Investigating patient safety culture across a health system: multilevel modelling of differences associated with service types and staff demographics.

OBJECTIVE: To use multilevel modelling to compare the patient safety cultures of types of services across a health system and to determine whether differences found can be accounted for by staffs' professions, organizational roles, ages and type of patient care provided. DESIGN: Application of a hierarchical two-level regression model. SETTING: All services in the South Australian public health system. PARTICIPANTS: Approximately half of the health staff (n = 14 054) in the 46 organizations, classified into 18 types of service, which made up the South Australian public health system. INTERVENTIONS: Staff completed the Safety Attitudes Questionnaire. MAIN OUTCOME MEASURES: Attitudes regarding Teamwork Climate, Safety Climate, Job Satisfaction, Stress Recognition, Perception of Management and Working Conditions in participants' workplaces. RESULTS: All SAQ indices showed statistically significant although modest variations according to service type. However, most of these differences were not accounted for by the differences in the demographic composition of services' staff. Most favourable safety attitudes were found in the breast screening, primary/community health services, community nursing and metropolitan non-teaching hospitals. Poorer cultures were reported in the psychiatric hospital, mental health, metropolitan ambulance services and top-level teaching hospitals. Demographic differences in safety attitudes were observed; particularly, clinical, senior managerial, aged care and older staff held more favourable attitudes. CONCLUSIONS: Differences in staff attitudes have been demonstrated at a macro-level across the type of health services but for the most part, differences could not be explained by staffing composition.

Improving patient safety: the comparative views of patient-safety specialists, workforce staff and managers.

INTRODUCTION: Methods for improving patient safety are predicated on cooperation between healthcare groups, but are the views of health professionals involved in promoting safety shared by other healthcare workforce staff and managers? AIM: To compare patient-safety suggestions from health workforce managerial and staff groups with those of patient-safety specialists. METHOD: Samples of managers (424) and staff (1214) in the South Australian state health system and 131 Australian patient-safety specialists were asked to write suggestions for improving patient safety. Group responses were content analysed and compared. RESULTS: Patient-safety specialists (83.2%) were more likely to make suggestions than were workforce managers (57.8%) or staff (44.1%). Workforce members from clinical professions were more likely than non-clinicians to tender suggestions. No relationship existed between the importance specialists and managers (ρ = -0.062, p = 0.880) and specialists and staff (ρ = -0.046, p = 0.912) attached to nine categories of suggestions. There was a high correlation between the importance that managers and non-managers attached to safety strategies (ρ = 0.817, p = 0.011). Among those who made suggestions, specialists were more likely to suggest implementing reviews and guidelines, and incident reporting. Workforce groups were more likely to recommend increased and improved staffing and staffing conditions, and better equipment and infrastructure. There were no significant differences in the proportions of group members recommending: improving management and leadership; increasing staff safety education and supervision; communication and teamwork; improved patient focus; or tackling specific safety projects. IMPLICATIONS: Differences between safety specialists' and workforce groups' beliefs about how to improve patient safety may impede the successful implementation of patient-safety programmes.

Time spent by health managers in two cultures on work pursuits: real time, ideal time and activities' importance.

OBJECTIVES: We compared health managers' judgements of: (1) the time they spent on nine major work activities, (2) the time they thought they should allocate and (3) the importance they attributed to each pursuit. These and managers' reasons for devoting time to activities were examined in an Anglo and a Confucian-Asian country. METHOD: A questionnaire survey of Australian (n = 251) and Singaporean health managers (n = 340). RESULTS: In both countries, the correlation between judgements of time spent on activities/activities' importance (1 and 3) was significantly less than the correlation between time spent/time that should be spent (1 and 2), which was less than the correlation between time that should be spent/activities' importance (2 and 3). Singaporeans said they devoted more time to some activities but the importance attached to work pursuits and the reasons given for actual time allocation were similar cross-culturally. CONCLUSIONS: There was evidence of considerable disparity between managers' actual and preferred time allocation and of the globalization of health managers' work values. Evidence regarding time use might contribute to a rethink of how managers' efficiency and effectiveness are construed.

Cultural and associated enablers of, and barriers to, adverse incident reporting.

AIM: Following the introduction of an electronic Incident Information Management System (IIMS) in New South Wales, Australia, the authors investigated enablers and barriers to the use of IIMS and factors associated with increased, static and decreased reporting rates. METHODOLOGY: An online and paper-based, anonymous survey of 2185 health practitioners collected information about their reporting behaviour and experiences of enablers/barriers: training, system accessibility, ease of use, system security, feedback, perceived value of IIMS and workplace safety culture. FINDINGS: The 79.3% of respondents who reported on IIMS were distinguished from non-reporters by having undertaken IIMS training and evaluating this highly. Users reporting more incidents post-IIMS were more likely than those with static or decreased reporting rates to evaluate their training highly and to have experienced all enablers. Users reporting fewer incidents were least likely to do so. The relative likelihood of the three reporting groups experiencing various enablers was similar. Those most frequently experienced by all groups were system security and accessibility. Barriers most frequently encountered were more culturally embedded-for example, poor workplace safety culture. The 'more' reporting group actually reported most, and the 'static' group least, incidents. LIMITATIONS/IMPLICATIONS: The sample was large but not randomly selected, which limits the generalisability of findings. PRACTICAL IMPLICATIONS: Interventions to increase reporting should target provision of training that endorses and fosters conditions shown to enhance reporting rates. ORIGINALITY: Enablers to incident reporting have been shown to be associated not only with reporting per se but also with changes to reporting patterns and rates.

Implementation of a patient safety incident management system as viewed by doctors, nurses and allied health professionals.

Incident reporting systems have become a central mechanism of most health services patient safety strategies. In this article we compare health professionals' anonymous, free text responses in an evaluation of a newly implemented electronic incident management system. The professions' answers were compared using classic content analysis and Leximancer, a computer assisted text analysis package. The classic analysis identified issues which differentiated the professions. More doctors commented on lack of feedback following incidents and evaluated the system negatively. More allied health staff found that the system lacked fields necessary to report incidents. More nurses complained incident reporting was time consuming. The Leximancer analysis revealed that while the professions all used the more frequently employed concepts (which described basic components of the reporting system), nurses and allied health shared many additional concepts concerned with actual reporting. Doctors applied fewer and more unique (used only by one profession) concepts when writing about the system. Doctors' unique concepts centred on criticism of the incident management system and the broader implications of safety issues, while the other professions' unique concepts focused on more practical issues. The classic analysis identified specific problems needing to be targeted in ongoing modifications of the system. The Leximancer findings, while complementing the classical analysis results, gave greater insight into professional groups' attitudes that relate to use of the system, e.g. doctors' relatively limited conceptual vocabulary regarding the system was consistent with their lower incident reporting rates. Such professional differences in reaction to healthcare innovations may constrain inter-disciplinary communication and cooperation.

Promoting safety: longer-term responses of three health professional groups to a safety improvement programme.

PURPOSE: Patient safety has been addressed since 2002 in the health system of New South Wales, Australia via a Safety Improvement Programme (SIP), which took a system-wide approach. The programme involved two-day courses to educate healthcare professionals to monitor and report incidents and analyse adverse events by conducting root cause analysis (RCA). This paper aims to predict that all professions would favour SIP but that their work and educational histories would result in doctors holding the least and nurses the most positive attitudes. Alternative hypotheses were that doctors' relative power and other professions' team-working skills would advantage the respective groups when conducting RCAs. DESIGN/METHODOLOGY/APPROACH: Responses to a 2005 follow-up questionnaire survey of doctors (n = 53), nurses (209) and allied health staff (59), who had participated in SIP courses, were analysed to compare: their attitudes toward the course; safety skills acquired and applied; perceived benefits of SIP and RCAs; and their experiences conducting RCAs. FINDINGS: Significant differences existed between professions' responses with nurses being the most and doctors the least affirming. Allied health responses resembled those of nurses more than those of doctors. The professions' experiences conducting RCAs (number conducted, leadership, barriers encountered, findings implemented) were similar. RESEARCH LIMITATIONS/IMPLICATIONS: Observational studies are needed to determine possible professional differences in the conduct of RCAs and any ensuing culture change that this may be eliciting. PRACTICAL IMPLICATIONS: There is strong professional support for SIPs but less endorsement from doctors, who tend not to prefer the knowledge content and multidisciplinary teaching environment considered optimal for safety improvement education. This is a dilemma that needs to be addressed. ORIGINALITY/VALUE: Few longer-term SIPs' assessments have been realised and the differences between professional groups have not been well quantified. As a result of this paper, benefits of and barriers to conducting RCAs are now more clearly understood.

Are health systems changing in support of patient safety? A multi-methods evaluation of education, attitudes and practice.

PURPOSE: The purpose of this study is to evaluate the effects of a health system-wide safety improvement program (SIP) three to four years after initial implementation. DESIGN/METHODOLOGY/APPROACH: The study employs multi-methods studies involving questionnaire surveys, focus groups, in-depth interviews, observational work, ethnographic studies, documentary analysis and literature reviews with regard to the state of New South Wales, Australia, where 90,000 health professionals, under the auspices of the Health Department, provide healthcare to a seven-million population. After enrolling many participants from various groups, the measurements included: numbers of staff trained and training quality; support for SIP; clinicians' reports of safety skills acquired, work practices changed and barriers to progress; RCAs undertaken; observation of functioning of teams; committees initiated and staff appointed to deal with adverse events; documentation and computer records of reports; and peak-level responses to adverse events. FINDINGS: A cohort of 4 per cent of the state's health professionals has been trained and now applies safety skills and conducts RCAs. These and other senior professionals strongly support SIP, though many think further culture change is required if its benefits are to be more fully achieved and sustained. Improved information-handling systems have been adopted. Systems for reporting adverse incidents and conducting RCAs have been instituted, which are co-ordinated by NSW Health. When the appropriate structures, educational activities and systems are made available in the form of an SIP, measurable systems change might be introduced, as suggested by observations of the attitudes and behaviours of health practitioners and the increased reporting of, and action about, adverse events. ORIGINALITY/VALUE: Few studies into health systems change employ wide-ranging research methods and metrics. This study helps to fill this gap.

The hierarchy of work pursuits of public health managers.

How public health is managed in various settings is an important but under-examined issue. We examine themes in the management literature, contextualize issues facing public health managers and investigate the relative importance placed on their various work pursuits using a 14-activity management model empirically derived from studies of clinician-managers in hospitals. Ethnographic case studies of 10 managers in nine diverse public health settings were conducted. The case study accounts of managers' activities were content analysed, and substantive words encapsulating their work were categorized using the model. Managerial activities of the nine public health managers were ranked according to the number of words describing each activity. Kendall's coefficient of concordance yielded W = 0.710, P < 0.000, revealing significant similarity between the activity patterns of the public health managers. A rank order correlation between the activity patterns of the average ranks for the public health sample and for the hospital clinician-managers (n = 52) was R = 0.420, P = 0.131, indicating no significant relationship between relative activity priorities of the two groups. Public health managers put less emphasis on pursuits associated with structure, hierarchy and education, and more on external relations and decision-making. The model of hospital clinician-managers' managerial activities is applicable to public health managers while identifying differences in the way the two groups manage. The findings suggest that public health management work is more managerialist than previously thought.

Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme.

BACKGROUND: Research on root cause analysis (RCA), a pivotal component of many patient safety improvement programmes, is limited. OBJECTIVE: To study a cohort of health professionals who conducted RCAs after completing the NSW Safety Improvement Program (SIP). HYPOTHESIS: Participants in RCAs would: (1) differ in demographic profile from non-participants, (2) encounter problems conducting RCAs as a result of insufficient system support, (3) encounter more problems if they had conducted fewer RCAs and (4) have positive attitudes regarding RCA and safety. DESIGN, SETTING AND PARTICIPANTS: Anonymous questionnaire survey of 252 health professionals, drawn from a larger sample, who attended 2-day SIP courses across New South Wales, Australia. OUTCOME MEASURES: Demographic variables, experiences conducting RCAs, attitudes and safety skills acquired. RESULTS: No demographic variables differentiated RCA participants from non-participants. The difficulties experienced while conducting RCAs were lack of time (75.0%), resources (45.0%) and feedback (38.3%), and difficulties with colleagues (44.5%), RCA teams (34.2%), other professions (26.9%) and management (16.7%). Respondents reported benefits from RCAs, including improved patient safety (87.9%) and communication about patient care (79.8%). SIP courses had given participants skills to conduct RCAs (92.8%) and improve their safety practices (79.6%). Benefits from the SIP were thought to justify the investment by New South Wales Health (74.6%) and committing staff resources (72.6%). Most (84.8%) of the participants wanted additional RCA training. CONCLUSIONS: RCA participants reported improved skills and commitment to safety, but greater support from the workplace and health system are necessary to maintain momentum.

Ambulance officers' use of online clinical evidence.

BACKGROUND: Hospital-based clinicians have been shown to use and attain benefits from online evidence systems. To our knowledge there have been no studies investigating whether and how ambulance officers use online evidence systems if provided. We surveyed ambulance officers to examine their knowledge and use of the Clinical Information Access Program (CIAP), an online evidence system providing 24-hour access to information to support evidence-based practice. METHODS: A questionnaire was completed by 278 ambulance officers in New South Wales, Australia. Comparisons were made between those who used CIAP and officers who had heard of, but not used CIAP. RESULTS: Half the sample (48.6%) knew of, and 28.8% had used CIAP. Users were more likely to have heard of CIAP from a CIAP representative/presentation, non-users from written information. Compared to ambulance officers who had heard of but had not used CIAP, users were more likely to report better computer skills and that their supervisors regarded use of CIAP as a legitimate part of ambulance officers' clinical role. The main reasons for non-use were lack of access(49.0%) and training(31.4%). Of users, 51.3% rated their skills at finding information as good/very good, 67.5% found the information sought all/most of the time, 87.3% believed CIAP had the potential to improve patient care and 28.2% had directly experienced this. Most access to CIAP occurred at home. The databases frequently accessed were MIMS (A medicines information database) (73.8%) and MEDLINE(67.5%). The major journals accessed were Journal of Emergency Nursing(37.5%), American Journal of Medicine(30.0%) and JAMA(27.5%). CONCLUSION: Over half of ambulance officers had not heard of CIAP. The proportion who knew about and used CIAP was also low. Reasons for this appear to be a work culture not convinced of CIAP's relevance to pre-hospital patient care and lack of access to CIAP at work. Ambulance officers who used CIAP accessed it primarily from home and valued it highly. Lack of access to CIAP at central work locations deprives ambulance officers of many of the benefits of an online evidence system.

Does restructuring hospitals result in greater efficiency?--An empirical test using diachronic data.

Hospitals are being restructured more frequently. Increased cost efficiency is the usual justification given for such changes. All 20 major teaching hospitals in Australia's two most populous states were investigated by classifying each over a 5-6 year period in terms of their cost efficiency (average cost per case weighted by Australian diagnosis-related group [AN-DRG] data and adjusted for inflation) and structure, categorized as traditional-professional (TP), clinical-divisional (CD), or clinical-institute (CI). In all, 12 hospitals changed structure during the study period. There was slight evidence that CD structures were more efficient than TP structures but this was not supported by other evidence. There were no significant differences in efficiency in the first or second years following changes from either TP to CD or TP to CI structures. All four hospitals changing from CD to CI structure became significantly less efficient. This may be due to frequency rather than type of change as they were the only hospitals that implemented two structural changes. Hospitals that changed or did not change structure were similar in efficiency at the beginning and at the end of the study period, in overall efficiency during the period, and in trends toward efficiency over time. The findings challenge those who advocate restructuring hospitals on the grounds of improving cost efficiency.

A 9 year prospective cohort study of endoscoped patients with upper gastrointestinal symptoms.

Despite the high prevalence of upper gastrointestinal symptoms and associated costs of diagnosis and management, evidence regarding long-term outcomes is scant. We studied symptom outcomes 18 months (FU1) and 8/9 years (FU2) post-index endoscopy to identify demographic, diagnostic and treatment factors associated with outcomes. A retrospective review of medical records at two Australian teaching hospitals identified a cohort of 302 patients who had an index endoscopy (performed by 23 endoscopists) 18 months previously. Patients were interviewed at FU1 and FU2. In total 34% (95%CI: 29.0 39.8) of patients were asymptomatic at FUI and 41% (95%CI: 35.6-46.6) at FU2. For 63%, outcomes at FUI predicted long-term outcome, with 19% (95%CI: 14.6-23.4) asymptomatic and 44% (95%CI: 38.4-50.0) symptomatic at both times. Those whose symptom status changed were as likely to deteriorate as improve (p > 0.05). Number and severity of presenting symptoms (F = 3.3, df = 3,277, p < 0.05) and older age (F = 2.8, df = 2,301, p < 0.05) were associated with poorer outcomes. Long-term outcome was unrelated to endoscopic diagnosis. Those symptomatic were significantly more likely to be on proton pump inhibitors (PPIs) or Histamine2 Receptor Antagonists (H2RAs) than those who were asymptomatic. Use of PPIs at FU2 was associated with a significantly better outcome than use of H2RAs. However this impact was relatively small, with 69% of patients on PPIs and 84% on H2RAs symptomatic at FU2. Upper gastrointestinal symptoms prompting endoscopy are chronic for the majority of patients regardless of diagnosis. Endoscopic diagnosis is of limited value in predicting long-term outcomes. The association between poor outcome and use of H2RAs and PPIs challenges views about their long-term effectiveness in symptom control.

Giving voice to health professionals' attitudes about their clinical service structures in theoretical context.

Within the context of structural theories this paper examines what health professionals say about their clinical service structures. We firstly trace various conceptual perspectives on clinical service structures, discussing multiple theoretical axes. These theories question whether clinical service structures represent either superficial or more profound changes in hospitals. We secondly explore which view is supported though a content analysis of the free text responses of 111 health professionals (44 doctors, 45 nurses and 22 allied health practitioners) about their clinical service structures in a questionnaire survey in two large hospitals that had implemented clinical service structures three years previously. Commentaries unfavourable toward clinical service structures were made by 47.7% of staff, favourable by 24.3%, mixed (both favourable and unfavourable) by 17.1% and non-evaluative statements were made by 10.8%. The most frequent criticisms were inefficient organisation of change (27%), poor management (24.3%), lack of cooperation between staff (15.9%) and failure to empower health practitioners (13.5%). All professions made more negative than positive evaluations of their clinical service structures but the ratio was highest for doctors and lowest for allied health. Ranking of nurses' and allied health staffs' specific evaluations were similar but both differed significantly from doctors'. Unfavourable or negative comments predominated, and change appears more superficial and less profound than advocates of structural contributions hope. Four types of belief systems about clinical service structures are apparent. Some study participants are disposed toward the status quo; others toward restructuring; yet others are team oriented; and a final group is tribally oriented. The implication of this paper for managers is that more work is needed if clinical service structures are to realise the promise of more multi-disciplinarity and less fragmentation across professional groups. For scholars, the implication is that marrying different theoretical frames with empirical data can serve to produce fresh perspectives and perhaps new insights.

A tale of two hospitals: assessing cultural landscapes and compositions.

Clinical directorate service structures (CDs) have been widely implemented in acute settings in the belief that they will enhance efficiency and patient care by bringing teams together and involving clinicians in management. We argue that the achievement of such goals depends not only on changing its formalized structural arrangements but also the culture of the organisation concerned. We conducted comparative observational studies and questionnaire surveys of two large Australian teaching hospitals similar in size, role and CD structure. Martin's conceptualization of culture in terms of integration, differentiation and fragmentation was applied in the analysis of the data. The ethnographic work revealed that compared to Metropolitan Hospital, Royal Hospital was better supported and more favourably viewed by its staff across six categories identified in both settings: leadership, structure, communication, change, finance and human resource management. Royal staff were more optimistic about their organisation's ability to meet future challenges. The surveys revealed that both staff groups preferred CD to traditional structures and shared some favourable and critical views of them. However Royal staff were significantly more positive, reporting many more benefits from CDs e.g. improved working relations, greater accountability and efficiency, better cost management, more devolvement of management to clinicians and a hospital more strategically placed and patient focused. Metropolitan staff were more likely to claim that CDs failed to solve problems and created a range of others including disunity and poor working relationships. There was greater consensus of views among Royal staff and more fragmentation at Metropolitan where both intensely held and uncertain attitudes were more common. The outcomes of implementing CDs in these two similar organisations differed considerably indicating the need to address cultural issues when introducing structural change. Martin's framework provides a useful antidote to researchers' tendency to focus at only one level of culture.

A survey of staff attitudes and comparative managerial and non-managerial views in a clinical directorate.

Widespread implementation of clinical directorates (CDs) has displaced traditional structures of hospitals over the past 20 years. Responses range from support for involving clinicians in organizational processes along with the associated managerial benefits, to criticism that foreshadows potential negative effects and warns that CDs will not of themselves resolve embedded health sector problems. There is limited empirical evidence about the transition and the views of staff toward CDs. To investigate staff attitudes, a questionnaire was developed and administered in a survey of 107 staff in a large hospital that had introduced CDs three years previously. Attitudes were assessed in terms of their intensity, polarity, uncertainty and positivism toward CDs. Managers and other staff held similar attitudes on 66% of questionnaire items. Significant differences were found in the remaining one-third of items. Managers were positive about CDs, whereas non-managers' approval was limited and muted. Managers' attitudes were more intense, less uncertain and less polarized than were non-managers'. They differed primarily in the areas of working relations and power. Over recent years, CDs seem to have become institutionalized and investigations into their operation have declined. Our results suggest that taking the benefits of CDs for granted is premature.

Gender differences in the symptoms and physical and mental well-being of dyspeptics: a population based study.

PURPOSE: To compare women and men with dyspepsia in terms of symptoms, physical and mental well-being and the relationships between individual symptoms and well-being. METHODS: A cross-sectional random telephone survey of 2300 Australians identified 748 people with dyspepsia who were interviewed regarding the number, types and severity of symptoms and physical (PCS) and mental well-being (MCS) measured by the SF-12. RESULTS: There were no significant gender differences in number or average severity of symptoms. Bloating, nausea, and early satiety were significantly more frequent among women; food regurgitation and heartburn in men. Dyspeptics (PCS = 47.1, MCS = 46.0) had poorer physical (p < 0.001) and mental well-being (p < 0.001) than did non-dyspeptics (PCS = 53.5, MCS = 55.3). Among dyspeptics, women (PCS = 46.4, MCS = 44.7) had poorer physical (p < 0.05) and mental well-being (p < 0.001) than males (PCS = 47.9, MCS = 47.5). Some symptoms were associated with low well-being for both sexes e.g. nausea. For women retching was related to poor physical well-being, and food regurgitation, dysphagia. bloating and epigastric pain to poor mental well-being. Among men epigastric pain and heartburn were associated with poor physical well-being, acid regurgitation with poor mental well-being, and vomiting with both. CONCLUSIONS: Dyspeptics report poorer physical and mental well-being than do non-dyspeptics. The difference between groups is greater for mental well-being, especially among women. Both physical and social factors may contribute to gender differences.