88

Japanese Journal of Comprehensive Rehabilitation Science (2017)

Original Article

Identification of communication skills that improve patient safety
culture: analysis of a communication skills training program foruniversity hospital staff
Shin-Ichi Izumi, MD, PhD,1, 2 Yoshihito Furusawa, MD, PhD,2 Musashi Bansho, MS,3
Itsushi Tonomura, BS3
Department of Physical Medicine and Rehabilitation, Tohoku University Graduate School of Biomedical
Engineering, Sendai, Miyagi, Japan2
Department of Physical Medicine and Rehabilitation, Tohoku University Graduate School of Medicine, Sendai,
Miyagi, Japan
3
Coaching Research Institute, COACH A Co., Ltd., Chiyoda-ku, Tokyo, Japan1

ABSTRACT
Izumi S, Furusawa Y, Bansho M, Tonomura I.
Identification of communication skills that improve
patient safety culture: analysis of a communication
skills training program for university hospital staff.
Jpn J Compr Rehabil Sci 2017; 8: 88-97.
Purpose: To elucidate the relationship between patient
safety culture and communication skills (CS).
Methods: A CS training program based on coachingtheory was conducted at a university hospital, and therelationship between the improvement of patient
safety culture and the improvement of CS before andafter training was analyzed. The trainees were 57 fulltime staff members of the hospital. Each trainee
selected around five close coworkers (collaborators; atotal of 285). For seven months, the trainees received
class lessons via an audio conference system, andCorrespondence: Shin-Ichi Izumi, MD, PhD
Department of Physical Medicine & Rehabilitation, Tohoku
University Graduate School of Biomedical Engineering,
2-1 Seiryo-cho, Aoba-ku, Sendai, Miyagi 980-8575, Japan.
E-mail: shinichi.izumi.c2@tohoku.ac.jp
Accepted: June 27, 2017.
Conflict of Interest: The first author Shin-Ichi Izumi
received a donation of 2.5 million yen from COACH A Co.,
Ltd. in 2010 for research purposes at the university, andalso received technical guidance without charge from
COACH A Co., Ltd. in order to implement external medicalcoaching workshops that he organized for health carepersonnel. He also serves as facilitator for the Medical
Coaching Study Group of the Japan Coach Association, a
specific nonprofit corporation affiliated with COACH A
Co., Ltd. Before conducting this research, Shin-Ichi Izumi
was reviewed and approved by the Tohoku University
Conflict of Interest Management Committee.
©Kaifukuki Rehabilitation Ward Association 2017
doi.org/10.11336/jjcrs.8.88

CW6_A7164D01_E.indd

88

at the same time conducted coaching interviews
with their collaborators. The collaborators assessed
the trainees’ CS and patient safety culture using
questionnaires before and after training.
Results: Excluding missing data, 259 subjects wereanalyzed. The patient safety culture improved group
showed a higher degree of improvement in CS
regarding “suggestions/requests” compared to the
non-improved group. Furthermore, improvement of
the “suggestions/requests” skill was related to theimprovement of patient safety culture regarding“supervisor/manager expectations and actions inpromoting safety” and “non-punitive response toerrors.”Conclusion: The present results suggest that
improvement in “suggestions/requests” skill may be
associated with improvement in patient safety culture.
Key words: patient safety, coaching, organizational
development, university hospital, multidisciplinary
team care
Introduction
Patient safety is the most fundamental prerequisite
in health care. The Committee on Quality of HealthCare in America lists the following five principles fordesigning safety systems in health care organizations[1].
(1) Provision of leadership placing patient safety as
the top priority goal of the health care organizationand making patient safety the responsibility of
every staff member.
(2) Respect for cognitive and physical limits ofhumans in system design.
(3) Promotion of effective team functioning throughteam training of clinical staff with patient
Jpn J Compr Rehabil Sci Vol 8, 20172017/09/01

13:07:10

Shin-Ichi Izumi et al.: Relation between patient safety culture and communication skills

participation.
(4) A nticipation of the unexpected through systemdesign for accident prevention and recovery, andby simulation training.
(5) C reation of an environment conducive to learning
by encouraging error reporting and freecommunication.
Among these principles, (1) is associated with thestaff’s sense of responsibility, (2) with the patient
safety system, (3) and (4) with education and training,and (5) with intra-organizational communication.
These are related to the management ability ofmanagers/supervisors who hold the responsibilities ofgoal setting, staff education, and working environment
improvement.
Rehabilitation medicine is team medical care inwhich multidisciplinary professionals work together
toward a common goal, and great importance is placedon the autonomy of individual disciplines as well as
close coordination among disciplines [2]. Therefore,
teamwork has a powerful influence on the quality ofrehabilitation medicine including patient safety.
There are two approaches to clinical team training:
simulation training and class training [3]. Simulation
training is learning by experiencing simulated clinicalsettings. Trainees acquire knowledge of fixed
procedures such as preoperative briefing and learn thethinking process of clinical decision-making using
clinical scenarios. In class training, trainees acquire
knowledge and communication skills (CS) throughlectures and discussions among participants. In
simulation training, although team behavior is
improved during the training period [3], whether there
is an actual effect on patient safety has not beenvalidated. For class training, the effect has been
demonstrated by the participants’ evaluation [4, 5] andthe frequency of actions leading to error prevention
observed in the clinical setting [5]. However, thetraining items that contribute to such effect remain
unknown. In addition, while it is relatively easy to
set a common goal for all participants when training
is conducted within a specific department such as
the emergency department [6], department of surgery[5] or department of radiology [4], this is not thecase when various professional disciplines acrossdepartments participate in training as the relationshipbetween the goals of the participants’ departments andthe training tasks tends to become diluted. For thatreason, there are no reports that verify the effect onpatient safety of team training for an entire healthcare organization including the administrative staff.
Moreover, we found no studies that elucidate therelationship between training that improves the
management skills of managers/supervisors andpatient safety in health care organizations.
As a scale to evaluate patient safety in health careorganizations, the Hospital Survey on Patient Safety
Culture was developed and validated by the Agency


CW6_A7164D01_E.indd

89

for Healthcare Research and Quality (AHRQ) [7]. The
Japanese version of this scale has been developed, andthe reliability and validity have also been confirmed[8, 9]. Taneda et al. [8], who developed the Japaneseversion of the scale, stated that diffusion of the attitudeand concept of making patient safety the top priority
for all staff members throughout the medicalorganization, in other words fostering a patient safety
culture, is essential for providing safe medicine.
There is probably no dispute that a close association
exists between patient safety and managers/
supervisors’ management capability. However, therelationship between specific manager/supervisor
skills and patient safety remains unclear. With theconsideration that CS is an important ability requiredof managers/supervisors to improve patient safety,
we conceived the idea of CS training. Then, we
hypothesized that improving the CS of managers/
supervisors would activate the organization that they
manage, which would in turn improve patient safety.
Consequently, we organized a 7-month CS training
program based on coaching theory at T University
Hospital [10]. Coaching was defined as communicationthat supports other persons’ voluntary action and goal
attainment [11], which was also used in other training
programs [3, 4]. In that study [10], CS assessment byothers (score for a questionnaire assessed by 5 to 10
persons selected by each trainee as close coworkers)
after training showed improvement compared tobefore training although the effect size was small, andonly 55% of all trainees showed improvement in the
CS assessment by others. Nevertheless, trainees’
improvement in CS assessment by others was related
to enhancement of organizational activity, which was
related to improvement in safety evaluation. However,in this previous study [10], we evaluated safety using
the question “I think my department is very safe”
scored on a 7-point scale. In addition, we did notanalyze the direct relationship between CS and safety.
Based on the hypothesis that training aimed at
improving CS would improve trainees’ CS andenhance patient safety culture among the staff working
in the departments managed by the trainees, the aimsof the present study were to elucidate the relationshipbetween CS and patient safety culture scales, and to
extract the factors in patient safety culture showing astrong relationship with individual items of CS
included in the training.
Methods
1. Subjects
Full-time employees at T University Hospital(approximately 2,200 full-time employees in total)
with managerial responsibilities who participatedvoluntarily in the CS training program (CSTP) (hereinreferred to as trainees) and the main persons working
with the trainees (subordinates or colleagues; herein
Jpn J Compr Rehabil Sci Vol 8, 201789

2017/09/01

13:07:10

90

Shin-Ichi Izumi et al.: Relation between patient safety culture and communication skills

referred to as collaborators) were included in thepresent study. Each trainee selected around fivecoworkers who were considered important in theexecution of the trainee’s duties, and requested theircooperation as described below. The number oftrainees was 57 and the number of collaborators 285,
making a total of 342 subjects participating in the
study.
2. Methods
The trainees attended class lessons in the form ofaudio conferences of 55 minutes per session, 4 sessions
per module, for a total of 9 modules (Table 1). The
purpose of the class lessons was to improve thetrainees’ CS, and not to solve specific health careissues such as patient safety. Each lesson consisted ofa lecture presented by a facilitator, role play, anddiscussion. Each trainee applied the skills learned in
the lessons to communication in their routine work,and conducted coaching interviews of approximately
30 minutes per session with each of his/hercollaborators as part of the routine work, for a totalof 9 sessions. The coaching interviews were notconducted for the purpose of assessing the trainee’s
CS learning outcome. In the interview, the trainee
clarified the collaborator’s goal and motivated thecollaborator’s initiative to bridge the gap between thegoal and the present status. The goal of the collaborator
was to be achieved by the collaborator him/herself
in the workplace, and the goal was not limited topromotion of team care or improvement of clinicalsafety by staff members including the trainee. In
addition, each trainee received 9 one-on-one coachingsessions given by the learning coach during the CSTP
period, and continued to work towards achieving his/her own goal.
Within one month before the trainee started the
CSTP (pre-CSTP) and between one and two weeks
after the trainee completed the program (post-CSTP),
each collaborator performed an assessment of thecorresponding trainee’s CS (CS assessment by others)
and responded to a questionnaire on patient safety
culture. The questionnaires were filled out
anonymously on the Internet. Responses to all thequestions were required.
For CS assessment, Coaching Skill Assessment
Plus (CSAplus, Appendix 1) developed by COACH A
Co., Ltd. was used. CSAplus consists of 12 categories
and 24 questions, and is scored on a 7-point scale. The
average score of all collaborators and the distributionof the responses obtained for each trainee werecommunicated to the trainee by the learning coach.
To evaluate the safety culture, the Japanese versionof the Patient Safety Culture Scale (Appendix 2) wasused. The scale consists of 12 factors and 42 items
scored on a 6-point scale (5 choices plus “notapplicable”). A valid questionnaire response wasdefined as having less than 22 items scored as “notapplicable.” To calculate the score for an item with a
missing value (“not applicable”), the sum of the scoresexcluding “not applicable” for that item was divided
by the total number of responses excluding “notapplicable,” according to Taneda et al. [8]. The trainee
and collaborator were not notified of the response
results.
Other variables including gender, age, andprofession of the trainees and collaborators wereextracted from the questionnaires.
3. Statistical analysis
Based on the pre-CSTP CSAplus scores, Cronbach’s
coefficient alpha was obtained and internal consistency
was assessed.
The paired t-test was conducted to compare thecollaborators’ pre-CSTP and post-CSTP scores
including the overall score (average score of 24 items)
and scores by category for CSAplus as well as theoverall score (average score of 42 items) and scoresby factor (12 factors) for the Patient Safety Culture
Scale.

Table 1. Class contents of the communication skills training course.
Module
1
2
3
4
5
6
7
8
9

Observation andCommunication types
Active listening

Contents
Tools for understanding the communication type of other persons

Purpose and method of listening, creating an environment for listening, conversation flow
Principles of communication, creating an environment for conversation, interest in
Building trust
other persons
Questions that are effective in shifting the viewpoint of other persons andStrategic questioning
broadening the range of choices
Accountability
Awareness of independent thinking and action
Complete unfinished matters pertaining to personal affairs, work, health, andSetting the foundation
human relationships
Influence
Skills of approval, suggestions, and requests
Case study
Coaching by other participants
Coaching in medical fields Leadership in a health care team, coaching in a medical interview

Jpn J Compr Rehabil Sci Vol 8, 2017

CW6_A7164D01_E.indd

90

2017/09/01

13:07:10

Shin-Ichi Izumi et al.: Relation between patient safety culture and communication skills

Collaborators whose post-CSTP overall scores for
the Patient Safety Culture Scale increased comparedto the pre-CSTP scores were classified into theimproved group, while collaborators who showed noincrease were classified into the non-improved group.
The two groups were compared with respect to thedegree of CS improvement (post-CSTP CSAplus −pre-CSTP CSAplus) for the overall score and scoresby category. For the CSAplus category that showed asignificant intergroup difference, collaborators wereagain divided into improved and non-improved
groups, and compared with respect to the degree of
improvement of patient safety culture (post-CSTP
score − pre-CSTP score) for each of the 12 factors.
Analysis of covariance with the pre-CSTP score as thecovariate was used in the study. Statistical analyses

91

were conducted using IBM SPSS Statistics 19.0.0(International Business Machines Corporation,
Armonk, New York). A p-value less than 0.05 wasconsidered significant.
This study was conducted after approval was
obtained from the Ethics Committee of the Tohoku
University School of Medicine (Approval No. 2011632).
Results
Among 285 participants, those with invalid
questionnaire responses were excluded. Eventually,
the data of 259 participants comprising 50 trainees and209 collaborators was analyzed (Table 2). Both thetrainees and collaborators were multidisciplinary

Table 2. Demographics of the subjects analyzed.
Trainees: n = 50

Number of subjects%

GenderMale
Female

34
16

68.0
32.0

Age (years)

20-29
30-39
40-49
50-

   1
   6
23
20

2.0
12.0
46.0
40.0

Professional discipline

Doctor, dentist
Nurse
Co-medical staffa
Office staff
Othersb

16
10
16
   5
   3

32.0
20.0
32.0
10.0
6.0

Number of subjects%

Collaborators: n = 209
FemaleMale
Female

108
101

51.7
48.3

Age (years)

20-29
30-39
40-49
50-

47
74
63
25

22.4
35.4
30.3
20.0

Professional discipline

Doctor, dentist
Nurse
Co-medical staffc
Office staff
Othersd

43
51
86
25
   4

20.5
24.4
41.1
12.0
1.9

Co-medical staff: 5 physical therapists, 3 pharmacists, 3 registered dietitians, 2 radiological
technologists, 1 clinical engineer, 1 medical technologist, and 1 social worker.
b
Others: 1 systems engineer and 1 teaching staff member of medical research in graduate
school.
c
Co-medical staff: 20 pharmacists, 14 physiotherapists, 12 radiological technologists, 9clinical engineers, 6 medical technologists, 6 dental hygienists, 5 registered dietitians, 5social workers, 3 occupational therapists, 3 speech-language-hearing therapists, 1
orthotist (outsourced), 1 orthoptist, and 1 clinical psychologist.
d
Others: 1 systems engineer, 1 teaching staff member of medical research in graduate
school, and 2 clinical research coordinators.
a

CW6_A7164D01_E.indd

Jpn J Compr Rehabil Sci Vol 8, 201791

2017/09/01

13:07:11

92

Shin-Ichi Izumi et al.: Relation between patient safety culture and communication skills

professionals from various departments. Paramedical
staff (hereinafter referred to as co-medical staff, a termcommonly used in Japan) among the trainees consistedof a large percentage of physical therapists, and one
trainee had participated in CS training in the past.
The overall Cronbach’s coefficient alpha for
CSAplus was 0.948 and that for the 12 categories
ranged from 0.688 to 0.889, showing adequate
reliability.
For CSAplus, significant improvement wasobserved in the overall score and in individual scoresfor 9 categories (Table 3). Among the categories

showing significant improvement, those that reached
the criterion for small effect size were “observation,”“tailor-made treatment,” “follow-up,” “questions,”“feedback,” “supporting others,” and “setting goals.”
For the Patient Safety Culture Scale, no significant
improvement was observed in the overall score or in
the individual scores for the 12 factors (Table 4).
A total of 106 subjects were classified into thepatient safety culture improved group and 103 subjects
into the non-improved group. Results of analysis
of covariance showed a significant difference inimprovement for the “suggestions/requests” category

Table 3. Assessment of communication skills by others.
nPre-CSTP

Post-CSTP

Degree of improvement (post-CSTP − pre-CSDP)

M

SD

M

SD

M

SD

t

p

Cohen's dEffect size
criteria

CSAplus, overall score

209

4.97

0.85

5.25

0.87

0.29

0.77

5.39

<.001

0.37

Small

Observations
Tailor-made treatment
Coaching flow
Listening
Non-verbal
Follow-up
Acknowledgement
Questions
Suggestions/requests
Feedback
Supporting others
Setting goals

209
209
209
209
209
209
209
209
209
209
209
209

4.83
4.80
5.29
5.50
5.56
4.32
5.35
4.78
5.03
4.33
4.95
4.88

1.09
1.08
1.05
1.13
1.05
1.48
1.06
1.10
1.06
1.23
1.25
1.13

5.13
5.05
5.35
5.62
5.71
5.07
5.39
5.24
5.23
4.75
5.26
5.23

1.03
1.06
0.96
1.14
0.97
1.28
1.08
1.04
1.00
1.06
1.16
1.14

0.31
0.25
0.06
0.13
0.15
0.75
0.05
0.46
0.21
0.43
0.30
0.35

1.14
1.06
1.00
1.09
0.94
1.53
0.97
1.04
1.08
1.15
1.16
1.12

3.89
3.42
0.90
1.68
2.29
7.10
0.72
6.39
2.74
5.37
3.80
4.55

<.001
<.001
.367
.095
.023
<.001
.475
<.001
.007
<.001
<.001
<.001

0.27
0.24
0.06
0.12
0.16
0.49
0.05
0.44
0.19
0.37
0.26
0.31

Small
Small
－
－
－
Small
－
Small
－
Small
Small
Small

n, number of samples; M, mean; SD, standard deviation; CSTP, communication skills training program;
Effect size, Cohen’s d was calculated by subtracting the pre-CSTP score from the post-CSTP score, and then dividing the mean difference by
the unbiased standard deviation. Then, the effect size was graded based on the following criteria.
Effect size criteria: small | d | >0.20; medium | d | >0.50; large | d | >0.80.

Table 4. Responses of collaborators to the Patient Safety Culture Scale.
n

Pre-CSTP

Post-CSTP

Degree of improvement (post-CSTP − pre-CSTP)

M

SD

M

SD

M

SD

t

p

Cohen’s dEffect size
criteria

Patient safety culture: overall score

209

142.5517.60

142.11

17.88

−0.44

11.38

−0.56

.575

−0.04

－

Frequency of event reporting
Overall perception of safety
Supervisor/manager expectations &actions promoting safety
Organizational learning/continuous
improvement
Teamwork within hospital units
Communication openness
Feedback and communication about
errorsNon-punitive response to errors
Staffing
Hospital management support forpatient safety
Teamwork across hospital units
Hospital handoffs & transition

209
209

11.13
13.28

2.37
2.40

11.02
13.40

2.53
2.31

−0.11
0.12

2.71
1.90

−0.59
0.92

.555
.358

−0.04
0.06

－
－

209

15.16

2.19

15.13

2.20

−0.03

1.91

−0.26

.794

−0.02

－

209

10.16

1.91

10.37

1.86

0.21

1.69

1.80

.073

0.12

－

209
209

14.82
10.00

2.41
2.17

14.66
   9.83

2.56
1.95

−0.15
−0.17

2.41
1.81

−0.92
−1.37

.358
.174

−0.06
−0.09

－
－

209

10.71

2.37

10.77

2.25

0.05

2.00

0.38

.702

0.03

－

209
209

   9.96
11.09

2.16
2.64

10.06
11.05

2.10
2.48

0.10
−0.04

1.78
2.25

0.80
−0.25

.422
.804

0.06
−0.02

－
－

209

10.67

2.00

10.70

2.03

0.02

1.64

0.22

.829

0.01

－

209
209

12.89
12.67

2.41
1.98

12.65
12.47

2.55
2.11

−0.24
−0.20

2.11
2.04

−1.66
−1.41

.099
.159

−0.11
−0.10

－
－

n, number of samples; M, mean; SD, standard deviation; CSTP, communication skills training program;
Effect size, Cohen’s d was calculated by subtracting the pre-CSTP score from the post-CSTP score, and then dividing the mean difference by
the unbiased standard deviation. Then, the effect size was graded by the following criteria.
Effect size criteria: small | d | >0.20; medium | d | >0.50; large | d | >0.80.

Jpn J Compr Rehabil Sci Vol 8, 2017

CW6_A7164D01_E.indd

92

2017/09/01

13:07:11

93

Shin-Ichi Izumi et al.: Relation between patient safety culture and communication skillsof CSAplus, but the effect size was graded as small(Table 5).
There were 95 subjects in the CSAplus “suggestions/requests” improved group and 114 in the non-improved
group. Results of analysis of covariance showed thatcompared to the non-improved group, the improved
group had significantly greater degrees of improvementin “supervisor/manager expectations & actions
promoting safety” and “non-punitive response toerrors” among the 12 factors in the Patient Safety
Culture Scale, but the effect size was graded as small(Table 6).

Culture Scale were improved to a greater extent
compared to the non-improved group, although theeffect size was small. This is the first report indicating
the relationship between CS and patient safety culture
revealed by conducting health care team training withparticipation by approximately one-sixth of the fulltime university hospital staff. The novelty of this study
is that our analysis proposes the CS category that
contributes to improvement of patient safety culture
and the patient safety culture factors that are affectedby the CS category. However, since the results wereobtained from a specific training program implemented
in one institution, further studies are required to
examine whether the CS category and patient safety
culture factors identified in this study also apply toother clinical environments or training programs.
Some possible reasons why the overall score of thePatient Safety Culture Scale did not change are thatthe scale was not dependent only on communication,and that the trainees’ CS improvement was not
sufficient. In fact, the effect size of CS assessment byothers was small. In previous studies on CS training[10, 12-14], many subjects also showed no
improvement in CS assessment by others. There areindividual differences in the attributes of transferring
learning contents to actions, and the mechanism
linking “acquiring knowledge” to “putting it into
practice” needs to be studied. In the present study,
improvement of the “suggestions/requests” skill,which was included in the “influence” module of the
CSTP, was shown to be related to the improvement

Discussion
We conducted a 7-month CS training program basedon coaching theory by enrolling university hospital
staff who were in leadership positions as trainees, andevaluated the outcome using CS assessment by others
as well as the Patient Safety Culture Scale scored by
the collaborators before and after the training. The
following results were obtained. (1) Significant
improvement was observed in CS assessment byothers although the effect size was small, while nodifference was observed in the Patient Safety Culture
Scale. (2) The CS for “suggestions/requests” wasrelated to improvement in the Patient Safety Culture
Scale. In the group with improved “suggestions/requests” skill, the scores for “supervisor/manager
expectations & actions promoting safety” and “nonpunitive response to errors” in the Patient Safety

Table 5. Comparison of coaching skills improvement in patient safety culture (overall) improved group and nonimproved group.
Degree of improvement of coachingskills (post-CSTP − pre-CSTP)
Patient safety culture(overall)improved group

Patient safety culture(overall)non-improved group

n

M

SD

n

M

CSAplus, overall score106

0.30 0.76

103

0.28 0.78

Observations
Tailor-made treatment
Coaching flow
Listening
Non-verbal
Follow-up
Acknowledgement
Questions
Suggestions/requests
Feedback
Supporting others
Setting goals

106 0.29
106 0.24
106 0.15
106 0.28
106 0.18
106 0.68
106 −0.06
106 0.47
106 0.34
106 0.37
106 0.32
106 0.33

1.09
1.08
0.91
1.16
1.07
1.48
1.03
0.92
1.04
1.03
1.12
1.14

103 0.32
103 0.27
103 −0.03
103 −0.03
103 0.11
103 0.83
103 0.16
103 0.45
103 0.06
103 0.48
103 0.29
103 0.38

SD

1.19
1.05
1.08
1.00
0.78
1.59
0.88
1.16
1.12
1.26
1.20
1.11

Paralleltest ofregression
lines

Significanceof regression

F

t

p

p

Comparison of coaching skills
improvement between patient
safety culture (overall) improved
group and non-improved groupFppartial η2

Effect size
criteria

0.25 .614−6.75 <.001

0.29 .590

.001

－

0.05
0.53
0.78
0.25
3.13
0.05
0.77
6.27
0.06
3.37
1.07
0.35

−10.13
−8.52
−9.69
−7.67
−9.03
−11.86
−6.74
－
−9.93
−10.91
−9.14
−8.10

0.52
0.27
1.39
3.03
0.45
0.13
1.59
－
4.14
0.28
0.37
0.01

.003
.001
.007
.014
.002
.001
.008
－
.020
.001
.002
.000

－
－
－
Small
－
－
－
－
Small
－
－
－

.816
.469
.377
.616
.078
.816
.382
.013
.809
.068
.302
.555

<.001
<.001
<.001
<.001
<.001
<.001
<.001
－
<.001
<.001
<.001
<.001

.472
.606
.239
.083
.504
.720
.208
－
.043
.596
.545
.932

n, number of samples; M, mean; SD, standard deviation; CSTP, communication skills training program;
Effect size criteria: small: partial eta squared >0.01; medium: partial eta squared >0.06; large: partial eta squared >0.14.
Parallel test of regression lines: presence or absence of interaction between patient safety culture (overall) improvement and pre-CSTP coachingskills. Parallel lines were not observed for “questions.”
Significance of regression: presence or absence of regression between pre-CSTP coaching skills and coaching skills improvement. All items
showing parallel regression lines were significant.



CW6_A7164D01_E.indd

Jpn J Compr Rehabil Sci Vol 8, 201793

2017/09/01

13:07:11

94

Shin-Ichi Izumi et al.: Relation between patient safety culture and communication skills

Table 6. Comparison of degree of patient safety culture improvement in the CSAplus (suggestions/requests)
improved group and non-improved group.
Degree of improvement of patient
safety culture (post-CSTP − pre-CSTP)

Patient safety culture: overall
score
Frequency of event reporting
Overall perception of safety
Supervisor/manager
expectations & actions
promoting safety
Organizational
learning/
continuous improvement
Teamwork within hospitalunits
Communication openness
Feedback andcommunication about errors
Non-punitive response toerrorsStaffing
Hospital management
support for patient safety
Teamwork across hospitalunits
Hospital handoffs &transition

CSAplus(suggestions/requests)
improved group

CSAplus(suggestions/requests)
non-improved group

n

M

n

95

0.50 9.61

SD

M

SD

Paralleltest ofregression
lines

Significanceof regression

F

t

p

p

Comparison of patient safety
improvement between CSAplus(suggestions/requests) improved
group and non-improved groupFppartial η2

Effect size
criteria

114 −1.23 12.66

1.45 .229

−4.49

<.001

1.26 .263.006－

95 −0.07 2.47
95 0.19 1.77

114 −0.15
114 0.06

2.90
2.01

1.64 .201
1.17 .281

−8.52
−7.07

<.001
<.001

0.14 .706
0.14 .712

.001
.001

－
－

95

0.33 1.78

114 −0.33

1.98

0.33 .569

−6.79

<.001

5.78 .017

.027

Small

95

0.25 1.62

114

0.18

1.75

0.84 .361

−7.60

<.001

0.21 .647.001－

95 −0.03 2.23

114 −0.26

2.55

0.28 .596

−6.89

<.001

0.22 .642.001－

95 −0.19 1.65

114 −0.15

1.94

1.59 .209

−9.03

<.001

0.01 .918

.000

－

95

0.27 1.93

114 −0.13

2.03

0.64 .425

−7.84

<.001

1.67 .198

.008

－

95

0.37 1.69

114 −0.13

1.84

0.50 .478

−7.18

<.001

4.39 .037

.021

Small

95 −0.16 2.06

114

0.06

2.40

1.84 .177

−8.14

<.001

0.04 .836

.000

－

95

0.06 1.67

114 −0.01

1.62

0.80 .372

−6.14

<.001

0.43 .514.002－

95 −0.24 1.84

114 −0.24

2.32

2.99 .086

−5.69

<.001

0.04 .847.000－

95 −0.27 1.81

114 −0.14

2.22

1.87 .173

−7.16

<.001

0.12 .726.001－

n, number of samples; M, mean; SD, standard deviation; CSTP, communication skills training program;
Effect size criteria : small: partial eta squared >0.01; medium: partial eta squared >0.06; large: partial eta squared >0.14.
Parallel test of regression lines: presence or absence of interaction between CSAplus (suggestions/requests) improvement and pre-CSTP patient
safety culture score. Parallel regression lines were observed in all items.
Significance of regression: presence or absence of regression between pre-CSTP patient safety culture score and patient safety culture
improvement. All items were significant.

of “supervisor/manager expectations & actions
promoting safety” and “non-punitive response toerrors” in the Patient Safety Culture Scale. These two
are unit-level factors, and they appear to be closely
related to daily communication with the manager/
supervisor’s subordinates, in comparison with theother unit-level factors of “communication openness,”“feedback and communication after errors,”“organizational learning/continuous improvement,”
and “teamwork within hospital units,” which are morestrongly associated with communication amongcolleagues, and “staffing,” which is an external
constraint. The results of this study suggest that
improving the skill of “suggestions/requests” is related
to the improvement of factors in the Patient Safety
Culture Scale, which are related to the leader’s routine
communication. However, this finding does not meanthat other skills are not necessary. This finding should
be interpreted as that “suggestions/requests” skill
contributes to improvement of patient safety culture
upon application of basic skills including “listening,”“acknowledgment,” and “questions” [15]. In fact, thescore for “listening” in CSAplus tended to be higher inthe patient safety culture improved group than in the
non-improved group. In the future, the CSTP shouldbe improved considering the relationship between
clinical safety culture and CS.
The CSTP differs from conventional health careteam training in two aspects. First, by practicing
coaching on the collaborators, the trainees fostered aculture of free communication in their own workplace,and facilitated their role as a leader including patient
safety. Second, learning coaches were available toassist trainees to initiate and continue actions towards
achieving their goals.
This research has the following limitations. First,
CSAplus used in this study has not been standardized
for CS assessment. Since there is no standardized
scale for measuring coaching skills, CSAplus wasused considering its consistency with the CSTP and
because it was used in multiple previous studies [10,12-14]. Second, the study was conducted at a single
institution, and not all the managers/supervisors
participated in the training program. Third, theJpn J Compr Rehabil Sci Vol 8, 2017

CW6_A7164D01_E.indd

94

2017/09/01

13:07:11

Shin-Ichi Izumi et al.: Relation between patient safety culture and communication skills

contents and schedule of coaching interviews with thecollaborators were not controlled, but were decided by
the trainees. Fourth, it was not possible to show theresults of objective safety indices such as the frequencyof medical malpractice. Fifth, the long-term training
effect after the completion of CSTP was not evaluated.
Further studies will be continued to improve andvalidate the CSTP and the assessment methods, withthe goal of contributing to the improvement of patient
safety culture.

Acknowledgment

This study was part of the “Development of a highly
specialized team medicine activation system” project of
Tohoku University, a selected center for “Establishment of ahealth personnel training system in university hospitals forthe promotion of team medicine” sponsored by the Japan
Ministry of Education, Culture, Sports, Science andTechnology, 2011.

References

1. Institute of Medicine (US) Committee on Quality of
Health Care in America; Kohn, LT, Corrigan JM,
Donaldson MS, editors: To Err is Human: Building a
Safer Health System. Washington (DC): National
Academy Press (US); 2000. p. 155-201.
2. Mikami M, Izumi S. Outline of rehabilitation medicine.
In: Mikami M, Izumi S, and Kagaya H, editor. Textbook
of Rehabilitation Medicine. 4th ed. Tokyo: Nankodo;
2016. p. 1-17.
3. Baker DP, Gustafson S, Beaubien JM, Salas E, Barach P.
Medical Team Training Programs in Health Care. In:
Henriksen K, Battles JB, Marks ES, Lewin DI, editors.
Advances in Patient Safety: From Research to Implementation(Volume 4: Programs, Tools, and Products). Rockville (MD):Agency for Healthcare Research and Quality (US); 2005. p.
253-267.
4. Donnelly LF, Dickerson JM, Goodfriend MA, Muething
SE. Improving patient safety: effects of a safety programon performance and culture in a department of radiology.
AJR 2009; 193: 165-71.
5. Halverson AL, Andersson JL, Anderson K, Lombardo J,
Park CS, Rademaker AW, Moorman DW. Surgical team

CW6_A7164D01_E.indd

95

training: the Northwestern Memorial Hospital experience.
Arch Surg 2009; 144: 107-12.
6. Morey JC, Simon R, Jay GD, Wears RL, Salisbury M,
Dukes KA, Berns SD. Error reduction and performance
improvement in the emergency department throughformal teamwork training: evaluation results of the
MedTeams project. Health Serv Res 2002; 37: 1553-81.
7. Agency for Healthcare Research and Quality: Hospital
Survey on Patient Safety Culture. Available from: https://www.ahrq.gov/professionals/quality-patient-safety/
patientsafetyculture/index.html (cited 2017 April 25).
8. Taneda K, Okumura Y, Aizawa Y, Hasegawa T. Reliability
and validity of the Japanese version of the hospital survey
on patient safety culture. JJQSH 2009; 4: 10-24.
9. Ito S, Seto K, Kigawa M, Fujita S, Hasegawa T,
Hasegawa T. Development and applicability of Hospital
Survey on Patient Safety Culture (HSOPS) in Japan.
BMC Health Services Research 2011 11:28.
10. Okamoto T, Suzukamo Y, Izumi S. The effects of the
training for communication skills on development ofclinical organization. JJQSH 2016; 11: 39-46.
11. Izumi S, Ando K, Ono M, Suzukamo Y, Michimata A,
Fukuhara S. Effect of coaching on psychological adjustment
in patients with spinocerebellar degeneration: a pilot study.
Clin Rehabil 2007; 21: 987-96.
12. Tanabe M, Suzukamo Y, Tsuji I, Izumi S. Communication
training improves sense of performance expectancy of
public health nurses engaged in long-term elderly
prevention care program. ISRN Nurs. 2012;2012:430560.
doi: 10.5402/2012/430560.
13. Michimata A, Suzukamo Y, Izumi SI. Development ofclinicians’ communication skills influences the satisfaction,
motivation, and quality of life of patients with stroke. Int J
Phys Med Rehabil 2013; 1: 174. doi:10.4172/2329-9096.
1000174.
14. Kanetaka K, Suzukamo Y, Kakui T, Michimata A, Izumi
S. Impact of a communication skills training course forstudents of therapist training schools. Jpn J Compr
Rehabil Sci 2013; 4: 47-54.
15. Izumi S, editor. A Guide to Coaching for Rehabilitation
Practice and Education. Tokyo: Ishiyaku Publishers, Inc.;2009.

Jpn J Compr Rehabil Sci Vol 8, 201795

2017/09/01

13:07:11

96

Shin-Ichi Izumi et al.: Relation between patient safety culture and communication skills

Appendix 1. The CSAplus used for the assessment of coaching skill.
Category
Observations

Tailor-made treatment

Contents of question
The subject notices my growth and results and communicates this to me.
The subject understands my way of thinking and values.
The subject matches his/her way of speaking and praise to my personality
and characteristics.
The subject draws out and develops my strengths and field of expertise.
The subject finishes our conversations with definite conclusions.

Coaching flow

Listening

The subject doesn’t go off topic, but instead keeps the goal in mind andworks on having a productive conversation.
The subject doesn’t interrupt or end conversations early, but instead listens
to me until I finish.
The subject doesn’t jump to conclusions or anticipate what I am saying,but instead listens calmly to what I have to say.
The subject is easy to talk to and approach for advice.

Non-verbal

Follow up
Acknowledgement

Questions

The subject uses responsive gestures and sounds when having a
conversation with me.
The subject sets up regular times and places to speak to me.
The subject speaks to me about my progress towards my goals.
The subject returns emails and telephone calls in a timely manner.
The subject communicates his/her appreciation to me.
The subject asks about what I am thinking before communicating his/her
own thoughts.
The subject asks questions to help me come to my own realizations.

Suggestions/requests

The subject’s proposals, requests and the contents of his/her assertions areclear and easy to understand.
The subject makes proposals and requests that motivate me.

Feedback
Supporting others
Setting goals

The subject asks for feedback about his/her own behavior.
The subject gives feedback to me about the progress of my goals.
The subject helps to facilitate me in reaching my goals.
The subject supports my success and growth.
The subject and I share the same goals as the organization.
The subject understands the goals that I am aiming for.

Note:
・The copyright and all other rights concerning this questionnaire belong to COACH A Co., Ltd.
・Copy, modification, transcription, reproduction, falsification, secondary use, partial use, andequivalent activities of the questionnaire are strictly prohibited.
・Permission of use may be granted for academic purposes not related to commercial use. Persons
who wish to use this questionnaire should contact COACH A Co., Ltd. to obtain prior permission.

Jpn J Compr Rehabil Sci Vol 8, 2017

CW6_A7164D01_E.indd96

2017/09/01

13:07:11

Shin-Ichi Izumi et al.: Relation between patient safety culture and communication skills

97

Appendix 2. Hospital Survey on Patient Safety Culture (Cited from Reference 8 with modification of theorder of factors)

OutcomeHospital level

Unit level

Factor

CW6_A7164D01_E.indd

Contents of question
Staff will freely speak up if they see something that may negatively affect patient care.
Communication
Staff feel free to question the decisions or actions of those with more authority.
openness
Staff are afraid to ask questions when something does not seem right.
We are given feedback about changes put into place based on event reports.
Feedback andcommunication
We are informed about errors that happen in this unit.
about errors
In this unit, we discuss ways to prevent errors from happening again.
Staff feel like their mistakes are held against them.
Non-punitive
When an event is reported, it feels like the person, not the problem, is being written up.
response to errors
Staff worry that mistakes they make are kept in their personnel file.
We are actively doing things to improve patient safety.
Organizational
learning/ continuous Mistakes have led to positive changes here.
improvement
After we make changes to improve patient safety, we evaluate their effectiveness.
We have enough staff to handle the workload.
Staff in this unit work longer hours than what is best for patient care.
Staffing
We use more agency/temporary staff than what is best for patient care.
We work in “crisis mode,” trying to do too much, too quickly.
My supervisor/manager says a good word when he/she sees a job done according toSupervisor/
established patient safety procedures.
manager
My supervisor/manager seriously considers staff suggestions for improving patient safety.
expectations &Whenever pressure builds up, my supervisor/manager wants us to work faster, even if
actions promoting
it means taking shortcuts.
safetyMy supervisor/manager overlooks patient safety problems that happen over and over again.
People support one another in this unit.
When a lot of work needs to be done quickly, we work together as a team to get the
Teamwork within
work done.
hospital units
In this unit, people treat each other with respect.
When one area in this unit gets really busy, others help out.
Things “fall between the cracks” when transferring patients from one unit to another.
Hospitalhandoffs & Important patient care information is often lost during shift changes.
transition
Problems often occur in the exchange of information across hospital units.
Shift changes are problematic for patients in this hospital.
Hospital management provides a work climate that promotes patient safety.
Hospital
The actions of hospital management show that patient safety is a top priority.
management support
Hospital management seems interested in patient safety only after an adverse eventfor patient safety
happens.
Hospital units do not coordinate well with each other.
There is good cooperation among hospital units that need to work together.
Teamwork acrosshospital units
It is often unpleasant to work with staff from other hospital units.
Hospital units work well together to provide the best care for patients.
When a mistake is made, but is caught and corrected before affecting the patient, howoften is this reported?
Frequency of event When a mistake is made, but has no potential to harm the patient, how often is thisreportingreported?
When a mistake is made that could harm the patient, but does not, how often is thisreported?
It is just by chance that more serious mistakes don’t happen around here.
Overall perception of Patient safety is never sacrificed to get more work done.
safetyWe have patient safety problems in this unit.
Our procedures and systems are good at preventing errors from happening.

Jpn J Compr Rehabil Sci Vol 8, 201797

2017/09/01

13:07:11