Examining the pathways by which work-life balance influences safety culture among healthcare workers in Taiwan: path analysis of data from a cross-sectional survey on patient safety culture among hospital staff.

OBJECTIVE: The aim of this study is to examine the pathways by which work-life balance influences safety climate in hospital settings. DESIGN: A national cross-sectional survey on patient safety culture. SETTINGS: Healthcare workers from 56 hospitals in Taiwan, covering three work settings: intensive care units, operation rooms and emergency departments. PARTICIPANTS: 14 345 healthcare workers took part in the survey and were included in the present analysis. PRIMARY AND SECONDARY OUTCOME MEASURES: The Safety Attitudes, Maslach's Burn-out Inventory and Work-life balance questionnaires were used to measure patient safety culture, teamwork, leadership, emotional exhaustion and work-life balance. Path analysis was conducted to determine the relationship between work-life balance and safety climate. We tested for mediating and moderating factors influencing this relationship. RESULTS: The path between work-life balance and safety climate was found to be significant (b=0.32, p<0.001) and explained through a serial mediation. This relationship was found to be mediated by emotional exhaustion followed by teamwork climate in a full mediation. Leadership factors such as identifying as a manager, moderated the indirect pathway between work-life balance and safety climate through teamwork climate (index of moderation: b=0.083, bias corrected 95% CI 0.044 to 0.120) but not through emotional exhaustion or the serial pathway. Subgroup analysis from non-managers on their perception of management was also found to moderate this relationship. CONCLUSION: We found work-life balance to be associated with safety climate through a fully mediated model. The mediation pathways are moderated by self-identified leadership and perceptions of leadership. Understanding the pathways on how work-life balance influences safety climate provides an explanatory model that can be used when designing effective interventions for implementation in system-based approaches to improve patient safety culture in hospital settings.

Development of the Joint Commission of Taiwan's Smart Healthcare Standard.

It is well known that information technology (IT) can play a pivotal role in enhancing healthcare quality and patient safety. The use of computational science to enhance the capabilities of hospital information systems helps deliver enhanced healthcare quality. "Smart healthcare" has become a popular term, reflecting the level of IT involvement in healthcare services. However, each hospital has a different level of IT development, and no clear definition of smart healthcare exists. In this study, we aimed to develop and validate a survey standard to evaluate the level of IT involvement in hospitals. The quality improvement task force of the Joint Commission of Taiwan (QITF-JCT) conducted a systematic literature review to identify the key elements of major healthcare IT functions. The modified Delphi technique was used to review the importance and appropriateness of these elements through an expert panel, and the JCT Smart Healthcare Standard version 1.0 (JCT-SHS 1.0) was drafted. A total of 40 healthcare quality improvement campaign (HQIC) application projects in 2018 were selected for evaluating nine key dimensions of hospital functions: security, digitization, automation, interconnection, connectivity, interoperability, mobility, computation, and artificial intelligence. The standard can be used smart hospital evaluation and executed by two experts by on-site evaluation and rating as three-level scale (norm, excellent, and innovative). The internal consistency and inter-rater reliability were investigated using Cronbach's α and kappa statistics, respectively. This standard was evaluated by using 40 HQIC application projects. The Cronbach's α values were in the range of 0.74-0.92, indicating the good internal consistency of the JCT-SHS 1.0 among the nine IT dimensions. The kappa correlation coefficients were 0.68 for security (p = 0.027), 0.47 for digitization (p = 0.042), 0.21 for automation (p = 0.048), 0.82 for interconnection (p = 0.014), 0.35 for connectivity (p = 0.036), 0.28 for interoperability (p = 0.042), 0.71 for mobility (p = 0.016), 0.47 for computation (p = 0.029), and 0.34 for artificial intelligence (p = 0.033), revealing moderate inter-rater reliability. The validation data indicated that the JCT-SHS 1.0 is a consistent and reliable instrument for evaluating the levels of IT development in the hospitals. Healthcare providers, external accreditation bodies, and policymakers may use the JCT-SHS 1.0 to assess and plan their organizational and system-wise IT strategy.

The Potential Risk Factors for Mortality in Patients After In-Hospital Cardiac Arrest: A Multicenter Study.

Background and Purpose: In-hospital cardiac arrest (IHCA) has high mortality rate, which needs more research. This multi-center study aims to evaluate potential risk factors for mortality in patients after IHCA. Methods: Data for this study retrospectively enrolled IHCA patients from 14 regional hospitals, two district hospitals, and five medical centers between 2013 June and 2018 December. The study enrolled 5,306 patients and there were 2,871 patients in subgroup of intensive care unit (ICU) and emergency room (ER), and 1,894 patients in subgroup of general wards. Results: As for overall IHCA patients, odds ratio (OR) for mortality was higher in older patients (OR = 1.69; 95% CI:1.33-2.14), those treated with ventilator (OR = 1.79; 95% CI:1.36-2.38) and vasoactive agents (OR = 1.88; 95% CI:1.45-2.46). Whereas, better survival was reported in IHCA patients with initial rhythm as ventricular tachycardia (OR = 0.32; 95% CI: 0.21-0.50) and ventricular fibrillation (OR = 0.26; 95% CI: 0.16-0.42). With regard to ICU and ER subgroup, there was no mortality difference among different nursing shifts, whereas for patients in general wards, overnight shift (OR = 1.83; 95% CI: 1.07-3.11) leads to poor outcome. Conclusion: For IHCA patients, old age, receiving ventilator support and vasoactive agents reported poor survival. Overnight shift had poor survival for IHCA patients in general wards, despite no significance in overall and ICU/ER subgroups.

Comparison of Patient Safety Incident Reporting Systems in Taiwan, Malaysia, and Indonesia.

OBJECTIVES: Incident reporting is one of the tools used to improve patient safety that has been widely used in health facilities in many countries. Incident reporting systems provide functionality to collect, analyze, and disseminate lessons learned to the wider community, whether at the hospital or national level. The aim of this study was to compare the patient safety incident reporting systems of Taiwan, Malaysia, and Indonesia to identify similarities, differences, and areas for improvement. METHODS: We searched the official Web sites and homepages of the responsible leading patient safety agencies of the three countries. We reviewed all publicly available guidelines, regulatory documents, government reports that included policies, guidelines, strategy papers, reports, evaluation programs, as well as scientific articles and gray literature related to the incident reporting system. We used the World Health Organization components of patient safety reporting system as the guidelines for comparison and analyzed the documents using descriptive comparative analysis. RESULTS: Taiwan had the most incidents reported, followed by Malaysia and Indonesia. Taiwan Patient Safety Reporting (TPR) and the Malaysian Reporting and Learning System had similar attributes and followed the World Health Organization components for incident reporting. We found differences between the Indonesian system and both of TPR and the Malaysian system. Indonesia did not have an external reporting deadline, analysis and learning were conducted at the national level, and there was a lack of transparency and public access to data and reports. All systems need to establish a clear and structured incident reporting evaluation framework if they are to be successful. CONCLUSIONS: Compared with TPR and Malaysian system, the Indonesian patient safety incident reporting system seemed to be ineffective because it failed to acquire adequate national incident reporting data and lacked transparency; these deficiencies inhibited learning at the national level. We suggest further research on the implementation at the hospital level to see how far national guidelines and policy have been implemented in each country.

An Application of Item Response Theory to Scoring Patient Safety Culture Survey Data.

Patient safety culture is important in preventing medical errors. Thus, many instruments have been developed to measure it. Yet, few studies focus on the data processing step. This study, by analyzing the Chinese version of the Safety Attitudes Questionnaire dataset that contained 37,163 questionnaires collected in Taiwan, found critical issues related to the currently used mean scoring method: The instrument, like other popular ones, uses a 5-point Likert scale, and because it is an ordinal scale, the mean scores cannot be calculated. Instead, Item Response Theory (IRT) was applied. The construct validity was satisfactory and the item properties of the instrument were estimated from confirmatory factor analysis. The IRT-based domain scores and mean domain scores of each respondent were estimated and compared. As for resolution, the mean approach yielded only around 20 unique values on a 0 to 100 scale for each domain; the IRT method yielded at least 440 unique values. Meanwhile, IRT scores ranged widely at each unique mean score, meaning that the precision of the mean approach was less reliable. The theoretical soundness and empirical strength of IRT suggest that healthcare institutions should adopt IRT as a new scoring method, which is the core step of processing collected data.

Improvements in patient safety culture: a national Taiwanese survey, 2009-16.

OBJECTIVE: To assess national trends in patient safety culture in Taiwan. DESIGN: A safety attitudes questionnaire (SAQ) was distributed to 144 hospitals from 2009 to 2016 (n = 392 341). SETTING: Taiwan's medical centers, regional hospitals and community hospitals. PARTICIPANTS: Hospital staff in Taiwan. INTERVENTIONS: None. MAIN OUTCOME MEASURES: 5-point Likert scale to assess changes in patient safety culture dimensions (teamwork, safety climate, job satisfaction, stress recognition, management and working conditions) converted to positive response rate (percentage of respondents who answered slightly agree or strongly agree on Likert scale). RESULTS: Dimensions for patient safety culture significantly increased in Taiwan over a period of 8 years, with an all-composite improvement in positive response rate of 4.6% (P < 0.001). Regional hospitals and community hospitals registered an all-composite improvement of 6.7 and 7.0%, respectively, while medical centers improved by 4.0%. Improvements for regional and community hospitals primarily occurred in teamwork (regional hospitals, 10.4% [95% confidence interval [CI], 10.2-10.6]; community hospitals, 8.5% [95% CI, 8.0-9.0]) and safety climate (regional hospitals, 11.1% [95% [CI], 10.9-11.4]; community hospitals, 11.3% [95% CI, 10.7-11.8]) (P < 0.001, all differences). Compared with nurses (5.1%) and pharmaceutical staff (10.6%), physicians improved the least (2.0%). Improvements for nurses and pharmacists were driven by increases in perceptions of teamwork (nurses, 9.8% [95% CI, 9.7-10.0]; pharmaceutical staff, 14.2% [95% CI, 13.4-14.9]) and safety climate (nurses, 9.0% [95% CI, 8.8-9.1]; pharmaceutical staff, 16.4% [95% CI, 15.7-17.2]) (P < 0.001, all differences). At study end, medical centers (55.1%) had greater all-composite measurements of safety culture than regional hospitals (52.4%) and community hospitals (52.2%) while physicians (63.7%) maintained greater measurements of safety culture than nurses (52.1%) and pharmaceutical staff (56.6%). CONCLUSION: These results suggest patient safety culture improved in Taiwan from 2009 to 2016.

Impact of disease-specific care certification on clinical outcome and healthcare performance of myocardial infarction in Taiwan.

BACKGROUND: The relationship between certification for specific disease care and clinical outcome was not well known. Previous studies regarding the effect of certification for acute stroke centers were limited by their cross-sectional design. This study aimed to investigate the effect of disease-specific care (DSC) certification on healthcare performance and clinical outcome of acute myocardial infarction (AMI). METHODS: This retrospective, longitudinal, controlled study was performed by analyzing the nationwide Taiwan Clinical Performance Indicators dataset from 2011 to 2018. Hospitals undergoing DSC certification for coronary care and reporting AMI indicators 1 year before, during, and 1 year after certification were included in group C, whereas hospitals not seeking DSC certification but reporting AMI indicators during the same period were included in group U. The primary endpoint was in-hospital mortality of AMI. RESULTS: In total, 20 hospitals (9 in group C and 11 in group U) and up to 16 173 AMI cases were included for analysis. In-hospital mortality was similar between both groups at baseline. However, the in-hospital mortality was significantly improved during and after certification periods in comparison with that at baseline in group C (6.8% vs 8.4%, p = 0.04; 6.7% vs 8.4%, p = 0.02), whereas there was no significant change in group U, resulting in a statistically significant difference between both groups during and after certification periods (odds ratio = 0.74 [95% CI = 0.60-0.91] and 0.78 [95% CI = 0.64-0.96]). Compared with group U, the improvement in healthcare performance indicators, such as door-to-electrocardiography time <10 minutes, blood testing for low-density lipoprotein cholesterol level, prescribing a beta-blockade or a P2Y12 receptor inhibitor during hospitalization, prescribing a statin on discharge, and consultation for cardiac rehabilitation, was significant in group C. CONCLUSION: The current study demonstrated the beneficial effect of DSC certification on clinical outcome of AMI probably mediated through quality improvement during the healthcare process.

The Hospital Patient Safety Culture Survey: Reform of Analysis and Visualization Methods.

Understanding the topography of hospital safety culture is vital for developing, implementing, and monitoring the effectiveness of tailored safety programs. Since 2009, the Chinese version of the Safety Attitudes Questionnaire (SAQ-C) has been introduced and administered to providers in many Taiwanese hospitals. The mean percentage of SAQ survey respondents who demonstrate attitudinal agreement within each of the SAQ domains, the percent agreement (PA) score, is used worldwide as the main parameter of safety culture surveys. However, several limitations within PA scoring have been identified. Our study sought to improve scoring methodology and develop a new graph layout for cultural topography presentation. A total of 37,163 responses to a national SAQ-C administration involving 200 Taiwan hospitals were retrospectively analyzed. To understand the central tendency and spread of safety culture scores across all participating hospitals, the median and interquartile range (IQR) of PA scores to the SAQ's teamwork domain were calculated, plotted, and named "safety culture grid." Study results denote limitations in the current PA scoring scheme, suggest SAQ analysis modification, and introduce a visualization graph layout that can provide richer information about safety culture dissemination than that available from currently utilized tools.

The gap between currently available evidence and awareness in clinical practice of wound care: It is the time to shower earlier.

BACKGROUND: A postoperative water-forbidden strategy has been used for many decades. However, evidence shows that early contact with water postoperatively does not increase the infection rate. Our study evaluated the gap between currently available evidence and awareness in clinical practice of postoperative wound care. METHODS: We conducted a systematic review to compare the outcomes between postoperative water-contact and water-forbidden groups. PubMed, EMBASE, and Cochrane databases were searched. A meta-analysis was conducted to calculate a pooled effect size by using random-effects models. On the basis of pooling results, a questionnaire survey was conducted to evaluate the gap from systematic review to clinical practice by clinical staff and patients. RESULTS: We reviewed 12 trials including 4,086 patients. Incidence of infection and wound complications did not differ significantly between water-contact and water-forbidden groups. Satisfaction was significantly higher in water-contact group than in water-forbidden group (risk ratio: 17.33; 95% confidence interval, 11.11-27.03). A survey of clinicians showed that awareness, acceptance of the evidence, and the current water-contact strategy differed among departments. However, many clinicians showed no willingness to apply the water-contact strategy for various reasons. A survey of patients showed low awareness of the issue and variety in willingness to contact water. CONCLUSION: Water-forbidden strategy causes inconvenience to patients. However, a majority of patients and clinicians still hesitated to apply the early water-contact strategy, even after viewing the results of the current review. Establishment of local clinical practice guidelines, advocacy from authorities, and promotion by social media for this strategy are warranted.

Shared decision making in Taiwan.

The paper aims to introduce the current status of shared decision making (SDM) in Taiwan under its mixed health care system and single-payer health insurance system. With experiences in promoting both evidence based medicine and patient safety, the Joint Commission of Taiwan has implemented a nationwide SDM program under the aegis of the Ministry of Health and Welfare since 2016, incorporating multiple approaches such as developing patient decision aids (PDAs), executing the Medical Decision Aids Campaign, establishing a SDM platform, and integrating SDM in clinical practice. In this article, we share the positive and negative responses to the SDM program from hospitals, health care providers, and patients.

Quality Improvement in Acute Ischemic Stroke Care in Taiwan: The Breakthrough Collaborative in Stroke.

In the management of acute ischemic stroke, guideline adherence is often suboptimal, particularly for intravenous thrombolysis or anticoagulation for atrial fibrillation. We sought to improve stroke care quality via a collaborative model, the Breakthrough Series (BTS)-Stroke activity, in a nationwide, multi-center activity in Taiwan. A BTS Collaborative, a short-term learning system for a large number of multidisciplinary teams from hospitals, was applied to enhance acute ischemic stroke care quality. Twenty-four hospitals participated in and submitted data for this stroke quality improvement campaign in 2010-2011. Totally, 14 stroke quality measures, adopted from the Get With The Guideline (GWTG)-Stroke program, were used to evaluate the performance and outcome of the ischemic stroke patients. Data for a one-year period from 24 hospitals with 13,181 acute ischemic stroke patients were analyzed. In 14 hospitals, most stroke quality measures improved significantly during the BTS-activity compared with a pre-BTS-Stroke activity period (2006-08). The rate of intravenous thrombolysis increased from 1.2% to 4.6%, door-to-needle time ≤60 minutes improved from 7.1% to 50.8%, symptomatic hemorrhage after intravenous thrombolysis decreased from 11.0% to 5.6%, and anticoagulation therapy for atrial fibrillation increased from 32.1% to 64.1%. The yearly composite measures of five stroke quality measures revealed significant improvements from 2006 to 2011 (75% to 86.3%, p<0.001). The quarterly composite measures also improved significantly during the BTS-Stroke activity. In conclusion, a BTS collaborative model is associated with improved guideline adherence for patients with acute ischemic stroke. GWTG-Stroke recommendations can be successfully applied in countries besides the United States.

Effectiveness of national evidence-based medicine competition in Taiwan.

BACKGROUND: Competition and education are intimately related and can be combined in many ways. The role of competition in medical education of evidence-based medicine (EBM) has not been investigated. In order to enhance the dissemination and implementation of EBM in Taiwan, EBM competitions have been established among healthcare professionals. This study was to evaluate the impact of competition in EBM learning. METHODS: The EBM competition used PICO (patient, intervention, comparison, and outcome) queries to examine participants' skills in framing an answerable question, literature search, critical appraisal and clinical application among interdisciplinary teams. A structured questionnaire survey was conducted to investigate EBM among participants in the years of 2009 and 2011. Participants completed a baseline questionnaire survey at three months prior to the competition and finished the same questionnaire right after the competition. RESULTS: Valid questionnaires were collected from 358 participants, included 162 physicians, 71 nurses, 101 pharmacists, and 24 other allied healthcare professionals. There were significant increases in participants' knowledge of and skills in EBM (p<0.001). Their barriers to literature searching and forming answerable questions significantly decreased (p<0.01). Furthermore, there were significant increases in their access to the evidence-based retrieval databases, including the Cochrane Library (p<0.001), MD Consult (p<0.001), ProQuest (p<0.001), UpToDate (p=0.001), CINAHL (p=0.001), and MicroMedex (p=0.024). CONCLUSIONS: The current study demonstrates a method that successfully enhanced the knowledge of, skills in, and behavior of EBM. The data suggest competition using PICO queries may serve as an effective way to facilitate the learning of EBM.

Learning from Taiwan patient-safety reporting system.

OBJECTIVE: The aim of this study is to create a national database to record incidents that endanger patient safety. We try to identify systemic problems in hospitals in order to avoid safety incidents in the future and improve the quality of healthcare. METHOD: The Taiwan Patient Safety Reporting System employs a voluntary notification model. We define 13 types of patient safety incidents, and the reports of different types of incidents are recorded using common terminology. Statistical analysis is used to identify the incident type, time of occurrence, location, person who reported the incident, and possible reasons for frequently occurring incidents. RESULTS: There were 340 hospitals that joined this program from 2005 to 2010. Over 128,271 incident events were reported and analyzed. The three most common incidents were drug-related incidents, falls, and endo tube related incidents. By analyzing the time of occurrence of incidents, we found that drug-related incidents usually occurred between 8 and 10 am. Falls and endo tube incidents usually occurred between 4 and 6 am. The most common location was wards (57.6%), followed by intensive care areas (13.5%), and pharmacies (9.1%). Among hospital staff, nurses reported the highest number of incidents (68.9%), followed by pharmacists (14.5%) and administrative staff (5.5%). The number of incidents reported by doctors was much lower (1.2%). Most staff members who reported incidents had been working for less than five years (58.1%). CONCLUSION: The unified reporting system was found to improve the recording and analysis of patient safety incidents. To encourage hospital staff to report incidents, hospitals need to be assisted in establishing an internal report and management system for safety incidents. Hospitals also need a protection mechanism to allow staff members to report incidents without the fear of punishment. By identifying the root causes of safety incidents and sharing the lessons learned across hospitals is the only way such incidents can be stopped from happening again.

Is it enough to set national patient safety goals? An empirical evaluation in Taiwan.

OBJECTIVE: In 2004, the Taiwan Department of Health set the national patient safety goals. To date, however, there has been no evaluation of these goals. This study aimed to develop a method to evaluate the status of the national patient safety goals in Taiwan. DESIGN: A cross-sectional questionnaire surveys to measure achievements on Taiwan's national patient safety goals. This survey was also followed up with an onsite audit to ensure accuracy. SETTING: All hospitals in Taiwan. PARTICIPANTS: A total of 361 hospitals in Taiwan respond to questionnaire survey and 80 randomly selected hospitals for onsite audit. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Average scores on achievements of the national patient safety goals. RESULTS: Among the 516 hospitals to which the questionnaire was sent, 361 (70%) responded. A total of 80 hospitals were randomly selected according to geographic location and size for onsite audit. The results show that the longer the period of implementation, the higher the average scores on achievements of the goals. After stratified analysis by hospital size, the large hospitals were found to have a higher average score in every goal, especially in the new goals. Furthermore, in terms of the difference between self-report results and the onsite audit, the score in the self-report was higher than the score given by experts upon onsite audit; however, they were similar. Most items were approximately the same in the self-report score and the onsite judgment, and those that differed were merely either one rank higher or lower. CONCLUSION: The self-report questionnaire combined with an onsite audit appears to be a promising approach for measuring scores on achievements of the national patient safety goals. The Department of Health could conduct this program annually to evaluate the progress and propose coping strategies.

Hospital safety culture in Taiwan: a nationwide survey using Chinese version Safety Attitude Questionnaire.

BACKGROUND: Safety activities have been initiated at many hospitals in Taiwan, but little is known about the safety culture at these hospitals. The aims of this study were to verify a safety culture survey instrument in Chinese and to assess hospital safety culture in Taiwan. METHODS: The Taiwan Patient Safety Culture Survey was conducted in 2008, using the adapted Safety Attitude Questionnaire in Chinese (SAQ-C). Hospitals and their healthcare workers participated in the survey on a voluntary basis. The psychometric properties of the five SAQ-C dimensions were examined, including teamwork climate, safety climate, job satisfaction, perception of management, and working conditions. Additional safety measures were asked to assess healthcare workers' attitudes toward their collaboration with nurses, physicians, and pharmacists, respectively, and perceptions of hospitals' encouragement of safety reporting, safety training, and delivery delays due to communication breakdowns in clinical areas. The associations between the respondents' attitudes to each SAQ-C dimension and safety measures were analyzed by generalized estimating equations, adjusting for the clustering effects at hospital levels. RESULTS: A total of 45,242 valid questionnaires were returned from 200 hospitals with a mean response rate of 69.4%. The Cronbach's alpha was 0.792 for teamwork climate, 0.816 for safety climate, 0.912 for job satisfaction, 0.874 for perception of management, and 0.785 for working conditions. Confirmatory factor analyses demonstrated a good model fit for each dimension and the entire construct. The percentage of hospital healthcare workers holding positive attitude was 48.9% for teamwork climate, 45.2% for perception of management, 42.1% for job satisfaction, 37.2% for safety climate, and 31.8% for working conditions. There were wide variations in the range of SAQ-C scores in each dimension among hospitals. Compared to those without positive attitudes, healthcare workers with positive attitudes to each SAQ dimension were more likely to perceive good collaboration with coworkers, and their hospitals were more likely to encourage safety reporting and to prioritize safety training programs (Wald chi-square test, p < 0.001 for all). CONCLUSIONS: Analytical results verified the psychometric properties of the SAQ-C at Taiwanese hospitals. The safety culture at most hospitals has not fully developed and there is considerable room for improvement.