Organizational Safety: Which Management Practices Are Most Effective in Reducing Employee Injury Rates?

Journal of Safety Research 33 (2002) 259–276 www.elsevier.com/locate/jsr

Organizational safety: Which management practices are most effective in reducing employee injury rates?

Alison G. Vredenburgh*

Vredenburgh and Associates, Inc., PMB 353, 2588 El Camino Real, Suite F, Carlsbad, CA 92008, USA

Received 6 December 2000; received in revised form 5 August 2001; accepted 19 November 2001

Abstract

Problem: While several management practices have been cited as important components of safety programs, how much does each incrementally contribute to injury reduction? This study examined the degree to which six management practices frequently included in safety programs (management commitment, rewards, communication and feedback, selection, training, and participation) contributed to a safe work environment for hospital employees. Method: Participants were solicited via telephone to participate in a research study concerning hospital risk management. Sixty-two hospitals provided data concerning management practices and employee injuries. Results: Overall, the management practices reliably predicted injury rates. A factor analysis performed on the management practices scale resulted in the development of six factor scales. A multiple regression performed on these factor scales found that proactive practices reliably predicted injury rates. Remedial measures acted as a suppressor variable. Discussion: While most of the participating hospitals implemented reactive practices (fixing problems once they have occurred), what differentiated the hospitals with low injury rates was that they also employed proactive measures to prevent accidents. Impact on Industry: The most effective step that hospitals can take is in the front-end hiring and training of new personnel. They should also ensure that the risk management position has a management-level classification. This study also demonstrated that training in itself is not adequate. D 2002 National Safety Council and Elsevier Science Ltd. All rights reserved.

Keywords: Safety culture; Risk management; Injury reduction; Accidents; Hazards

* Tel.: +1-760-434-4741; fax: +1-760-434-6029. E-mail address: [email protected] (A.G. Vredenburgh).

0022-4375/02/$ - see front matter D 2002 National Safety Council and Elsevier Science Ltd. All rights reserved. PII: S0022-4375(02)00016-6 260 A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276

1. Introduction

On an average day, 17 US workers are killed and 16,000 are injured in work-related accidents, resulting in a cost to industry of more than US$110 billion annually (Barr, 1998). This injury rate is increasing. Traditional safety efforts have focused on the engineering aspects of safety; however, relatively few accidents (10%) are a consequence of unsafe mechanical or physical conditions. While most on-the-job accidents and injuries appear to result from employees’ unsafe acts, incidents typically are not caused by single operator errors, but are end-events in a chain of interacting factors on several systems levels (Wilpert, 1994). While many unsafe acts are committed, very few will penetrate an organization’s defenses to result in accident or injury (Reason, 1994). It is becoming increasingly apparent that it is restrictive to discuss failures of large-scale technological systems solely in terms of the technological aspects. Individuals, their organizations, groups, and cultures are all-important factors in the design, construction, operation, and monitoring of technological systems. Until recently, this issue has been described in the related literature in terms of ‘‘human error.’’ While human error does contribute to accidents, the behavioral causes of failure are often found to be far more subtle when incidents are analyzed as part of a technological system (Pidgeon, 1991). Many expectations are built into the current US health and safety legislation that specifies the responsibilities of managers and employees with regard to safe working practices. These suppositions are more likely to be fulfilled if a positive cultural attitude toward safety exists. The costs of failure to comply with these expectations are increasing. As workers become more educated, they are more likely to expect safer working conditions; a more safety and environmentally conscious public is increasingly willing to express its disapproval of companies that are perceived to behave carelessly. This public reproach was evident during the American consumer boycott of Exxon gasoline following the Valdez oil spill (Turner, 1991). Researchers have found that safety performance is affected by an organization’s socially transmitted beliefs and attitudes toward safety (Ostrom, Wilhelmsen, & Kaplan, 1993). The concept of safety culture (Pidgeon, 1991) was developed as a result of the 1986 Chernobyl accident, which focused attention on the human and organizational elements contributing to the unsafe operation of technological systems. Safety culture is an organization’s norms, beliefs, roles, attitudes, and practices concerned with minimizing exposure of employees to workplace hazards (Turner, 1991). The goal of a safety culture is to develop a norm in which employees are aware of the risks in their workplace and are continually on the lookout for hazards (Ostrom et al., 1993). A safety culture motivates and recognizes safe behavior by focusing on the attitudes and behaviors of the employees. It is a process—not a program; it takes time to develop and requires a collective effort to implement its many features (Barr, 1998). Changing a company’s culture is more difficult than issuing a new policy statement. Traditional customs and practices constrain new thinking (Kletz, 1985). While many authors on safety management attach great importance to a formal statement of a company’s safety policy, Kletz (1993) does not believe such a statement will impact a company’s accident record. He believes that the culture or ‘‘common law’’ of a company is more influential, conveyed by such actions as a phone call from the head office immediately after A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276 261 an incident, asking not if anyone was hurt, but when the plant would be back on line. In this case, the cultural ‘‘message’’ is that production, not people or safety, is the priority. Researchers have found a direct organizational culture–performance link. According to Siehl and Martin (1990), a ‘‘strong’’ organizational culture is one where espoused values are consistent with behavior and where employees share the same view of the firm. Conversely, a weak culture results when people at all levels of the hierarchy fail to share the values espoused by management. The challenge facing organizations is to discover how to displace existing cultural patterns where they lack an appropriate concern with safety, and to replace them with new, self-perpetuating elements, which show a greater degree of care. While there are many potential external influences that make it difficult to define a ‘‘strong’’ safety culture across settings, there are many features that safety cultures from successful organizations have in common. In order to cultivate a strong safety culture, several measures can be taken. Zohar’s (1980) study of safety climate used a factor analysis to identify climate dimensions that could discriminate among factories based on their safety climate levels. A few practitioners and experts (Cohen & Cleveland, 1983; Pidgeon, 1991; Turner, 1991) described factors they believe to be prevalent in the safety culture of organizations that have low injury rates. The variables described below are a compilation of the factors found across several of these reports. Six management practices have been consistently discussed in reports concerning safety culture: (a) rewards, (b) training, (c) hiring, (d) communication/feedback, (e) participation, and (f) management support. The objective of the current study was to determine the extent to which these six variables predict employee injury rates.

2. Six management practices studied

2.1. Worker participation

Worker participation (or employee involvement) is a behavioral-oriented technique that involves individuals or groups in the upward communication flow and decision-making process within the organization. The amount of participation can range from no participation, where the supervisor makes all decisions, to full participation, where everyone connected with, or affected by, the decision is involved. Employees close to the work are recognized as often being the best qualified to make suggestions about improvements. Participative managers will solicit opinions from other individuals or groups before making final decisions, especially for those that affect the employees. The empowerment of employees is both a management style and attitude. Empowering workers provides them with authority, responsibility, and accountability for required decisions and ensures that both employees and management are involved in setting goals and objectives. It induces employees to do their best work as individuals and as a team, while relieving the manager to plan, monitor, lead, and mentor (Cohen & Cleveland, 1983). In the United States, employee involvement has tended to focus on greater personal influence on the shop floor and on a greater role in the decision-making involving the employees’ daily work experience (Cohen & Cleveland, 1983). 262 A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276

Safety committees have become a standard feature of workplace safety programs; however, committees themselves do not necessarily mean effective employee involvement. Committees must be given real power to implement change. The members must be in positions where they can have a positive impact on the committee’s work (such as production and engineering supervisors), and must be well trained. Participation has been found to be a key component in successful hospital injury prevention programs. In a 1992 study done by the Department of Veterans Affairs Medical Center (VAMC) in New Jersey, a program was implemented to reduce lost-time injury cases. The intervention included the involvement of all levels of employees in every phase of the safety program. This program dramatically reduced the lost-time injury cases within 1 year of implementation (Garrett & Perry, 1996).

2.2. Safety training

In order for employees to be active participants in a safety program, they must receive occupational safety training. A well-designed and administered training program should emphasize safe work practices and be derived from a true assessment of need. Training should be followed with a program based on goal-setting and performance feedback (Cohen & Jensen, 1984). Training program assessment should verify that the safe work practices could be demonstrated to be effective and to endure beyond cessation of performance feedback. According to Cohen and Jensen, there should be a redefinition of group norms sustained through informal influences such as peer modeling of desired behaviors, continued management support of the program, and a behavior sampling procedure specifying performance-based criteria. Safety training provides the means for making accidents more predictable. The basic difference between safe employees and those who frequently get hurt is that safe employees can recognize hazards and hazardous actions and understand the consequences. To improve the quality of safety and health for all employees, organizations should institute a systematic, comprehensive safety and health training program for new employees, provide a mentor for these employees, and use a buddy system to help orient new employees in the safety and health and quality systems. They should also institute a system of continual re- education and retraining of employees in current safety and health issues (Roughton, 1993). Several issues affect the perception of risk levels and should be understood when training employees in occupational safety. People tend not to use the likelihood of injury in their judgments of product safety; rather, the severity of injury plays the foremost role in decisions to read warnings and act cautiously (Young, Brelsford, & Wogalter, 1990). Vredenburgh and Cohen (1995) found that the level of perceived danger increased compliance to warnings and instructions; therefore, it is critical that all employees are trained to identify the hazards associated with their workplace.

2.3. Hiring practices

The development of a safety culture can be facilitated if recruitment criteria for new personnel include the selection of people who are predisposed to displaying a safety- conscious attitude in their work. If an organization fosters a safety-conscious image, the A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276 263 recruitment task will be influenced because those with compatible attitudes and expectations would be more likely to seek out this company, presumably in part due to a desire for a safe work environment (Turner, 1991). Eckhardt (1996) states that while interviewers cannot influence whether someone is an inherent risk-taker, they can place such applicants in jobs with a corresponding level of high-risk tasks. Recruiters can also select candidates with a lower propensity to take risks. While it has been a long held belief, by different authorities, that many personal characteristics such as gender, age, stature, and body weight are possible risk factors for work-related injuries, none of these traits have been reasonably correlated with the occurrence of injury-producing incidents or their severity. One’s medical history, medical examination, or spine X-rays are sometimes able to reveal some clues of potential health risks. However, medical advice or warning regarding a career choice might be disregarded by an applicant who needs a job (Lin & Cohen, 1984b).

2.4. Reward system

People are motivated to behave in ways that lead to desired consequences; they will modify their behavior to conform to a cultural norm if it is perceived that compliance will lead to a desirable outcome. Culture is learned through a connection that is made between behaviors and consequences. Thompson and Luthans (1990) state that since organizational culture occurs in an environment where there are multiple reinforcements and reinforcing agents, changing an organization involves identifying the various reinforcing agents in order to determine their effects on the change process. A correctly designed safety-incentive program reinforces the reporting of a hazard or an unsafe act that leads to an injury while giving bonuses for fewer lost-time accidents. A safety incentive program must be part of a campaign that runs parallel to safety education and training. It must be directed at the prevention of accidents, not punishment after an accident occurs (Peavey, 1995). Informational (feedback, self-recording), social (praise, recognition), and tangible reinforcers (trading stamps, cash bonuses) have been used as well as nonmonetary privileges (Komaki, Barwick, & Scott, 1978). As with any policy, the effort to develop a strong safety culture is unlikely to be effective if the organization is not reinforcing the desired behaviors (or is rewarding inconsistent behaviors such as speed or production rates). A well-designed incentive program offers recognition, which can help modify behavior. A key characteristic of a successful incentive program is that it receives a high level of visibility within the organization. Participants must be able to comprehend what the incentive program is designed to accomplish and how their performance will be measured (Halloran, 1996). Simply distributing prizes and money without pairing them with a clear, consistent set of contingencies reduces the potential to achieve the desired outcome. It may even increase the undesired behavior, more accidents (Swearington, 1996).

2.5. Management commitment

In one of the first investigations of safety climate, Zohar (1980) found that management’s commitment to safety is a major factor affecting the success of an 264 A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276 organization’s safety programs. This commitment can manifest itself through job training programs, management participation in safety committees, consideration of safety in job design, and review of the pace of work. For example, people working for a supervisor that never mentions safety perceive that safety is unimportant; as a result, they will not place a strong emphasis on safety (Hofmann & Stetzer, 1996). The degree to which management values safety is expressed in its style and level of assumable risk. These two factors are the most influential components of culture; however, safety professionals have very little influence over these variables. When discussions of safety are conducted in a false or insincere rhetoric, the phony statements are readily seen for what they are (Turner, 1991). In five plants recognized by the National Safety Council for no lost workdays, all of the plants required advance approval by safety personnel for any changes in the design of the work facilities. In four of the plants, the plant safety director had direct contact with the plant manager on a daily basis (Cohen & Cleveland, 1983). The motivation to perform a job in a safe manner is a function of both the individual’s own concern with safety as well as management’s expressed concern for safety. Safety concerns must result in an observable activity on the part of management; they must be demonstrated in their behavior as well as their words (Hofmann, Jacobs, & Landy, 1995). In the 1992 Veteran’s Hospital (VAMC) study, the guiding force behind the initiative to reduce the number of injury cases was management’s commitment, which began at the very top management level, with the Medical Center Director. Without sincere support from top hospital administrators, this project would not have achieved its level of success (Garrett & Perry, 1996).

2.6. Communication and feedback

The role of feedback concerning employees’ performance is critical because behaviors resulting in industrial accidents are not typically new occurrences. Their causes are deeply rooted in past minor incidents, where damage was insignificant and workers and bystanders were not injured (Kletz, 1993). Regular feedback on performance can be communicated to employees through posted charts and a review of behavioral data in safety meetings (Roughton, 1993). The incubation model of disasters suggests that near-miss events will often differ from actual incidents by the absence of the final trigger event and the intervention of chance. Pidgeon (1991) states that organizations can interpret near-miss incidents as warning signals. In some contexts, such as the aviation industry (Hall & Hecht, 1979), a high premium is placed on the analysis and dissemination of incident data obtained on a ‘‘no- fault’’ reporting basis. In the five National Safety Council award-winning plants, the organizations had some form of employee hazard identification system in which they were encouraged to report hazards to management (Cohen & Cleveland, 1983). In order to encourage communication, it is important not to blame employees when accidents occur. As managers have gained experience with the techniques used to improve quality, they have learned the importance of improving the process of production. Many managers now work to solve production problems upstream rather than inspecting for defects down- stream (Roughton, 1993). A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276 265

Consistent and forthright communication is an essential characteristic of any strong organization. Good communication leads to trust, which is a fundamental element of strength. In order for organizations to foster a climate where employees are alert to hazards, they must have an appreciation of the employees’ and organizations’ tendency to conceal and distort significant available information (Pidgeon, 1991). In order to influence safety practices, feedback must be provided to the employees who are capable of using it. It needs to be given to those working at the point in the process where their behavior can effectively influence outcomes. People cannot behave in a safety-conscious manner unless they have the authority to change their own actions to improve their work conditions. It is illogical to ask employees to be careful if they do not have the power or discretion to avoid hazards (Turner, 1991). Laws (1996, p. 26) writes, ‘‘motivation is no big deal, you can motivate a baboon. But if you don’t back that motivation with tools, skills, training, counseling, and leadership, then all you have is a highly frustrated, motivated ape that cannot get the job done.’’

3. The hospital environment

In a study conducted by the National Institute for Occupational Safety and Health (NIOSH), only 8% of the 3686 hospitals surveyed met all of NIOSH’s basic components of an effective occupational safety and health program for hospital employees (Lin & Cohen, 1984a). Healthcare workers are at great risk for injury; nationally, the total lost workday injury and illness incidence rates for hospitals (4.1) are greater than those for private industry (3.6). Furthermore, workers in home health care (5.0) and nursing care (8.8) are at greater risk than construction workers (4.9; Cal/OSHA, 1997). Healthcare employees have to cope with psychological stress resulting from shift rotations and the frequent need to work overtime. Of the 27 occupations ranked as the highest stress, 15 were occupations found in hospitals (Lin & Cohen, 1984a). Since hospitals never shut down, and rarely slow down, numerous hazards develop due to fatigue from long hours, stress, rotating shift work, and changes in policy. One shift may create a hazard (such as leaving a cart blocking an emergency exit) that is overlooked by subsequent shifts (Johnson, 1997). Hospital employees must face the daily traumas of life and death as well as the constant interaction with a diverse patient population. Many people may expect that the occupational safety and health services would be conveniently accessible to hospital personnel; however, there tends to be a lack of focus in this area shown by hospital administration, which has received many complaints and criticisms from the affected healthcare workers (Werdegar, 1980). A possible explanation of this deficiency is that since medical facilities are to provide treatment and improve health, special facilities for employee care may appear redundant (Lin & Cohen, 1984a). The proper focus of attention to improve a hospital’s quality of service, and employee and patient safety is not on the personnel who participate in a flawed process, but the processes that create the flaws. Hospitals that employ quality improvement methods have been found to achieve new levels of efficiency, patient satisfaction, safety, clinical effectiveness, and profitability (Berwick, Godfrey, & Roessner, 1990). However, due to 266 A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276 the health services’ traditional orientation toward sick care rather than health maintenance and hazard prevention and because of the concern for the cost of safety and health management, the implementation of an employee safety and health program has rarely been considered a top priority by hospital administration. Hospital employees typically do not participate in hazard management; thus, a great deal of resources are often required to train employees in communication and problem-solving skills and in quality/measurement techniques (NIOSH, 1983). Quality assessment often lacks the necessary evaluation tools. It also is missing a general theory regarding the source of hazards in the complex processes of health care. To the extent that quality measurement tools have been developed, they tend to unveil the symptoms, not their underlying causes (Berwick et al., 1990). Several common types of injuries to hospital employees have been recognized and identified: strains and sprains, needle punctures, communicable diseases, toxic and hazardous substances, dermatitis (caused by handling cleansers, medicines, antiseptics, and solvents), and thermal burns (primarily in food service, laundry, and sterilizing areas). Back sprains and strains are the most common injuries to hospital workers; 46% of nurses, aides, orderlies, and attendants report back injuries, as opposed to 26% in private industry occupations (Cal/OSHA, 1997). These injury data must be collected and reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Occupational Safety and Health Administration (OSHA). The hospital environment was selected for the current study because injury data were thought to be readily available to use as a criterion measure and because it represents a growing and dynamic influence within the US service industries. It was also selected because incidence rates among various sectors of health services are at least one-third above the average service industry rates (NIOSH, 1983). While few people would dispute the importance of workplace safety, a review of the literature reveals a paucity of well-controlled studies demonstrating the efficacy of workplace safety programs. While well-controlled studies are reported in simulated work settings, in-house safety programs are notable for their lack of systematic assessment. The accounts reported in trade journals are primarily anecdotal.

4. Method

4.1. Participants

Participants were risk managers from 62 hospitals located in several states in the United States. They were recruited from professional organizations for hospital risk managers as well as direct mail and phone solicitation to hospitals. Participation was voluntary. Public, private, and investor-owned hospitals were solicited. All participating hospitals were medical/surgical; none were neuropsychiatric or nursing homes. Most respondents were managers (55 or 89%); seven (11%) were not in management. Rousseau (1990) states that research concerning culture frequently focuses upon key informants who are identified as those possessing special or more complete knowledge than others in the organization. Hospital risk managers were presumed to have more complete information about their institutions’ risk management programs, and thus, were A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276 267 solicited as participants. While the 62 participants performed the risk management function, 26 had the title of risk manager, 3 were in human resources, 10 were in administration, 8 were called safety officers, 5 were nurses, and 8 did not fit into the above categories. Seventy-four percent of the respondents had worked at their participating hospital for 5 or more years. Respondents were asked if their facility had undergone a change in ownership during the 3-year period of study. Of the 62 respondents, 57 (92%) reported no change, 3 (5%) reported a change in owner with no impact on the responses to survey items and 2 (3%) reported a change that may have impacted survey items. Participating hospitals ranged in size from 55 to 6000 employees (full-time equivalent), with a median size of 390 employees. Most of the hospitals, 40 (65%) were public, 21 were private (34%), and one provided no information.

4.2. Level of analysis

Climate researchers have often debated issues concerning the level of analysis and aggregation procedures. Climate surveys, which collect data at the individual level, provide limited information about the actual activities of an organization. Culture research calls for in-depth case studies that may require multiple organizations as the units of analysis to compare performance. In order to change an organization, data concerning an organization, as well as how that organization compares to others are required (Reichers & Schneider, 1990). The goal of the present study is to determine what factors, across organizations, predict injury rates; thus, the unit of study is at the organizational level. When studying organizational culture, the focal unit (whole organization, department, or work group) must be specified. When the level of analysis is not identified, there is a risk of ambiguity that Rousseau (1990) feels plagued much of the early climate research. In the current study, participating risk managers were informed, ‘‘Please keep your responses general, to your hospital as a whole.’’

4.3. Instruments

4.3.1. Organizational factors data Perception surveys have been used to effectively identify improvements in and deterioration of safety system elements (Ostrom et al., 1993). Participating hospitals were evaluated for the six predictor variables via an instrument designed for this study. Items were adapted from Ostrom and his colleagues’ study and pilot-tested with risk managers from three hospitals. Items that were unclear to these risk managers were reworded until there was agreement in the interpretation of the questions. Participants were given the instructions, ‘‘Considering only the hospital where you work, please respond to the following questions by circling the appropriate number following each question.’’ Extent scales 1 = no extent to 5 = a great extent followed each item. Three items were developed to assess each of the six management practices. A sample item used to assess training was ‘‘To what extent do you believe that the safety training provided to personnel is adequate to enable them to assess hazards in their work areas?’’ A sample item to evaluate level of participation was ‘‘To what extent do 268 A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276 safety committees or teams have the power to implement change?’’ See Table 1 for all items. Additional items solicited the frequency of the safety meetings, the frequency that top administrators met with safety committee members, and the type of rewards used. There was also an item to determine whether the hospital had changed ownership (such as

Table 1 Management practices survey items Management practice Survey item Rewards To what extent do you think that work-related injuries are due to a lack of rewards for reporting hazards? To what extent are employees rewarded for reporting a safety hazard (e.g., thanked, have employee recognized in hospital newsletter, receive cash or other awards)? To what extent are employees punished for reporting a safety hazard (e.g., they are ignored or told to keep it quiet)?* Training To what extent do you believe that the safety training provided to personnel is adequate to enable them to assess hazards in their work areas? To what extent does the training program perform assessments following instruction to verify that the safe work practices are being carried out in the work areas? To what extent do you think that work-related injuries are due to a lack of training?* Management commitment To what extent do you think that work-related injuries are due to a lack of management support in correcting employee safety hazards? To what extent do supervisors in your hospital enforce safe working procedures? To what extent do the administrators of your hospital demonstrate that safety is important to them (e.g., take immediate action to eliminate safety hazards, list safety issues high on the agenda of management meetings)? Communication To what extent does your hospital use a hazard reporting system and feedback where employees can communicate hazard information before incidents occur? To what extent are near-miss incidents analyzed as warning signals that must be studied and corrected? To what extent do you think that work-related injuries are due to a lack of feedback to employees about their unsafe behavior?* Selection To what extent are employees hired based on a good safety record in their previous positions? To what extent does management seek information about job candidates’ prior safety performance in selecting or transferring employees? To what extent do you think that work-related injuries are due to a lack of hiring people who are safety conscious?* Participation To what extent do employees participate in identifying safety problems? To what extent does management solicit opinions from employees before making final decisions? To what extent do safety committees or teams have the power to implement change? * Reverse-scored. A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276 269 from public to private). If they responded yes, they were then asked if their responses would be different if they pertained to the hospital under previous ownership. There was little demographic data requested to protect anonymity of the hospitals. Internal consistency reliability of the overall management practices scale was calculated at .86 (coefficient a).

4.3.2. Hospital injury data Participating hospitals provided data for the criterion variable via an instrument designed specifically for this study. This form provided respondents with a space to document the number of injuries for 15 injury categories. Injury categories were generated based on injury data (OSHA 200 forms) provided as examples from two facilities. Participants were asked to ‘‘Please fill in the number of injuries of each type that occurred to hospital employees during the 3 previous years, in the shaded area below.’’ These categories included ‘‘sprains, strains, and fractures,’’ ‘‘communicable or infectious diseases,’’ ‘‘needle punctures,’’ and ‘‘fractured/crushed fingers or hands.’’ Participants were asked to indicate the number of injuries (frequency) of each type that occurred to hospital employees during the 3-year period (1994–1996). There was also a statement in the instructions, ‘‘If you cannot easily provide the information in the format as it is requested on this form, you may send copies of your hospital’s OSHA 200 forms covering this 3-year period. Remember to remove your hospital’s name from the top of the forms to insure confidentiality.’’ If the data was sent on the OSHA 200 forms, the researcher tallied and converted the data onto the survey form and destroyed the OSHA forms. In order to maintain confidentiality, few demographic questions were included. The three demographic items requested the type of facility (public, private, investor-owned), the hospital’s full-time equivalent (FTE) employment (to control for facility size differences), and whether this included per diem and contractor employees.

4.3.3. Severity data In order to assign weights to calculate the composite criterion, severity data were collected. Since severity is very difficult to measure from existing data due to a variety of regulatory and organizational constraints, perceived severity ratings by an ‘‘expert’’ panel were used. The instrument (with the same 15 injury categories) was pilot-tested with two physicians. Some changes were then made to the instructions to increase clarity. The 14 experts who completed this questionnaire were all physicians who work in hospitals as part of their job. Because physicians are used as experts to testify in court as to the extent of damages resulting from an injury, they were selected to rank the injuries concerning their severity. Participants were instructed, ‘‘For my doctoral dissertation, I need to have rankings assigned to each of the risk factors listed below in order that I may assign weights for the statistical analysis. Considering your work in the hospital(s) where you practice, and based on your experience, please rank the hazards from 1 (not severe)to15(extremely severe). Please take into consideration such factors as days off work, permanent or long-term inability to perform current job duties, medical expenses, and whether the hazard is life- threatening (not probability of occurrence).’’ 270 A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276

4.4. Procedure

Participants were solicited via telephone to participate in a research study concerning hospital risk management. During this discussion, the experimenter explained the system to protect anonymity. Research materials, a confidentiality agreement, and a pre-addressed return envelope were mailed to volunteers. Responses were assigned random numbers; thus, it was impossible to link data to its hospital. Participants received follow-up calls or faxes to remind them to return the surveys. Since the researcher did not know who responded, all original contacts were recontacted. There was a statement on the written reminder that thanked them if they had already returned the survey.

4.4.1. Response rate Out of the 194 phone calls (only calls that reached the risk manager were counted), 125 agreed to participate (64%) and were mailed surveys. Of these 125 surveys, 74 were returned (59%); however, only 62 had criteria information and were usable for the regression analyses (50%).

5. Results

The central question addressed in this study concerned the degree to which six management practices predicted hospital employee injury rates. To evaluate this issue, several steps were required.

5.1. Expert rankings

In order to compare hospitals’ employee injury rates, it was necessary to determine both the frequency and severity of the injuries. Severity data were collected as expert rankings, which were converted into an interval scale and used to weight the frequency data. An estimate of reliability of the responses by the 14 expert raters was .82. Two of the raters were found to have contributed the most to the variance in the ratings. By removing both, reliability increased to .87. The rankings of the remaining 12 raters were then converted into an interval scale using Thurstone’s discriminate model.

5.2. Computing the criterion

There was a large range in the frequencies of the different injury types. Table 2 presents the mean (adjusted for number of employees to control for hospital size) and relative frequencies of the 15 injury types. The mean frequency is the annual average for each injury type based on 3-year’s injury data. The first step in computing the criterion measure was to weight the frequencies of each injury type with the severity factor developed from the physicians’ expert rankings. The total number of (weighted) injuries per hospital ranged from 19 to 1780 injuries, with an average of 262 injuries and a standard deviation of 327. The total number of (weighted) injuries was divided by the number of full-time A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276 271

Table 2 Averages and relative frequencies of the injury types (across all hospitals) Injury type Mean Percent Mean frequency/year frequency/year of total (per 100 employees) Sprains, strains, and fractures 40.25 34 6.00 Needle punctures, blood exposure 14.94 13 2.70 Contusions 14.87 13 2.10 Lacerations/cuts 10.35 9 1.90 Cumulative trauma disorder (CTD) 7.51 6 1.40 Other (allergic reactions, 6.53 5 0.87 unknown causes) Disease exposure 5.35 5 0.69 Burns 3.23 3 0.61 Abrasions 3.78 3 0.60 Eye injuries 3.08 3 0.59 Skin disease 2.86 2 0.36 Finger injuries 2.20 2 0.34 Toxic exposure 2.01 1 0.34 Mental stress 0.86 1 0.19 Human or animal bites 0.50 0 0.13 Total 118.11 100 18.82

employees for each hospital, resulting in the number of (weighted) injuries per employee for each participating hospital. These values ranged from 0.03 to 1.12, with a mean of 0.43 (weighted) injuries per employee and a standard deviation of 0.22. Several of the responding risk managers included a note with their injury data indicating that their hospitals did not record illness data. Some respondents noted that their hospitals recorded exposure to illnesses, while others reported that they recorded only actual infections. As a result of the variability in the recording and reporting of exposure to diseases/illnesses, the incident types, ‘‘communicable or infectious diseases’’ and ‘‘needle punctures, blood exposure’’ were not used in the calculation of the criterion variable; thus, only the 13 injury types were used (see Table 2 for the 15 injury categories). The final criterion variable (one observation per hospital) ranged from 0.02 to 0.90 injuries per employee, with a mean of 0.30 injuries and a standard deviation of 0.17.

5.3. Predicting injuries

The principal analysis was a linear multiple regression that assessed the predictive capacity of management practices (subscales) Participation, Management support, Train- ing, Hiring practices, Communication/feedback,andRewards of hospital employee injury rates. The multiple correlation was .41, R2=.165, and adjusted R2=.137. A significant F statistic [ F(2,59) = 5.84, P < .01] indicated a reliable linear relationship between the management practice subscales and the criterion. The only management practice that individually predicted injury rates was Hiring practices; the multiple correlation was .268, R2=.07, and adjusted R2=.06. A reliable linear relationship [ F(1,60) = 4.66, P < .05] was established. 272 A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276

Another variable that was found to account for the differences in injury rates was whether the person who performed the risk management function was classified as a manager. The multiple correlation was .274, R2=.075, and the adjusted R2=.06. A significant linear relationship [ F(1,60) = 4.87, P < .05] was found. The size of the hospital (number of employees) also predicted injury rates, with smaller hospitals averaging more injuries per employee than the larger ones. The multiple correlation was .380, R2=.145, and the adjusted R2=.130. An exploratory factor analysis was conducted to verify that the management practices items (predictors) loaded onto the expected subscales (the six management practices). Six factors, with eigenvalues > 1, emerged in 10 iterations and were rotated using the Varimax method. In total, the solutions accounted for 69% of the variance in the data: Factor 1 accounted for 29.7% of the variance; Factor 2 accounted for 10.8%; Factor 3 accounted for 8.0%; Factor 4 accounted for 7.2%; Factor 5 accounted for 6.6%; and Factor 6 accounted for 6.1%. The items comprising the six factor scales did not correspond to the categories derived from the practitioners’ reports (the management practices subscales). As a result of the factor analysis, six factor scales were developed. Items were accepted for a factor scale if they had a correlation with the factor (factor loading coefficient) greater than .70. A multiple regression analysis was performed using the six factor scales identified in the factor analysis to determine whether the factor scales predicted injury rates. The six factor scales were entered (items equally weighted within the factor scales). Factors 1 and 2 made a significant contribution to the prediction of the variance in hospital employee injury rates; the multiple correlation was .385, R2=.15, and adjusted R2=.12. A relationship between Factors 1 and 2 and injury rates [ F(2,59) = 5.14, P < .01] was found. Table 3 provides the items comprising Factors 1 and 2; the items comprising Factor 1 (near-miss incidents are analyzed as warning signals, and supervisors enforce safe work practices) were reactive. There was a safety violation that needed correction. Factor 2 contained proactive practices concerning the initial selection and training of employees. Because Factor 1 was positively related to injury rates (i.e., the more hospitals performed these desirable actions, the higher their employee injury rates), Factor 1 was acting as a suppressor variable. Factor 1 controlled for a portion of the error variance of Factor 2,

Table 3 Best predictors of employee injury rates items comprising factors 1 and 2 Factor Correlations Critical questions with criterion 2 À .227 Predict injury rates To what extent are employees hired based on a good safety record in their previous positions? To what extent does management seek information about job candidates’ prior safety performance in selecting or transferring employees? To what extent does the training program perform assessments following instruction to verify that the safe work practices are being carried out in the work areas? 1 .192 Suppressor To what extent are near-miss incidents analyzed as warning signals that must be studied and corrected? To what extent do supervisors in your hospital enforce safe working procedures? A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276 273

Table 4 Model summary Factor RR2 Adjusted R2 S.E. R2 change b F 2 .227 .051 .036 0.165 .051 À .366 3.253 1 .385 .148 .120 0.158 .097 .341 5.143** ** P < .01. which was negatively related to criterion (see Table 4 for the model summary). Thus, while all of the participating hospitals, to some extent employed the reactive measures comprising Factor 1, the primary difference in performance was that the participants with lower injury rates also performed the proactive measures (Factor 2), while the hospitals with high injury rates relied solely on ‘‘putting out fires’’ or ‘‘fixing’’ hazards after problems had occurred. Post-hoc tests were performed to determine whether there were possible alternate explanations for the results. Since the type of hospital was categorical (public, private, investor-owned), a nonparametric (independent sample Mann–Whitney) test was performed; the type of hospital made no difference in the employee injury rates. A Mann– Whitney test was also performed to determine if the job title of the person (risk manager, safety officer, nurse, etc.) who performed the risk-management function had any impact on injury rates. No difference was found.

6. Discussion

The most important finding of this study is that when organizations take proactive measures to protect their employees, the company derives a financial benefit in reduced lost time and workers compensation expenses. While previous research has typically discussed management practices as general goals, the current study systematically examined the specific elements of these practices that predict employee injury rates. Consistent with Eckhardt (1996) and Turner (1991), the current study found that the consideration of safety performance in the selection of employees was found to be a significant predictor of injury rates. The results from this study may help establish a bona fide occupational requirement for requesting these data (to avoid discrimination claims). Furthermore, since safety behavior is often tied to quality of performance, it is probable that an added benefit of this approach may be an improvement in productivity. When reviewing the results of this study, one may be inclined to believe that the items comprising Factor 1 actually caused the poor injury performance. However, with further analysis, it becomes apparent that Factor 1 is acting as a suppressor variable. It would be incorrect to infer that analyzing near miss incidents and enforcing safety practices increased injury rates; in fact, these measures were employed by both high and low performing hospitals. Therefore, it is not recommended that hospitals discontinue the practices of Factor 1, if they are in effect; however, resources and focus should be channeled toward the proactive measures of Factor 2. The most effective step that hospitals can take is in the front-end hiring and training of new personnel. They should also ensure that the risk management position has a 274 A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276 management-level classification. This study also demonstrated that training in itself is not adequate. Organizations must verify that the safe practices taught in the classes are being implemented in the work areas. The results of this study can be used to determine which factors to emphasize when performing an organizational development change in safety culture. While it is not recommended that hospitals discontinue the reactive practices that are in effect, resources and focus should be channeled toward more proactive measures. Due to the high turnover of hospital personnel, selection of new employees is an ongoing process; therefore, there is ample opportunity to consider safety records when selecting new employees (Cal/OSHA, 1997). A few hospital risk managers wrote that they were unable to obtain information about job candidates’ prior injury records from other facilities. One reliable and valid approach to solicit this type of information is through the behavioral based interview (Thornton & Byham, 1982). To use this approach, the interviewer must be trained in the concepts and techniques of behavioral interviews. An example of a question that may be used to assess an employee’s safety record is ‘‘Please describe the types of accidents or near misses you have had in your current or previous jobs.’’ Another example is ‘‘Please provide an example of when you had to call a co-worker’s attention to a possible violation of a safety regulation.’’ The applicant should describe the situation, the action he/she took, and the result (Huck, personal communication, July 1998). The injury rates at smaller hospitals were found to be higher than the larger ones. These findings may result from these institutions having a less comprehensive safety program, causing them to take a more reactive approach to injury prevention. The data collected in this study to measure management practices reflected the perceptions (and potential biases) of the risk managers. It is not possible to determine a ‘‘true’’ level of these characteristics. The number of responses used in the factor analysis poses another limitation; the 12 responses that had missing criterion data were included in this factor analysis to raise the sample size to 74. This number is somewhat lower than the ‘‘rule of thumb’’ of five per item (which would require 90 responses), due to the difficulty in recruiting hospitals. However, according to Tabachnick and Fidell (1989, p. 603), ‘‘If there are strong, reliable correlations and a few, distinct factors, a sample size of 50 may even be adequate, as long as there are notably more cases than factors.’’ Distinct, strong correlations were found in this study. This issue was further mitigated by using a high factor-loading cutoff score (.70). Since this was the first study of this type, a replication and extension of this work is recommended. A recommended follow-up study is to select two comparable hospitals, preferably within the same system, with the same (or similar) scores on the four management practices comprising Factors 1 and 2. A preliminary assessment could be conducted to establish a baseline measure of the performance of these practices. An intervention can then be developed to maximize performance on the three proactive items identified in this study as the best predictors of low injury rates (Factor 2). This intervention would emphasize a front-end approach where new personnel are screened and selected based on their past safety records. The approach could include behavior-based assessment. In addition, after these new (and existing) personnel are trained in appropriate safe work practices, an assessment will be performed to verify that the safe behaviors have been implemented in the work areas. A.G. Vredenburgh / Journal of Safety Research 33 (2002) 259–276 275

While the level of reactive practices (Factor 1) should be measured, the practices should not be changed. This intervention would be implemented in one of the facilities, with the second acting as a comparison site. A program evaluation could be performed with 3- year’s archival data as the baseline measure. Data could then be collected at 6-month intervals following the intervention for a period of 3 years. Any preliminary differences between the two facilities would serve as covariates. This proposed study would determine whether taking a proactive approach positively influences safety culture to reduce employee injury rates.

Acknowledgements

Many thanks to my dissertation chair, Richard Sorenson, who provided guidance throughout this research. This study was funded in part by Error Analysis.

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Alison Vredenburgh holds a PhD in Industrial–Organizational Psychology and a MS in Systems Management. She is currently a postdoctoral research fellow at the School of Medicine (Department of Anesthesiology) at the University of California, San Diego, where she is researching medical error. She is President of Vredenburgh and Associates Inc., a consulting firm specializing in human factors and safety. Her principle publications are in the areas of human factors, ergonomics, and workplace management practices. She is active in the Human Factors and Ergonomics Society, where she has held several leadership roles.