8 | 29.7 | .0001 |
| Telling others about my mistakes is embarrassing | 48.5 | 46.3 | 27.1 | .0001 |
| I feel ashamed when I make a mistake in front of my coworkers | 47.7 | 43.8 | 29.6 | .0001 |
| I am rewarded for taking quick action to report a serious mistake | 38.5 | 22.6 | 32.5 | .0001 |
| If reporting were anonymous, I would be more willing to report medical errors. | 30.6 | 38.5 | 41.4 | .095 |
| * Percentage includes strongly agree and agree. |  |  |  |  |

## Conclusions

- Culture can vary by unit, job level
- Culture should first be measured so culture change interventions can be tailored to different units, department, and groups of staff
- Remember: Culture change takes time!
- Ideally, culture should be measured again after intervention has been implemented

## Questions????

## Contact Information

- Kerry Bommarito
- kbommarito@wustl.edu
- Washington University School of Medicine
- 660 S. Euclid Avenue
- Box 8051
- St. Louis, MO 63110
- 314-454-8221