ORIGINAL ARTICLE

Safety Perceptions of Health Care Leaders in 2 Canadian Academic Acute Care Centers David H. Goldstein, MB, BCh, BAO, MSc (Comm Health), FRCP, MSc (Human Fact),*† James M. Nyce, PhD,‡ and Elizabeth G. Van Den Kerkhof, RN, DrPH*§ Objectives: An estimated 7.4% of patients admitted to acute care facilities in Canada experience injury or death due to health care mishaps, and 38% of these events are deemed preventable. Commitment of executive leaders to a culture of safety is important for the reduction of risk to Canadian patients. The purpose of this study was to examine the safety climate from a leader's perspective in 2 Canadian acute care settings, with attention paid to high reliability organization (HRO) principles. Methods: The Patient Safety Culture in Healthcare Organizations questionnaire was administered to leaders in 2 acute care hospitals in Ontario between June and January 2009. The primary outcome measures were senior leadership support for safety and supervisory leadership support for safety. Misalignment between the safety climate and HRO principles was defined as greater than 10% of respondents reporting problematic or neutral leadership support for safety. Results: Of the 142 respondents (67% response rate), both medical/ nursing leaders and tertiary care clinical leaders were significantly more likely than board/administrative leaders to report problematic/neutral responses. Overall, executive leadership perceptions of the safety climate were not aligned with HRO principles. Conclusions: The significant differences in response between board/ administrative leaders and those involved in frontline patient care suggest that a weak safety culture exists in these 2 health care organizations. The cultivation of a stronger organizational safety culture, in alignment with HRO principles, could lead to lower rates of preventable mishaps and support risk identification and mitigation in perioperative settings. Key Words: patient safety, leadership, high reliability organization (J Patient Saf 2014;00: 00–00)

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milestone study from the Institute of Medicine described the seriousness and extent of errors with patient care in America.1 In Canada, in 2000, an estimated 185,000 (7.4%) of 2.5 million hospital admissions were associated with one or more adverse events, and 70,000 (38%) of these were deemed to be potentially preventable.2 Approximately 5,000 to 10,000 Canadians die annually from adverse events occurring with hospital admission.3 Preventable surgical adverse events likely account for a large fraction of incidents.4 For example, human error has been indicated in 63% to 87% of anesthetic deaths.5 Similar adverse event rates in health care are reported globally.6–11 Effective leaders are essential for improved patient safety.12,13 An effective leader is one who can gain the trust of others, who can acquire their support and participation, who can work both From the Departments of *Anesthesiology and Perioperative Medicine, and †Surgery, Queen's University, Kingston, Ontario, Canada; ‡Department of Anthropology, Ball State University, Muncie, IN; and §School of Nursing, Queen's University, Kingston, Ontario, Canada. Correspondence: David H. Goldstein, MD, MB, BCh, BAO, MSc, FRCP, MSC, Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston General Hospital, 76 Stuart St, Kingston, Ontario, Canada, K7L 2V7 (e‐mail: [email protected]). Supported by Queen's University. The authors disclose no conflict of interest. Copyright © 2014 by Lippincott Williams & Wilkins

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independently and in teams, and who has excellent communication skills that can help accomplish common tasks. Leaders can use social influence to direct their organization in a specific direction to achieve specific goals.14 An institutional focus on safety needs to be supported by health care leaders at the level of both administrative executives and health care providers.13 Although leaders have the authority to improve patient safety, their commitment is highly variable.15 Furthermore, little is known regarding what health care leaders perceive a safety climate to entail and health care leaders' understanding of their role in enhancing patient safety via the cultivation of an institutional culture/climate of safety. A high reliability organization (HRO) refers to an organization that successfully avoids catastrophic adverse events although it operates under hazardous conditions in which accidents are expected because of inherent high risk and complexity.16 High reliability organizations embody an underlying set of characteristics, which represent a practical philosophy enabling safe practice in hazardous and complex environments.17,18 The 5 key characteristics of HROs are (1) preoccupation with failure, which assists in seeing where adverse events are possible and mitigating risk at an early stage; (2) a reluctance to simplify interpretations, enabling detection of subtle signal or unexpected events; (3) sensitivity to operations, which maintains awareness of realtime situations/context and the ability to perceive early or potential errors; (4) a commitment to resilience, involving ongoing staff training about what to do if the worst does happen; and (5) deference to expertise, in which leaders are willing to listen and respond to frontline staff.18 These 5 characteristics of HROs can secure a safer environment by enabling successful containment of unexpected events and anticipation of potential failure through the cultivation of mindful leadership.18,19 High reliability organization characteristics also nurture a “just culture,” in which open reporting systems allow adverse events to be reported without fear of incurring blame or shame.19 High reliability organization principles have been adopted by leaders in high-risk industries such as aviation (aircraft carriers, air traffic control) and nuclear power generation plants17 and may reduce the frequency and severity of errors in high-risk organizations.20–25 It is our general hypothesis that safety-literate leaders, who share a common understanding of today's best practice safety science concepts, can align safety principles with the values, vision, mission, and overall strategy of corporate hospital plans.12 Effective health care leaders can also inspire in their staff a greater degree of safety vigilance and lead organizations to commit to the principles of HROs. All this can help contribute to safer hospital experiences. However, in health care, there is currently limited understanding of safety culture measurement and subsequent management initiatives to improve safety culture.13 The goal of the current investigation was to assess the safety climate in 2 acute care hospitals in Canada from the perspective of the organization's leaders. The specific research objectives were to (1) describe the safety climate as understood by board members, senior and supervisory leadership; (2) examine the relationship www.journalpatientsafety.com

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between different leader types, safety perceptions, and the support for safety in tertiary versus ambulatory health care settings; and (3) determine the degree of existing alignment between leadership safety climate perspectives and HRO principles.

METHODS After approval from our institutional Research Ethics Board and senior executives at both hospitals, the PSCHO questionnaire was administered to employees in leadership positions in 2 local acute care hospitals to assess their perceptions of their institution's safety climate.

Participants Individuals included in the study held senior leadership positions. These included board members, senior executives (chief executive officers, chiefs of staff, chief nursing executives, and chief financial officers), medical academic department and division heads, medical and nursing operational program directors, nursing unit managers, clinical nursing educators, practitioners, and specialists. In some cases, these recipients had responsibility at both participating sites. Here, chiefs of staff, medical academic department and division heads, and medical program directors were assigned to the center where they provided most of their service. In January 2009, a paper questionnaire was sent to all eligible participants in both hospitals (N = 212) through interhospital mail or Canada Post. Up to 2 follow-up letters and questionnaires were sent to nonrespondents, approximately 4 and 8 weeks after the initial mail out.26 A third party conducted survey distribution and data entry, and investigators, including the data analyst, were blinded to the identity of the participants.

The Patient Safety Culture in Healthcare Organizations Questionnaire The Patient Safety Culture in Healthcare Organizations (PSCHO) questionnaire evolved from research on HROs at a Stanford-based patient safety research program and from modifications of earlier validated surveys used by similar groups.27,28 This included the Stanford Patient Safety Center for Inquiry survey and the Modified Stanford Patient Safety Culture Survey.27–29 These surveys were developed to determine attitudes that can contribute to a safety climate and cover 7 broad concepts: leadership commitment to safety, organizational resources available to support patient safety, prioritization of safety over production, the presence of effective and open communication, the ability to report problems and errors without fear of punishment or shame, organizational safety training initiatives, and the frequency of unsafe events.13,27,30 The PSCHO consisted of the 14 questions adapted from the Modified Stanford Patient Safety Culture Survey27 focusing on components believed to be most relevant to leaders and categorized as either senior leadership support for safety or supervisory leadership for safety. Responses were on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree” with an option of “not applicable.” Responses to these questions provided problematic, neutral, or nonproblematic perceptions with regard to issues of patient safety. The questionnaire also captured information about age, time in organization, sex, role, and differences across work settings.

Data Analysis Descriptive statistics were calculated for demographic characteristics. Role was categorized into board, administration,

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medical leaders, and nursing leaders. Because of the sample size, board/administration and medical/nursing categories were combined for the purpose of bivariable and multivariable analysis. The 14 questions making up the concepts of senior leadership support for safety (F1) and supervisory leadership support for safety (F2) were assessed for reliability using Cronbach α, after reassigning values because of reverse coding for some of the questions. Responses were classified into whether they were problematic (score of 1 or 2 on the Likert scale), neutral (score of 3), or not problematic (score of 4 or 5) toward safety. The percentage of respondents reporting problematic/neutral responses for individual questions regarding senior leadership support for safety and supervisory leadership support for safety was also calculated. Problematic and neutral responses were considered to indicate a negative response to patient safety.27 Frequencies and percentages were calculated for problematic alone and problematic or neutral combined. The analyses were stratified by role (board/administration versus medical/nursing leaders).

RESULTS Of the 142 respondents (a 67% response rate), most (68%) were female nursing managers, older than 50 years, and had worked in a tertiary care setting for more than 10 years (Table 1). Board/administrative leaders were significantly more likely to be older and men but less likely to be in the workplace for more than 10 years, compared with medical/nursing leaders (Table 1). Cronbach α values on the domains of perception and support for a safety climate ranged from 0.86 in the total sample for F1 to 0.90 in the total sample and the medicine/nursing group for F1/F2 combined.

Perception and Support for a Safety Climate The percentage of respondents reporting problematic/neutral responses about senior leadership support and supervisory leadership ranged from 11% to 76% (Table 2). The top 3 concerns (problematic/neutral responses combined) identified under senior leadership support for safety were as follows (Table 2): (1) concern about the balance between patient safety and productivity (62%), (2) consideration of patient safety when changing programs (49%), and (3) senior management's awareness of the patient care risks (48%). The top 3 concerns related to supervisory leadership support for safety were (1) (lack of) reward for taking quick action to identify serious mistakes (76%), (2) supervisor/ manager (does not) say a good word (or reward) for a job done according to established patient safety procedures (46%), and (3) need to work faster even if it means taking shortcuts (30%). Considering senior leadership and supervisory support for safety (F1 and F2) together, 19% of the respondents perceived the climate to be problematic and 38% perceived it to be problematic or neutral. The medical/nursing leaders were significantly more likely to report problematic/neutral responses compared with the board/ administrative leaders on all questions related to senior leadership and supervisory leadership support for safety (Table 3). The 3 most problematic issues identified by the medical/nursing leaders were (1) reward for taking quick action to identify a serious mistake (79% stated problematic or neutral), (2) organization effectively balances the need for patient safety and the need for productivity (70% stated problematic or neutral), and (3) senior management has a clear picture of the risk associated with patient care (59% stated problematic or neutral). The most problematic areas for board/administrative leaders were (1) reward for taking quick action to identify a serious mistake (63% stated problematic or © 2014 Lippincott Williams & Wilkins

Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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Leadership Perceptions of Safety

TABLE 1. Demographic Characteristics of Respondents Total Group

Age ≤50 y >50 y Sex Male Female Site Tertiary care Ambulatory care Time in organization 10 y Role Board members Senior administrators Medical managers Nursing managers Grouped role Board/administration Medical/nursing leaders

Role

Statistic

n (%)

Board/Administration, n (%)

Medical/Nursing, n (%)

χ2 (P)

69 (50.7) 60 (44.1)

6 (24.0) 19 (76.0)

63 (60.6) 41 (39.4)

10.8 (

Safety Perceptions of Health Care Leaders in 2 Canadian Academic Acute Care Centers.

An estimated 7.4% of patients admitted to acute care facilities in Canada experience injury or death due to health care mishaps, and 38% of these even...
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