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Identifying Organizational Cultures That Promote Patient Safety

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Identifying Organizational Cultures That Promote Patient Safety 300 October–December 2009 Identifying organizational cultures that promote patient safety Sara J. Singer Alyson Falwell David M. Gaba Mark Meterko Amy Rosen Christine W. Hartmann Laurence Baker Background: Safety climate refers to shared perceptions of what an organization is like with regard to safety, whereas safety culture refers to employees’ fundamental ideology and orientation and explains why safety is pursued in the manner exhibited within a particular organization. Although research has sought to identify opportunities for improving safety outcomes by studying patterns of variation in safety climate, few empirical studies have examined the impact of organizational characteristics such as culture on hospital safety climate. Purpose: This study explored how aspects of general organizational culture relate to hospital patient safety climate. Methodology: In a stratified sample of 92 U.S. hospitals, we sampled 100% of senior managers and physicians and 10% of other hospital workers. The Patient Safety Climate in Healthcare Organizations and the Zammuto and Krakower organizational culture surveys measured safety climate and group, entrepreneurial, hierarchical, and production orientation of hospitals’ culture, respectively. We administered safety climate surveys to 18,361 personnel and organizational culture surveys to a 5,894 random subsample between March 2004 and May 2005. Secondary data came from the 2004 American Hospital Association Annual Hospital Survey and Dun & Bradstreet. Hierarchical linear regressions assessed relationships between organizational culture and safety climate measures. Findings: Aspects of general organizational culture were strongly related to safety climate. A higher level of group culture correlated with a higher level of safety climate, but more hierarchical culture was associated with lower safety climate. Aspects of organizational culture accounted for more than threefold improvement in measures of model fit compared with models with controls alone. A mix of culture types, emphasizing group culture, seemed optimal for safety climate. Practice Implications: Safety climate and organizational culture are positively related. Results support strategies that promote group orientation and reduced hierarchy, including use of multidisciplinary team training, continuous quality improvement tools, and human resource practices and policies. Key words: hospital characteristics, organizational culture, patient safety, safety climate, survey Sara J. Singer, MBA, PhD, is Assistant Professor of Health Care Management and Policy, Harvard School of Public Health, Boston, MA. E-mail: [email protected]. Alyson Falwell, MPH, is Director of Operations, The Altos Group, Oakland, CA. David M. Gaba, MD, is Director, Patient Safety Culture Institute, VA Palo Alto Health Care System, CA. Mark Meterko, PhD, is Investigator, Center for Organization, Leadership, and Management Research, VA Boston Healthcare System, MA. Amy Rosen, PhD, is VA Research Career Scientist, Center for Health Quality, Outcomes and Economic Research, Bedford VAMC, MA. Christine W. Hartmann, PhD, is Research Scientist, Center for Health Quality, Outcomes, and Economic Research, Bedford VAMC, MA. Laurence Baker, PhD, is Professor, Department of Health Research and Policy, Stanford University, CA. Health Care Manage Rev, 2009, 34(4), 300-311 Copyright A 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Organizational Cultures That Promote Patient Safety 301 ublication of startling statistics nearly a decade ago about the extent of preventable medical errors Figure 1 Phas directed attention to the ‘‘culture of safety’’ in Competing values framework, adapted health care organizations (Institute of Medicine, 2000). from Quinn 1984 Subsequent research has sought to identify opportunities for improving safety outcomes by studying patterns of variation in what has been termed ‘‘safety climate’’ (Flin, Burns, Mearns, Yule, & Robertson, 2006). Climate and culture are not synonymous, although they are often used interchangeably (Zohar, 1980). Climate has been ‘‘defined as a perceptually based description of what the organization is like in terms of practices, policies, procedures, and routines, while culture helps define the underlying reasons and mechanisms for why these things occur in an organization based on fundamental ideolo- gies, assumptions, values, and artifacts’’ (Ostroff, Kinicki, & Tamkins, 2003). Thus, climate refers to shared per- ceptions related to a given, specific area of interest, such as safety (Schneider & Bowen, 1993), whereas culture refers to employees’ fundamental ideology and orienta- tion (Trice & Beyer, 1993) and explains why an objec- tive like safety is pursued in the manner exhibited within a particular organization (Schein, 1992). and participation and distributes rewards equally among Limited research has examined organizational charac- members. An entrepreneurial culture is characterized by teristics that may affect safety climate in hospitals (Zohar innovation, by risk taking, by focus on growth, and by & Luria, 2004). In particular, we know little about how rewards for individual initiative. It should be noted that the organizational context could be modified to improve ‘‘risk taking’’ in this context does not imply taking risks safety climate. A better understanding of this relation- with respect to patient safety but rather with patient care ship could reveal, for example, whether aspects of gen- processes, often with the explicit intent of improving eral organizational culture predispose some hospitals to some aspect of patient safety. A hierarchical culture better safety climate. values predictable operations, which it achieves through structure, rules, policies, and procedures; rewards are al- located according to rank. Finally, a production-oriented Theory and Conceptual Framework culture is rational, with a focus on rewards for goal ac- complishment. According to the CVF, the overall cul- Drawing on expanding evidence linking safety outcomes ture of an organization will reflect some particular mix of to climate measures in health care and other indus- these four dimensions. Thus, the CVF framework allows tries (e.g., Clarke, 2006; Hofmann & Mark, 2006), we for the simultaneous consideration of potentially com- assumed that a strong safety climate is beneficial for peting organizational characteristics and provides a means patient safety. We conceived of safety climate both as to encapsulate concisely the complex nature of organi- a property of organizations as a whole and as varying zational culture. among groups within organizations (Gaba, Singer, & Working within the CVF framework, we considered Rosen, 2007). Following organizational psychology the- likely relationships between levels of organizational cul- ory which suggests that general organizational context ture and safety climate. Organizations with higher levels shapes specific aspects of climate (Wallace, Popp, & of group culture were hypothesized to have higher levels Mondore, 2006), we examined organizational culture and of safety climate (Hypothesis 1). We based this predic- its relationship to patient safety climate in 92 U.S. hos- tion on previous findings that strong groups are char- pitals. In this way, we explored the potential for basic acterized by the psychological safety that encourages the assumptions, values, and beliefs to play a role in safety openness about mistakes and concerns necessary for or- climate. ganizations to learn and to improve (Edmondson, 1999). In this study, organizational culture was operational- The participation, the inclusion, and the shared decision ized using the competing values framework (CVF; Quinn making inherent in group culture have promoted col- & Rohrbaugh, 1983; Figure 1). The CVF framework laboration and learning from peers (Cameron & Quinn, posits four organizational culture dimensions. A group 1999; Shortell et al., 1995). Collegiality has also facili- culture emphasizes teamwork, cohesiveness, mentorship, tated the implementation of processes related to improved Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 302 Health Care Management REVIEW October–December 2009 patient safety (Kaissi, Kralewski, Dowd, & Heaton, 2007). and routines designed to take pressure off employees and Thus, we expected that group-oriented culture would be to reinforce the importance of safety, such as time-outs reflected in the policies, procedures, practices, and rou- for groups to reflect before and after procedures. Con- tines related to safety—the safety climate—in an orga- versely, production pressure has been shown to impede nization. More group-oriented cultures have also been safety climate and improvement in the operating room positively associated with a variety of better outcomes (Gaba, Howard, & Jump, 1994). More production- (Cameron & Quinn, 1999; Carman et al., 1996; Meterko, oriented cultures have also been negatively related to per- Mohr, & Young, 2004; Shortell et al., 1995, 2000; Zazzali, formance measures (Cameron & Quinn, 1999; Carman Alexander, Shortell, & Burns, 2007). et al., 1996; Meterko et al., 2004; Shortell et al., 1995, Higher levels of entrepreneurial culture were also 2000; Zazzali et al., 2007). hypothesized to be associated with higher levels of safety The previous hypotheses emphasize the influences climate (Hypothesis
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