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Microsoft PowerPoint - Developing a safety culture in Healthcare R


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									     Developing a Safety Culture in Healthcare

                      Rhona Flin,
        Industrial Psychology Research Centre
            Patient Safety Research Group

                        VMIA, Melbourne, September 2009

                Welcome to the Industrial Psychology Research Centre. The centre specialises in the application
                of psychology to high reliability workplaces.

                The group has worked with the oil industry since 1986, and regularly engage in consultancy
                projects. We are currently working with the offshore oil industry, civil aviation, nuclear power
                generation, surgery, emergency services, conventional power generation and transportation.

                Interests of the centre include:

                •Accident analysis
                •Incident command
                •Occupational stress
                •Emergency decision making
                •Crew Resource Management
                •Measuring and managing safety culture/climate
                •Human factors aspects of safety management and emergency response

Clients include: Agip, AKER Offshore (Norway), AMEC, Amerada Hess, AMOCO, British Energy, BHP, BP,
Brown & Root, Chevron, Civil Aviation Authority, Coflexip Stena Offshore, Conoco Phillips, Defence Evaluation
and Research Agency (DERA), EC (DGTREN), First Group, Halliburton, Health & Safety Executive, KBR, Kerr
McGee, National Power, NHS, Powergen, Royal College of Surgeons, Salamis SGB, Schlumberger, SCPMDE,
Shell, Talisman, Texaco, Total Fina Elf, Transocean Sedco Forex, UBS Warburg & UK Nuclear Imc.

    Safety Culture FAQs

•   What is it?
•   Why is it important?
•   How does it influence safety outcomes?
•   How do you diagnose (measure) it?
•   How do you treat (enhance) it?

          What is safety culture?
Term introduced following Chernobyl accident
  in nuclear industry (1986)
    • The necessary framework that prioritises safety
      within the organisation which is the responsibility
      of the management hierarchy

    • The attitude of staff at all levels in responding to
      and benefiting from the framework

     Zohar, 1980 ‘Safety Climate’

“The perceptions of policies
 and procedures which specify
 the priority given to safety”
 (Zohar & Luria, 2005)

       Why is culture important?
 • Culture (national, professional and
   organizational) influences human
 • Culture therefore impacts on work
   behaviour, management practices and
   thus can effect the performance of

    Safety culture and behaviour

• Worksites with more positive safety culture
  show lower accident rates
• Workers who perceive their supervisors/
  managers to be more committed to safety
  engage in more safety-related behaviours and
  fewer risk taking behaviours
• Motivational mechanism linking culture to
  behaviour – expectations/ rewards linked to
  behaviour of managers/ supervisors (Zohar, 2002)
( Landy & Conte 2006)

    The Bristol Royal Infirmary Inquiry
•   BBC News    November 1999
•   Money came first, baby inquiry told

•   Stephen Bolsin blew the whistle at Bristol

•   The Bristol heart scandal whistleblower has told a
    public inquiry that managers ignored him because
    they thought they might lose government cash.
•   Consultant anaesthetist Dr Stephen Bolsin said
    that senior staff wanted to maintain the hospital's
    designation as a specialist children's heart facility.
•   He told the inquiry: "The analogy that was used
    was of a train where occasional passengers were
    falling off, and the train had to keep moving in
    order to attract funding.
•   "That was one of my concerns about the
    subjugation of patient safety by reasons of funding
    and continued activity in high risk areas."
•   Former Bristol Royal Infirmary chief executive Dr
    John Roylance, later struck off by the General
    Medical Council, was "dismissive" of his attempts
    to bring the high death rates to his attention, he
•   And surgeon James Wisheart, who was also
    banned from practising, was angry that he had
    discussed the unit's performance with other

   Kennedy (2006) NHS England

“Safety still struggling to be on the agenda.
 Strong leadership needed.”

  Surgical safety culture (Flin et al, 2006)

                                     CONSULTANT    TRAINEE
                                      SURGEONS    SURGEONS
                                        agree       agree
    Pre-list briefing is important       37%        51%
    for safety
    Junior members should                90%        77%
    question decisions made by
    senior OR members
    Encouraged to report                 41%        44%
    incidents I observe
    In favour of postoperative           44%        72%

   Surgeons’ view of their Trust’s
       commitment to safety
• “If I were to fail in the following areas which would
   concern my NHS Trust most?” (% surgeons
   ranking as first):
                     Patient safety 42%
                     Reduce waiting lists 27%
                     Saving costs 15%
                     Trust’s reputation 16%
i.e. 58% of surgeons think their NHS Trust is
   primarily concerned with something other than
   patient safety
138 consultant surgeons in Scotland
(Flin, Yule, Paterson-Brown & Maran, The Surgeon, 2006)

  Organisational factors associated with
      a safety culture (HSE, 1999)
• Senior management
• Management style
• Visible management
• Good communication
  between all levels of
  employee [management
• A balance of health and
  safety and production
  goals [management

      Organisational factors
  associated with a safety culture
           (HSE, 1999)

“Senior Management Commitment - crucial
  to a positive health and safety culture. It is
  best indicated by the proportion of
  resources (time, money, people) and
  support allocated to health and safety
  management and by the status given to
  health and safety” (p 46).

 Nuclear Industry: Safety Culture

‘On a personal basis, managers at the most senior
  level demonstrate their commitment by their
  attention to regular review of the processes that
  bear on nuclear safety, by taking direct interest in
  the more significant questions of nuclear safety or
  product quality as they arise, and by frequent
  citation of the importance of safety and quality
  in communications to staff.’

   (International Atomic Energy Authority, 1997)


  Company                      MOTIVATION                   UNSAFE
Commitment to                                                                       PATIENT
Safety                                                 Errors- loss of SA, poor      INJURY
                            Expectations regarding     decision making etc
                                                       Not taking precautions
Department/                                            Rule Breaking
                            Supervisor Leadership      Risk Taking
   Unit                     Style                                                   WORKER
                                                       Not speaking up              INJURY
Supervisor                                             Not reporting incidents/
Commitment to               Peer Pressure              near misses
Work Pressure,
Safety System

                 Flin (2004) Proposed Model of Safety Climate and Injury Outcomes
                 Based on Zohar (2003); Neal & Griffin (2004)

          Why Attempt to Measure?
• Diagnosis – level of safety, characteristics
  of prevailing culture
• Identify problems/ problem areas
• Establish baseline
• Track changes
• Evaluate interventions
• Benchmark @ local, national, international

                       Offshore oil platforms:
                     benchmarking safety culture
4.50                                                                   Satisfaction
                                                                       with safety
4.30                                                                   measures

3.90                                                                   Perceived
3.70                                                                   commitment to

3.30                                                                   Willingness to
                                                                       report incidents

2.50                                                                   competence
       B/99   C/99    D/99   E/99   F/99   G/99   H/99   K/99   L/99

       Safety culture questionnaires

                 Psychometric criteria
• Construct validity
     – Content validity (inc theoretical basis)
     – Internal structure
     – Criterion validity
• Reliability
   – Stability over time
• For analysis – attention to levels & within group
• Flin, Burns, Mearns, Yule & Robertson (2007, QSHC) Review of 12
  hospital safety culture measures shows limited psychometric

Hospital Survey on Patient Safety Culture (AHRQ, USA)
Consists of 42 items measuring 12 dimensions plus 2 single items

‘Unit-level dimensions of safety culture’
• Organizational learning – Continuous improvement
• Teamwork within units
• Non-punitive response to error
• Staffing
• Supervisor/ manager expectation and actions promoting safety
• Communication openness
• Feedback and communication about error

‘Hospital-level dimensions of safety culture’
• Hospital management support for patient safety
• Teamwork across hospital units
• Hospital handoffs [handovers] and transitions

• Overall perceptions of safety
• Frequency of event reporting
• Patient safety grade (of the hospital unit)
• Number of events reported

   Patient Safety Climate in
      Scottish Hospitals
                  Cakil Sarac
    Supervisors: Rhona Flin, Kathryn Mearns
                     School of Psychology

          This work is funded by

Scottish Patient Safety Alliance (2007-2011)

Scottish Patient Safety Programme

            NHSScotland is the first health service in the world to adopt a
            national approach to improving patient safety.

Outcome Aims: Reduce healthcare associated infections
              Reduce adverse surgical incidents
              Reduce adverse drug events
              Improve the organizational and leadership culture on safety

Adverse events in one Scottish acute hospital

Williams, Olsen, Crichton, Flin, et al. (2008). Detection of adverse events in a Scottish hospital using
           a consensus-based methodology. Scottish Medical Journal,53, 426-30.

 • The estimated cost of adverse events in terms of bed days was £69,189
        Scotland wide would cost £297 million per annum

 The proposed sample for the first stage is all clinical staff at one acute
 hospital per Scottish NHS Board
                                                                  Organisations by Region

                                                                  Ayrshire & Arran
                                                                  Dumfries & Galloway
                                                                  Forth Valley
                                                                  Greater Glasgow &
                                                                  Western Isles

 HSOPSC (Hospital Survey on Patient Safety Culture): standardized
 instrument which was developed by the Agency for Healthcare
 Research and Quality (AHRQ) to assess hospital staff opinions about
 patient safety issues, medical error, and event reporting.

       • Covers wide range of safety climate dimensions

       • Provides a more comprehensive report on scale development and
       psychometric properties than the other questionnaires (Flin et al, 2006)

       • Designed both for clinical and non-clinical staff

       • Has been widely used which allows benchmark data

           Author                Country            Sample size           Factor Analysis

AHRQ, 2007                 USA               1437 (21 hospitals)         CFA and EFA
Olsen, 2008                Norway            1919 clinical and non       CFA
                                                clinical staff
Pfeiffer, et al., (2008)   Switzerland       2989 clinical and non       CFA and EFA
                                                clinical staff across
                                                61 services (1
Smiths, et al., 2007       Netherlands       583 clinical and non        EFA
                                                clinical staff across
                                                23 units (8 hospitals)

Waterson, et al., 2008     England           1461 clinical and non       CFA and EFA
                                                clinical staff (3
Sarac, C. & Lajunen, T.,   Turkey            240 clinical staff (10      CFA
    2007                                         hospitals)

Studies using HSOPSC

                      Customisation for Scotland
• in order to customise the instrument for Scottish healthcare system,
  a number of interviews were conducted with healthcare staff

            • demographic questions, job codes and
              incident reporting items had to be adapted for Scotland.

                   • incorporate the NHS Staff Survey (Aston Business School, 2007)
                     job descriptions and also to add the incident reporting items to the
                    original instrument to avoid this confusion.

Safety Behaviour: Healthcare staffs’ safe behaviours were assessed
  by self report items based on Neal and Griffin’s (2000) safety
  compliance and safety participation items.

 Proposed model:

 Safety Climate                     Worker Behaviours                 Worker Injuries
 Supervisor/ manager
 expectation and actions
                                    Safety Compliance
 promoting safety                   Safety Participation              Patient Outcomes
 Teamwork within units
 Non-punitive response to error

 Hospital management support
 for patient safety

  • The procedure for administration of the questionnaires was determined
   in conjunction with each participating Board or hospital.

   • Paper questionnaires / but web-based version were made available

   • Administration February – September 2009.

   • A confidential summary report prepared for each participating hospital.

   • Pilot study was based in one of the smaller hospitals

   Culture – Behaviour Path?

                 Safety            Worker
Manager                          Motivation/         Worker           Unsafe
behaviour        Culture
                                 competence         Behaviour        Or Safe?


         Further information
 Further information

  lists of projects and papers and reports


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