Comparing safety climate between two populations of hospitals in the United States.

Based on mounting evidence that better safety climate is related to lower incidence (Naveh, Katz-Navon, and Stern 2005; Hofmann and Mark 2006; Neal and Griffin 2006; Vogus and Sutcliffe 2007; Singer et al. 2008b;) and greater reporting (Cohen et al. 2004; Weingart et al. 2004; Gandhi et al. 2005;) of adverse events and to increased communication among managers and staff (Hofmann and Morgeson 1999), considerable effort among hospitals is being focused on improving safety climate. Along with hospitals' own efforts, several voluntary, collaborative initiatives that could improve safety climate (e.g., Leapfrog Group's patient safety leaps, and Institute for Healthcare Improvement's 5 Million Lives campaign) have garnered substantial participation among both public and private hospitals. “Benchmarking” of safety-climate survey results through participation in such collaborative initiatives is an effective way for hospitals to target quality improvement efforts. Benchmarking enables a hospital to compare its survey results with those of other hospitals, thereby facilitating identification of relative strength and weakness. It is being encouraged by numerous organizations. Since 2002, the Joint Commission's performance improvement standard (PI.01.01.01) has encouraged hospitals to collect data on staff perceptions of safety risks and improvement opportunities and to compare data with external sources (Joint Commission on Accreditation of Health Care Organizations 2002). The Agency for Healthcare Research and Quality (AHRQ) established the Hospital Survey on Patient Safety Culture Comparative Database for this purpose in 2006. Its 2009 database included safety-climate results from 622 hospitals (Sorra et al. 2009). Independent investigators engaged in benchmarking safety climate have also identified systematic differences in safety climate within and among hospitals, which provide clues to improving safety climate more generally (Singer et al. 2003; Thomas, Sexton, and Helmreich 2003; Makary et al. 2006; Sexton et al. 2006a, b, c; Vogus and Sutcliffe 2007; Hartmann et al. 2008; Singer et al. 2008a, 2009). Benchmarking safety-climate survey results across health care systems is difficult due to coordination challenges. Our own effort to measure and benchmark safety climate is unique in that we used essentially the same survey instrument and sampling and administration procedures at approximately the same time in two discrete populations of hospitals in the United States: the Veterans Health Administration (VA) health care system and a national sample, excluding VA hospitals. This provided a novel opportunity to compare safety climate across two populations encompassing great diversity in both individual hospital characteristics and overall organizational structure, and potentially to identify any hospital features systematically related to safer care. Differences in safety climate between VA and other U.S. hospitals may inherently exist because the VA is a nationally integrated network, while few U.S. hospitals come from large, integrated systems and none come from nationally integrated systems. As a system, the VA enjoys distinct advantages in broadly implementing and enforcing compliance with standardized safety activities. The VA conducts several initiatives with potential to improve safety climate. For example, the VA National Center for Patient Safety was established specifically to promote a systems approach to preventing and reducing harm to patients and to encourage hospitals to conduct root cause analyses after safety incidents (http://www.va.gov/ncps/vision.html, accessed on August 26, 2008, for NCPS). In this paper, we examine differences in safety climate between 69 diverse U.S. hospitals and 30 VA hospitals using cross-sectional employee surveys. Given potential advantages in promoting strong safety climate in a nationally integrated network, we hypothesized that safety climate among VA hospitals would be stronger than among U.S. hospitals. Differences in safety climate between U.S. and VA samples may arise from multiple sources. First, there may be variation between the two samples in measured characteristics associated with safety climate—for instance, one sample may contain more large hospitals than the other. The residual difference in safety climate between the two samples would be attributable to differential effects of the sample characteristics between the two health care systems (e.g., hospital size may impact VA hospitals differently than U.S. hospitals). We performed comparisons of safety climate in these two settings that allowed us to discern the relative impact of these potential sources of difference. We hypothesized that variance in observed sample characteristics would explain more of the difference in safety climate between U.S. and VA hospitals than would differential effects of sample characteristics on the two groups.