title: An assessment of safety climate in Kuwaiti public hospitals
Creators: name: Al Salem, Gheed F.
Publisher: name: University of Glasgow
Year: 2018
Subjects: subject: Safety culture, safety climate, safety climate assessment, hospital safety, patient safety, Kuwait.

description: Background: Patient safety in healthcare organisations received global attention following the Institute of Medicine’s release of its hallmark report “To Err Is Human: Building a Safer Health System”, where it was estimated that 44,000–98,000 patients die annually in US hospitals as a result of errors in care. Similar rates of error and avoidable harm have been reported in different research studies in many modern health systems across the world. “Safety Culture” has been identified as a key element of healthcare organisations’ ability to learn from errors and reduce preventable harm to patients resulting from health care. The perceived importance of safety culture in improving patient safety and its impact on patient outcomes has led to a growing interest in the assessment of safety culture in healthcare organisations. The use of safety climate questionnaires is one of the most popular methods for assessing safety culture. These questionnaires are thought to help in measuring healthcare workers' perceptions of the prevailing safety culture or “safety climate” in their organisations. Since no surveys of safety climate have been conducted at public hospitals in the state of Kuwait, nor are valid or reliable survey instruments available, this thesis aimed to investigate patient safety climate in public hospitals in Kuwait. The main objectives of the study were: 1. To identify an existing safety climate tools to be employed in my PhD thesis. 2. To test the psychometric properties of the identified tool in a sample of Kuwaiti public hospitals. 3. To provide a measure of the prevailing safety climate in Kuwaiti public hospitals. 4. To explore with key stakeholders the main findings of the safety climate survey and identify the potential barriers and facilitators to safety improvement initiatives in Kuwaiti public hospitals. Based on the overall findings, a series of recommendations are made for clinical leaders, policy makers and others to consider and a conceptual model informing a systems’ based approach to safety culture theory and practice is proposed for future research. Methods: A multi-method, triangulated approach including both quantitative and qualitative methods was adopted for the study. There were four phases of the research: A systematic review of published literature on safety climate tools used in acute hospital settings was carried out using seven electronic databases, with manual searches of bibliographies of included papers and key journals. A suitable tool was identified. A cross-sectional survey of 1,511 healthcare staff in three public hospitals was conducted for two purposes: Firstly, to assess the psychometric properties of the identified tool and develop an optimum model for assessing safety climate in Kuwaiti hospitals. Secondly, to provide an assessment of the current state of safety climate in Kuwaiti hospitals. Finally, interviews with key personnel were conducted to extend the examination of the survey findings and provide a rounded picture of the current state of safety climate in Kuwaiti public hospitals. Results: The search strategy identified 3,576 potential papers. Of these, eighty-eight papers were reviewed, with five studies meeting the inclusion criteria. Three out of five studies, covering three tools, were rated as ‘good’ quality papers and reported more robust psychometric properties. The Hospital Survey on Patient Safety Culture (HSOPSC) was selected as the most appropriate for my PhD thesis (in terms of usability, applicability and psychometric properties), and was pilot tested with minor modifications. A modified version of the HSOPSC was used to conduct the survey using a sample of healthcare staff with an 87% (n=1,310) response rate. Results of psychometric evaluation, including exploratory factor analysis, confirmatory factor analysis, reliability and correlation analysis, showed an optimal model of eight factors and 22 safety climate items. General evaluation of the prevailing safety climate amongst the workforce in acute hospital settings was conducted. The dimensions “Teamwork within units” (84%), “organisational learning-continuous improvement” (82%), “supervisor/manager expectations and actions promoting safety” (77%) and “management support for patient safety” (74%) were identified as strongly positive areas for the three hospitals. The dimensions “Non-punitive response to error” (34%), “communication openness” (47%) and “frequency of event reporting” (50%) were identified as areas in need of improvement. Building on the survey findings, interviews with key stakeholders added rich insight into hospital employees' perceptions on safety and allowed exploration of emerging issues in more detail. The research findings of my PhD thesis, and of the literature informed the design of a preliminary framework that aims to extend the examination of the construct of safety climate beyond the domains and items that typically inform safety climate theory to include system wide factors which potentially influence the prevailing safety culture/climate. Conclusions: This is the first validation study of a Standardised safety climate measure in a Kuwaiti healthcare setting. The study assessed the psychometric properties of the HSOPSC questionnaire and constructed an optimal model for assessing patient safety climate in Kuwaiti hospitals. It highlighted important patient safety and staff wellbeing concerns to inform organisational and national learning, and provided a baseline for measuring patient safety climate in Kuwaiti hospitals. As such, my PhD thesis raises and emphasizes the critical importance of appropriate validation of safety climate questionnaires before extending their usage in different countries or healthcare contexts. It provided new knowledge about areas of strength and weakness in safety climate with the potential to drive local improvements in Kuwaiti public hospitals. It is recommended that future investigations of patient safety culture and climate combine both quantitative and qualitative approaches and adopt a system wide approach to inform safety climate theory and questionnaire development, leading to stronger frameworks guiding safety culture research and practice.