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A comprehensive obstetrics patient safety program improves safety climate and culture

      Objective

      The purpose of this study was to determine the effect of an obstetrics patient safety program on staff safety culture.

      Study Design

      We implemented (1) obstetrics patient safety nurse, (2) protocol-based standardization of practice, (3) crew resource management training, (4) oversight by a patient safety committee, (5) 24-hour obstetrics hospitalist, and (6) an anonymous event reporting system. We administered the Safety Attitude Questionnaire on 4 occasions over 5 years (2004-2009) to all staff members that assessed teamwork and safety cultures, job satisfaction, working conditions, stress recognition, and perceptions of management.

      Results

      We observed significant improvements in the proportion of staff members with favorable perceptions of teamwork culture (39% in 2004 to 63% in 2009), safety culture (33% to 63%), job satisfaction (39% to 53%), and management (10% to 37%). Individual roles (obstetrics providers, residents, and nurses) also experienced improvements in safety and teamwork, with significantly better congruence between doctors and nurses.

      Conclusion

      Safety programs can improve workforce perceptions of safety and an improved safety climate.

      Key words

      Safety culture is defined as the integration of safety thinking and practices into clinical activities. This includes development of systems for data collection and reporting, the reduction of tendencies to place blame on individuals, and a focus on real or potential system latencies.
      • Singer S.J.
      • Gaba D.M.
      • Geppert J.J.
      • Sinaiko A.D.
      • Howard S.K.
      • Park K.C.
      The culture of safety: results of an organization-wide survey in 15 California hospitals.
      • Weeks W.B.
      • Bagian J.P.
      Developing a culture of safety in the Veterans Health Administration.
      Improvement of patient safety, in terms of risk and outcomes, in a healthcare system depends on the building of a patient safety culture; some investigators have argued that the key to quality improvement may lie in this type of organizational change.
      • Moss F.
      • Garside P.
      • Dawson S.
      Organisational change: the key to quality improvement.
      For Editors' Commentary, see Table of Contents
      Safety climate is the quantitative description of the safety culture. Safety climate can be assessed in several ways that include examination of adverse events (outcomes measures),
      • Haynes A.B.
      • Weiser T.G.
      • Berry W.R.
      • et al.
      A surgical safety checklist to reduce morbidity and mortality in a global population.
      • Pronovost P.
      • Needham D.
      • Berenholtz S.
      • et al.
      An intervention to decrease catheter-related bloodstream infections in the ICU.
      analysis of adherence to practices (process measures),
      • Zohar D.
      • Livne Y.
      • Tenne-Gazit O.
      • Admi H.
      • Donchin Y.
      Healthcare climate: a framework for measuring and improving patient safety.
      • Williams S.C.
      • Schmaltz S.P.
      • Morton D.J.
      • Koss R.G.
      • Loeb J.M.
      Quality of care in US hospitals as reflected by standardized measures, 2002-2004.
      or calibration of healthcare teams' attitudes about issues relevant to safety.
      • Sexton J.B.
      • Helmreich R.L.
      • Neilands T.B.
      • et al.
      The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research.
      Many patient safety programs have shown significant reductions in adverse outcomes; however, less is known of the impact of such efforts on staff safety perceptions and attitudes.
      • Pronovost P.J.
      • Berenholtz S.M.
      • Goeschel C.
      • et al.
      Improving patient safety in intensive care units in Michigan.
      With the hypothesis that a multifaceted approach to enhance the overall safety culture would reduce the rate of adverse outcomes, we partnered with our hospital (Yale–New Haven Hospital) and our malpractice carrier (MCIC Vermont, Inc, New York, NY) to assess and improve our safety climate. The goal of this program was to improve patient safety and the safety culture, decrease patient injury, and decrease liability losses through a program that identified and initiated cultural changes and specific risk-reduction clinical practices. We reported the details of the incremental reduction in adverse outcomes, as measured by the obstetrics Adverse Outcomes Index, over a 3-year period in a previous publication.
      • Pettker C.M.
      • Thung S.F.
      • Norwitz E.R.
      • et al.
      Impact of a comprehensive patient safety strategy on obstetric adverse events.
      Simultaneously, we aimed to determine the effect of a comprehensive obstetrics patient safety program on staff perceptions of safety and teamwork that was measured by the Safety Attitude Questionnaire (SAQ), which is a standardized and validated questionnaire that measures staff attitudes towards safety and quality in the workplace.
      • Sexton J.B.
      • Helmreich R.L.
      • Neilands T.B.
      • et al.
      The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research.

      Materials and Methods

      We sequentially introduced multiple patient safety interventions from December 2002 to November 2006 at a university-based obstetrics service at Yale–New Haven Hospital. The details of this program have been previously described.
      • Pettker C.M.
      • Thung S.F.
      • Norwitz E.R.
      • et al.
      Impact of a comprehensive patient safety strategy on obstetric adverse events.
      Briefly, the effort involved the initiation of the following interventions:

       Outside expert review

      In 2002, 2 independent consultants (a maternal–fetal medicine physician and a nurse specialist/leader) initiated an outside expert review. This site visit culminated in a review and recommendations that focused on principles of patient safety, evidence-based practice, and consistency with standards of professional and governing bodies.

       An obstetrics patient safety nurse

      An obstetrics patient safety nurse was responsible for data collection (which was begun prospectively in September 2004) on a “case occurrence” basis.
      • Will S.B.
      • Hennicke K.P.
      • Jacobs L.S.
      • O'Neill L.M.
      • Raab C.A.
      The perinatal patient safety nurse: a new role to promote safe care for mothers and babies.
      This nurse also led educational efforts (team training, electronic fetal monitoring certification), directed the anonymous event reporting system, and initiated and led adverse event reviews.

       Protocol and guideline

      Protocol and guideline development began in 2004; the aim was to codify and standardize existing practices.

       Reporting system

      An anonymous, computerized event reporting system (Peminic, Inc, Princeton, NJ) was initiated in 2004 and allowed any hospital worker to report events that may have caused or could cause harm to a patient/visitor.

       An obstetrics hospitalist/Yale on-call attending

      An obstetrics hospitalist/Yale on-call attending physician position was implemented in 2004 to provide a consistent system of inpatient coverage and resident supervision. This coverage was provided by a Maternal-Fetal Medicine specialist 24 hours a day, 7 days a week.

       Obstetrical Patient Safety Committee

      This multidisciplinary committee (physicians, nurses, administrators) was initiated in 2004 was responsible for quality assurance and quality improvement reviews and, in particular, addressed the need for protocols and policies to improve safety and efficiency.

       The SAQ

      The SAQ is a tool that was adapted from the aviation field and is used for the assessment of healthcare employee perception of teamwork and safety.
      • Sexton J.B.
      • Helmreich R.L.
      • Neilands T.B.
      • et al.
      The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research.

       Team training

      Started in 2005, team training was a continuing series of crew resource management seminars that were based on seminars of airline and defense industries. Four-hour classes included videos, lectures, and role-playing and integrated obstetrics staffing domains (physicians, nurses, administrators, assistants). Seminars were organized as a 1-time training opportunity for existing staff members. New employees who were hired after the initial set of seminars received training shortly after beginning work. Crew resource management techniques have been reinforced since that time through obstetrics simulations in an on-site simulation facility. Completion of the crew resource management seminar was a condition for employment and/or clinical privileges.

       Electronic fetal monitoring certification

      Electronic fetal monitoring certification, which began in 2005, involves dissemination and review of National Institute of Child Health and Human Development guidelines, a review of tracings, the allocation of study guides, and voluntary review sessions and culminates in a standardized, certified examination. All medical staff members and employees who are responsible for fetal monitoring interpretation were obligated to take this examination. New employees who were hired after the initial effort were required to take this examination within 1 year of employment; a passing score was required within 18 months. There was a 100% pass rate among physicians and midwives and a 98% pass rate on first attempt among nurses over the time of this study.

       Workforce safety climate

      Workforce safety climate was assessed with the obstetrics SAQ.
      • Sexton J.B.
      • Holzmueller C.G.
      • Pronovost P.J.
      • et al.
      Variation in caregiver perceptions of teamwork climate in labor and delivery units.
      This anonymous survey helps to detect perceived systemic weaknesses and differences of opinion over time or between employee groups (eg, staff, nursing, physicians) that result from a professional education that is marked by differing languages/vocabularies and contrasting perspectives. The survey consists of a series of statements to which the respondent is able to answer with agreement or disagreement, with a 5-point Likert scale (disagree/never, disagree/rarely, neutral/sometimes, agree/most of the time, agree/always). Agreement with a statement, for instance, is concluded when a respondent answers either “most of the time” or “always.” The survey involves 58 questions and takes approximately 10 minutes to complete. Sample questions include: “I would feel safe being treated here as a patient,” “The physicians and nurses here work together as a well-coordinated team,” and “Morale in this unit/clinical area is high.”
      The SAQ has been validated in nonobstetrics healthcare settings. Favorable scores are associated with shorter lengths of stay, fewer medication errors, lower ventilator-associated pneumonia rates, lower bloodstream infection rates, and lower risk-adjusted mortality rates.
      • Sexton J.B.
      A matter of life and death: social, psychological, and organizational factors related to patient outcomes in the intensive care unit.
      • Sexton J.B.
      • Thomas E.J.
      • Helmreich R.L.
      Frontline assessments of healthcare culture: Safety Attitudes Questionnaire norms and pscyhometric properaties.
      Furthermore, having favorable scores in 4 of 6 safety domains is associated with lower nurse turnover.
      • Sexton J.B.
      A matter of life and death: social, psychological, and organizational factors related to patient outcomes in the intensive care unit.
      The SAQ was administered on 4 occasions (2004-2009) to all Labor & Birth Unit staff members (includes attending obstetricians, nurse midwives, pediatricians, neonatologists, anesthesiologists, residents, nurses, surgical technicians, aides, and social workers) to survey patient safety culture. The SAQ measures caregiver assessments of safety and quality within 6 climate domains: (1) teamwork culture (perceived quality of collaboration between personnel), (2) safety culture (perceptions of a strong and proactive organizational commitment to safety), (3) job satisfaction (positivity about the workplace), (4) working conditions (perceived quality of the work environment and logistical support), (5) stress recognition (acknowledgement of how performance is influenced by stressors), and (6) perceptions of management (approval of managerial action).
      • Sexton J.B.
      • Helmreich R.L.
      • Neilands T.B.
      • et al.
      The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research.
      Demographic characteristics of respondents were not assessed.
      Sexton has published standards for the determination of the clinical significance of SAQ results.
      • Sexton J.B.
      • Thomas E.J.
      • Helmreich R.L.
      Frontline assessments of healthcare culture: Safety Attitudes Questionnaire norms and pscyhometric properaties.
      • Sexton J.B.
      • Grillo S.
      • Fullwood C.
      • Pronovost P.
      Assessing and improving safety culture.
      • Sexton B.
      Teamwork and taskforce: a two factor model of aircrew performance.
      Differences of ≥10% over time or between groups are considered clinically significant. Overall scores that show 80% agreement that the teamwork climate is favorable are considered the target for change; <60% indicates an area of higher risk. We also analyzed responses between 2004 and 2009 and between caregiver groups (physicians/midwives, residents, nurses) with chi-square testing.
      This project was reviewed by the Chair of the Yale University Human Investigations Committee and was deemed a quality assurance activity and thus not required to undergo review by the Committee.

      Results

      Details of the numbers of surveys that were administered and returned are listed in the Table. The median total number of employees who responded to each survey was 191 (range, 183–198). Overall response rates were 89%, 95%, 94%, and 72% for each period of administration respectively (median, 91.5%). The last survey (2009) added our postpartum staff, which accounted for a larger number of surveys that were administered. Although this administration period showed the lowest response rate, the total number of surveys returned was largely unchanged. The last survey was administered by computer, rather than on paper, which may have affected response rates.
      TABLESurvey response numbers and rates
      Variable2004200620072009
      Target respondents, n234230231310
      Surveys administered, n215209201254
      Surveys returned, n192198189183
      Response rate, %89959472
      Pettker. Obstetrics patient safety program improves safety culture. Am J Obstet Gynecol 2011.
      Responses demonstrated agreement with satisfactory conditions within the 6 domains (teamwork culture, safety culture, job satisfaction, working conditions, stress recognition, and perceptions of management; FIGURE 1, FIGURE 2, FIGURE 3, FIGURE 4, FIGURE 5, FIGURE 6). There were clinically significant increases (according to the SAQ criteria of >10%) in perceptions of teamwork culture, safety culture, and job satisfaction from 2004-2009; however, no category has yet attained the target goal of 80%.
      Figure thumbnail gr1
      FIGURE 1Changes in perception of teamwork culture
      Difference between 2004 and 2009 statistically significant (P < .0001) by χ2 testing.
      Pettker. Obstetrics patient safety program improves safety culture. Am J Obstet Gynecol 2011.
      Figure thumbnail gr2
      FIGURE 2Changes in perception of safety culture
      Difference between 2004 and 2009 statistically significant (P < .0001) by χ2 testing.
      Pettker. Obstetrics patient safety program improves safety culture. Am J Obstet Gynecol 2011.
      Figure thumbnail gr3
      FIGURE 3Changes in perception of job satisfaction
      Difference between 2004 and 2009 statistically significant (P = .009) by χ2 testing.
      Pettker. Obstetrics patient safety program improves safety culture. Am J Obstet Gynecol 2011.
      Figure thumbnail gr4
      FIGURE 4Changes in perception of working conditions
      Difference between 2004 and 2009 statistically significant (P = .048) by χ2 testing.
      Pettker. Obstetrics patient safety program improves safety culture. Am J Obstet Gynecol 2011.
      Figure thumbnail gr5
      FIGURE 5Changes in perception of stress recognition
      Difference between 2004 and 2009 not statistically significant (P < .6) by χ2 testing.
      Pettker. Obstetrics patient safety program improves safety culture. Am J Obstet Gynecol 2011.
      Figure thumbnail gr6
      FIGURE 6Changes in perception of management
      Difference between 2004 and 2009 statistically significant (P < .0001) by χ2 testing.
      Pettker. Obstetrics patient safety program improves safety culture. Am J Obstet Gynecol 2011.
      When we compared responses from 2004 with those of 2009 with chi-square testing, statistically significant improvements were seen for teamwork culture (P < .0001), safety culture (P < .0001), job satisfaction (P = .009), and perceptions of management (P < .0001). Perceptions of favorable working conditions actually declined between 2004 and 2009 (P = .048); perceptions of stress recognition showed no statistically significant change (P = .6).
      In 2004, at study inception, positive perception of safety and teamwork cultures were low among obstetrics providers (attending physicians and nurse midwives), residents, and nurses (Figure 7). Clinically significant differences were seen in the perception of teamwork culture between obstetrics providers and nurses. Perceptions of both safety and teamwork climate demonstrated clinically and statistically significant improvements over time among all 3 caregiver domains by chi-square testing (P < .01).
      Figure thumbnail gr7
      FIGURE 7Changes in perception of safety culture and teamwork culture within 3 caregiver domains (physicians/midwives, residents, and nurses)
      Each asterisk designates changes (2004-2009, within provider domains) that were statistically significant (P < .01) by χ2 testing.
      OB, attending and midwife; RN, registered nurse.
      Pettker. Obstetrics patient safety program improves safety culture. Am J Obstet Gynecol 2011.

      Comment

      Berenholtz and Pronovost
      • Berenholtz S.M.
      • Pronovost P.J.
      Monitoring patient safety.
      have proposed a safety scorecard that consists of 4 domains: outcome measures (How often do we harm patients?), process measures (How often do we use evidence-based medicine?), structural measures (How do we know we learned from our mistakes?), and staff attitudes surveys (How well have we created a culture of safety?).
      We describe the overall improvement of safety climate, as measured by workforce surveys, in the setting of a comprehensive patient safety effort. In a previous report, we demonstrated the improvement in adverse outcomes, as assessed by the obstetrics Adverse Outcome Index, that were related to this project.
      • Pettker C.M.
      • Thung S.F.
      • Norwitz E.R.
      • et al.
      Impact of a comprehensive patient safety strategy on obstetric adverse events.
      The combination of both improved quality of care and safety climate is a powerful argument for the usefulness of a comprehensive and programmatic approach to patient safety.
      We did not surpass the 80% targets for any of the 6 climate domains. This remains an important long-term goal for our continuing patient safety effort. This shortcoming should not undervalue the importance of attaining significant overall improvement. Continued quality improvement is a critical element of any patient safety effort.
      Our safety program did not have positive impact on all domains of the safety culture. Notably, perception of working conditions and workforce stress recognition did not show improvements. At this time, we have not conducted any direct investigation into the reasons that perceptions of working conditions worsened. We speculate that other activities and pressures in our workplace may have limited improvement in these areas or that our specific quality improvement measures were not directed specifically at these measures. Other events that occurred simultaneously during this period that may have affected working conditions and stress recognition were the conversion to an electronic medical record and computerized order entry, an increasing cesarean delivery rate, and staffing challenges because of increased patient acuity and triage census. That job satisfaction scores improved in the face of declining working conditions scores is a contradiction that we are unable to assess further. We speculate that pressures that are defined under working conditions were unable to overcome other positive enhancements that were not measured by the SAQ that influence job satisfaction.
      The validity of surveys is highly dependent on response rate. Notably, our response rate was lowest during our last survey period, likely because of an attempt to capture a larger number of respondents and a growth in the number of surveys distributed (Table). Moreover, our fourth (and last) survey was done on computer, which is a change that may have affected response rates. As a result, we do not believe that the drop in response rate meaningfully affects the results of the survey for that period.
      Many different patient safety climate surveys are available. The Agency for Healthcare Research and Quality's Hospital Survey on Patient Safety Culture is a publicly available tool with a centralized comparative database that allows organizations to benchmark survey results. This survey was not available at the time we started our initiative, so we chose to continue using the SAQ so that we could make meaningful comparisons over time within our own unit. The SAQ is also supported by a systematic review that demonstrates that only the SAQ has been used to explore the relationship between safety perceptions and patient outcomes.
      • Colla J.B.
      • Bracken A.C.
      • Kinney L.M.
      • Weeks W.B.
      Measuring patient safety climate: a review of surveys.
      Although the primary motivations that drive patient safety efforts are quality care and the elimination of harm, many secondary benefits must be considered. For instance, economic savings that are associated with the elimination of the costs of adverse events are an important factor that guides investment in patient safety by governments and healthcare institutions.
      • Zhan C.
      • Miller M.R.
      Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization.
      • Schmidek J.M.
      • Weeks W.B.
      What do we know about financial returns on investments in patient safety? A literature review.
      • Paradis A.R.
      • Stewart V.T.
      • Bayley K.B.
      • Brown A.
      • Bennett A.J.
      Excess cost and length of stay associated with voluntary patient safety event reports in hospitals.
      Improved workforce culture and satisfaction are also important secondary benefits that aid with staff recruitment and retention. Many hospital organizations conduct employee opinion surveys to gauge the quality of the workplace for potential strengths and areas for improvement; staff safety surveys may be seen as an extension of this.
      There currently is debate as to whether healthcare culture and climate are important predictors of quality of care.
      • Hann M.
      • Bower P.
      • Campbell S.
      • Marshall M.
      • Reeves D.
      The association between culture, climate and quality of care in primary health care teams.
      According to a review by Sexton et al,
      • Sexton J.B.
      • Grillo S.
      • Fullwood C.
      • Pronovost P.
      Assessing and improving safety culture.
      there is ample evidence that demonstrates that safety climate scores correlate with unsafe staff behaviors, safety-specific organizational citizenship behaviors, patient injury, and accidents. Our results add to the growing body of evidence that a healthy safety culture develops in tandem with safer patient care. Further work to investigate perceptions of safety and quality from the patient's perspective is also warranted.

      Acknowledgments

      We would like to acknowledge MCIC Vermont, Inc, its leadership, and the individual hospitals of MCIC Vermont, Inc, that contributed with similar patient safety initiatives at their own institutions.

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