Circulation 36,825 • Volume 18, No. 1 • Spring 2003

Stanford-VA Palo Alto Survey Examines Health Care Workers’ Attitudes Toward Safety

Sara J. Singer, MBA

If the corporate scandals of 2002 teach anything, it is that corporate culture plays a powerful role in determining the actions of employees. In this regard, culture in health care organizations is similar. The “safety culture” of a hospital may be a key determinant of its ability to achieve high levels of patient safety. Creating and maintaining a strong, organizational culture of safety is an important responsibility of senior management. In practice, it is difficult for senior managers to ensure that the values and expectations necessary to create a safe culture permeate the norms and routines of behavior among front-line personnel. Findings from a survey of personnel in 15 hospitals suggest safety culture in hospitals could be improved. There is wide variation among hospitals, and perceptions of safety culture differ significantly between senior managers and front-line personnel.

Defining a Culture of Safety

What is a culture of safety? This is a difficult question, and there is little evidence available about the impact of various aspects of culture upon medical errors. Given the complexity of health care organizations and a legal environment that hinders openness about errors, many managers are unsure about how to implement strategies to improve safety culture, despite significant public attention to patient safety.

Evidence from other high hazard industries suggests that organizations need a “culture of safety” to minimize errors.1-3 The nuclear power industry has gone so far as to adopt safety culture as a formal element of nuclear power safety.4,5 Components of a safety culture include a commitment to safety as the primary priority; the necessary resources, incentives, and rewards for safety; openness about errors and problems; commitment to organizational learning; cohesion, loyalty, and teamwork among staff; and respect for senior management.6,7

Measuring Safety Culture

Creating a culture of safety in health care institutions is challenging, and some institutions are more successful than others. There is no gold standard for determining if a given organization demonstrates an active safety culture. Surveys have measured specific aspects of culture in health care organizations, such as teamwork and production pressure, or assessed specific high-hazard work units, such as operating rooms or intensive care units.8,9 Some have classified institutions into pre-defined cultural types10,11 and have tried to correlate cultural types or dimensions with specific care practices or outcomes.12-15

The Stanford-VA PSCI Survey

In contrast, our team of investigators from Stanford University and the VA Palo Alto Health Care System Patient Safety Center of Inquiry (PSCI) designed and implemented a survey in 2001 with support from the Agency for Healthcare Research and Quality. The purpose of this study was to study employee attitudes toward patient safety and patient safety experiences among 15 diverse hospitals around California. Participating hospitals were selected by investigators for their initiative in promoting patient safety within their own institution, their diversity in size, ownership type, hospital system affiliation, and their geographic location (mostly in northern California). The survey examined ways in which attitudes vary by hospital, job class, and clinical status. By comparing our survey results to results from a survey conducted by the Naval Postgraduate School, we also studied the extent to which health care safety culture differs from a recognized high reliability organization, naval aviation. The hospital survey involved all hospital employees, including senior management, physicians, and other employees and multiple hospitals of different types. Nearly 50% of hospital personnel responded. The comparable Navy questionnaire contained 23 closely matched questions and similarly surveyed from 1998 to 2001 all personnel in 226 squadrons, with an 85% response.

The overall results were mixed. The good news is that a majority of hospital employees responded in ways indicative of a culture of safety. The bad news is that a substantial minority of respondents gave a response suggesting the absence of a culture of safety (a “problematic response”). Hospital employees also reported a small but appreciable incidence of unsafe acts.

Clinicians, Nurses Most Pessimistic

Average overall problematic response among hospital employees was 18%. Another 18% of responses were neutral, also potentially suggesting the absence of safety culture. Those studying high reliability organizations raise concerns when problematic attitudes and experiences exceed about 10%. Hospitals surveyed failed to meet this threshold for 21 out of 30 questions. A third of hospital personnel surveyed, for example, indicated they feel they are not rewarded for taking quick action to identify a serious mistake, and almost as many believed they would be disciplined if a mistake they made was discovered. Almost a third felt it was not hard for doctors or nurses to hide serious mistakes. Eight percent of those surveyed admitted to doing something unsafe for the patient in the last year, and far more said they had witnessed someone else doing something that appeared unsafe. Many employees felt significant production pressure.

Responses by senior managers were almost always more optimistic than those by front-line workers. Front-line workers, for example, were almost twice as likely to believe that senior managers did not have a clear understanding of the risks associated with patient care, and were more than twice as likely to feel they are not rewarded for taking quick action to identify a serious mistake. Not surprisingly given their routine participation in patient care, the response by clinicians was more pessimistic than non-clinicians. Among clinicians, nurses were the most pessimistic.

There was wide variation among participating hospitals. With few exceptions, participating hospitals were neither always better nor worse than the average, suggesting opportunities for improvement and learning at all of them.

In comparison to navy aviators, the hospital results are even more concerning. Hospital personnel reported more than three times more problematic response overall than navy aviators. Problematic response among hospital workers on individual questions was up to 12 times greater than among aviators. Hospital professionals working directly in high-hazard domains, such as the operating room or emergency department, where safety culture should be strongest, gave an even higher problematic response than hospital workers overall (22%). Of hospital personnel, these professionals would be expected to have work experiences most analogous to those of the aviators.

Improving Safety Culture

While we do not yet know the extent to which safety culture correlates with patient outcomes, common sense and examples from other industries suggest that hospitals and perhaps other health care organizations should make an effort to improve safety culture. After reporting results individually to the executive teams of participating hospitals, Stanford and VA PSCI investigators convened hospital and safety managers to discuss ways to address the problem.

The most compelling strategy presented for addressing safety culture was to create a “reporting for learning” process. This strategy acknowledges that effective reporting requires more than establishing a phone number for employees to call to recommend improvements. Some of our hospitals had tried this approach, only to find themselves overwhelmed by suggestions to which they could not respond. Phone volume peaked quickly then rapidly declined as the phone line got a reputation for being a dead end for ideas. Participating hospitals identified the following features of a successful reporting process:

  • Leadership: Hospital leaders must establish safety as a priority. One hospital required every team to report its analysis directly to senior managers.
  • A learning and improvement cycle: Analysis focuses on systems rather than individuals and is non-punitive. Analysis should include trend and aggregate data.
  • Accountability: Improvement team members must be held accountable for identifying effective solutions. One hospital required improvement teams to send their action plans directly to the CEO for sign-off.
  • Timely feedback: The system must feed back useful information to front-line workers, especially those who report the problem, and must do so in a timely manner. One hospital set and met a 45-day limit by which a senior manager would notify an employee of action taken in response to a problem report.
  • Incentives and rewards for pursuing safety: A simple, but powerful reward implemented by one hospital was a formal letter of thanks from the Chief Executive.
  • Buy-in: An organization should use education and communication strategies to broaden the “circle of believers” beyond the CEO and a few safety champions. Some opportunities include new employee orientation, mandatory patient safety training, just-in-time root cause analysis participant training, as well as informal interactions. Employee newsletters and email “safety-grams” can be used to discuss lessons learned and to share improvements and recommended practices.
  • Realistic goals: System improvements must be resource sensitive and not redundant.

Project investigators have developed another promising intervention to address the apparent difference of opinion about safety culture between senior managers and front-line workers. Borrowing from “managing by walking around” strategies popular among for-profit corporate executives, the VA Palo Alto PSCI has designed “Inward Bound: Workplace Expeditions for Health Care Executives.” Inward Bound provides a structured curriculum to help hospital executives spend time in hospital workplaces to enable them to learn about what is really happening in their hospital, to build relationships with front-line workers, and to foster an open safety culture. The program intends to make workplace visits a regular and on-going part of safety leadership.

These and other interventions are likely necessary to improve safety culture in hospitals and to achieve safety cultures consistent with high reliability organizations.

For more information about the Patient Safety Consortium or the hospital culture survey, see the “Best Practices for Patient Safety” website at: or contact Sara Singer at: [email protected]. If you would like to participate in Inward Bound contact David Gaba at [email protected].

Sara Singer is Executive Director of the Center for Health Policy and is also a Senior Research Scholar at Sanford University.


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