Patient safety climate (PSC) perceptions of frontline staff in acute care hospitals: examining the role of ease of reporting, unit norms of openness, and participative leadership.

BACKGROUND: Increased awareness regarding the importance of patient safety issues has led to the proliferation of theoretical conceptualizations, frameworks, and articles that apply safety experiences from high-reliability industries to medical settings. However, empirical research on patient safety and patient safety climate in medical settings still lags far behind the theoretical literature on these topics. PURPOSE: The broader organizational literature suggests that ease of reporting, unit norms of openness, and participative leadership might be important variables for improving patient safety. The aim of this empirical study is to examine in detail how these three variables influence frontline staff perceptions of patient safety climate within health care organizations. METHODOLOGY: A cross-sectional study design was used. Data were collected using a questionnaire composed of previously validated scales. FINDINGS: The results of the study show that ease of reporting, unit norms of openness, and participative leadership are positively related to staff perceptions of patient safety climate. PRACTICE IMPLICATIONS: Health care management needs to involve frontline staff during the development and implementation stages of an error reporting system to ensure staff perceive error reporting to be easy and efficient. Senior and supervisory leaders at health care organizations must be provided with learning opportunities to improve their participative leadership skills so they can better integrate frontline staff ideas and concerns while making safety-related decisions. Finally, health care management must ensure that frontline staff are able to freely communicate safety concerns without fear of being punished or ridiculed by others.

Staff, space, and time as dimensions of organizational slack: a psychometric assessment.

BACKGROUND: : In the theoretical and research literature, organizational slack has been largely described in terms of financial resources and its impact on organizational outcomes. However, empirical research is limited by unclear definitions and lack of standardized measures. PURPOSE: : The aim of this study was to assess the psychometric properties of a new organizational slack measure in health care settings. METHODS: : A total of 752 nurses and 197 allied health care professionals (AHCPs) employed in seven pediatric Canadian hospitals completed the Alberta Context Tool, an instrument measuring organizational context, which includes the newly developed organizational slack measure. The nine-item, 5-point Likert organizational slack measure includes items assessing staff perceptions of available human resources (staffing), time, and space. We report psychometric assessments, bivariate analyses, and data aggregation indices for the measure. FINDINGS: : The findings indicate that the measure has three subscales (staff, space, and time) with acceptable internal consistency reliability (alphas for staff, space, and time, respectively:.83,.63, and.74 for nurses;.81,.52, and.76 for AHCPs), links theory and hypotheses (construct validity), and is related to other relevant variables. Within-group reliability measures indicate stronger agreement among nurses than AHCPs, more reliable aggregation results in all three subscales at the unit versus facility level, and higher explained variance and validity of aggregated scores at the unit level. PRACTICE IMPLICATIONS: : The proposed organizational slack measure assesses modifiable organizational factors in hospitals and has the potential to explain variance in important health care system outcomes. Further assessments of the psychometric properties of the organizational slack measure in acute and long-term care facilities are underway.

The relationship between organizational leadership for safety and learning from patient safety events.

OBJECTIVE: To examine the relationship between organizational leadership for patient safety and five types of learning from patient safety events (PSEs). STUDY SETTING: Forty-nine general acute care hospitals in Ontario, Canada. STUDY DESIGN: A nonexperimental design using cross-sectional surveys of hospital patient safety officers (PSOs) and patient care managers (PCMs). PSOs provided data on organization-level learning from (a) minor events, (b) moderate events, (c) major near misses, (d) major event analysis, and (e) major event dissemination/communication. PCMs provided data on organizational leadership (formal and informal) for patient safety. EXTRACTION METHODS: Hospitals were the unit of analysis. Seemingly unrelated regression was used to examine the influence of formal and informal leadership for safety on the five types of learning from PSEs. The interaction between leadership and hospital size was also examined. PRINCIPAL FINDINGS: Formal organizational leadership for patient safety is an important predictor of learning from minor, moderate, and major near-miss events, and major event dissemination. This relationship is significantly stronger for small hospitals (<100 beds). CONCLUSIONS: We find support for the relationship between patient safety leadership and patient safety behaviors such as learning from safety events. Formal leadership support for safety is of particular importance in small organizations where the economic burden of safety programs is disproportionately large and formal leadership is closer to the front lines.

Development of a measure of patient safety event learning responses.

OBJECTIVE: To define patient safety event (PSE) learning response and to provide preliminary validation of a measure of PSE learning response. DATA SOURCES: Ten focus groups with front-line staff and managers, an expert panel, and cross-sectional survey data from patient safety officers in 54 general acute hospitals. STUDY DESIGN: A mixed methods study to define a measure of learning responses to patient safety failures that is rooted in theory, expert knowledge, and organizational practice realities. EXTRACTION METHODS: Learning response items developed from the literature were modified and validated in front-line staff and manager focus groups and by an expert panel and second group of external experts. Actual learning responses gleaned from survey data were examined using exploratory factor analyses and reliability analysis. PRINCIPAL FINDINGS: Unique learning response items were identified for minor, moderate, major events, and major near misses by an expert panel. A two-factor model of major event learning response was identified (factor 1=event analysis, factor 2=dissemination/communication of learnings). Organizations engage in greater learning responses following major events than less severe events and, for major events, organizations engage in more factor 1 responses than factor 2 learning responses. CONCLUSIONS: Eleven to 13 items can measure learning responses to PSEs of differing severity. The items are feasible, grounded in theory, and reflect expert opinion as well as practice setting realities. The items have the potential for use to assess current practice in organizations and set future improvement goals.

Categorizing errors and adverse events for learning: a provider perspective.

There is little agreement in the literature as to what types of patient safety events (PSEs) should be the focus for learning, change and improvement, and we lack clear and universally accepted definitions of error. In particular, the way front-line providers or managers understand and categorize different types of errors, adverse events and near misses and the kinds of events this audience believes to be valuable for learning are not well understood. Focus groups of front-line providers, managers and patient safety officers were used to explore how people in healthcare organizations understand and categorize different types of PSEs in the context of bringing about learning from such events. A typology of PSEs was developed from the focus group data and then mailed, along with a short questionnaire, to focus group participants for member checking and validation. Four themes emerged from our data: (1) incidence study categories are problematic for those working in organizations; (2) preventable events should be the focus for learning; (3) near misses are an important but complex category, differentiated based on harm potential and proximity to patients; (4) staff disagree on whether events causing severe harm or events with harm potential are most valuable for learning. A typology of PSEs based on these themes and checked by focus group participants indicates that staff and their managers divide events into simple categories of minor and major events, which are differentiated based on harm or harm potential. Confusion surrounding patient safety terminology detracts from the abilities of providers to talk about and reflect on a range of PSEs, and from opportunities to enhance learning, reduce event reoccurrence and improve patient safety at the point of care.

Learning from preventable adverse events in health care organizations: development of a multilevel model of learning and propositions.

BACKGROUND: Preventable adverse events represent learning opportunities. Indeed, understanding and learning from preventable adverse events are the new organizational imperatives in health care. However, health services researchers note that there is a dearth of research on learning from failure in health care and, in industry, a limited capacity to learn from incidents and failure. PURPOSE: We address the gap between awareness of preventable adverse events and knowledge that relates to how to respond to them effectively. We develop a multilevel model of learning and theorize factors that influence learning from preventable adverse events. METHODOLOGY: Drawing upon theories of organizational learning and organizational behavior, we develop a multilevel model of learning from failure, where perceived characteristics of the events, group composition and dynamics, and the behavioral and structural arrangements of health care organizations are proposed to play important roles. PRACTICAL IMPLICATIONS: Our model highlights factors that facilitate learning from failure and others that impede it. Awareness and attention to these factors can help health care managers extract learning from failures, like preventable adverse events, and may ultimately contribute to reducing the occurrence of preventable adverse events and improving quality of care.