Development of a Finnish patient safety culture survey (TUKU) and evaluation methodology
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1 Development of a Finnish patient safety culture survey (TUKU) and evaluation methodology Teemu Reiman and Elina Pietikäinen Teemu.reiman@vtt.fi, elina.pietikainen@vtt.fi
2 Background our premises Patient safety culture is considered a significant phenomena affecting the quality and safety of care Patient safety culture can be defined as the willingness and ability of an organization to understand safety (and the hazards) as well as the willingness and ability to act on safety (Reiman et al. 2010). The idea is to focus on presence of certain prerequisites for safe work, not so much on incidents and adverse events as such A positive view on safety Aim is to be able to manage proactively the conditions in which health care work is carried out as well as develop practices, competence etc. The TUKU patient safety culture questionnaire is based on a model of safety culture that separates three perspectives to culture: Psychological factors, Organizational functions, and Social processes TUKU measures the psychological factors and employees perceptions of the organizational functions TUKU functions as one data gathering tool in an evaluation of patient safety culture 2
3 Previous work Patient safety culture has been evaluated predominantly by surveys, e.g.: Hospital Survey on Patient Safety Culture (Sorra & Nieva 2004) Safety Attitudes Questionnaire (Sexton et al. 2006). The existing surveys do not make explicit their background theory on patient safety culture or patient safety Sometimes a set of qualitatively different dimensions have been combined. From a systems perspective certain dimensions critical for controlling safety are missing Many surveys focus on measuring things that are in most acute need for improvement that is ok, but it does not provide an overview of the patient safety culture 3
4 Development of the TUKU questionnaire 1 TUKU-survey was developed in a publicly funded research project in 2008 The survey had two parts: psychological factors and organizational dimensions Psychological factors of work instrument was based on the CULTURE-survey developed by Reiman and Oedewald (2004). The part measuring organizational dimensions was developed specifically for the TUKU survey with the help of an extensive literature review (Reiman et al. 2007, Reiman et al. 2010) E.g. Hospital Survey on Patient Safety (Sorra & Nieva 2004), safety climate survey (Zohar et al. 2000) were used as benchmark The organizations that participated in the piloting commented the survey before data collection => format of some questions was revised The TUKU 1 survey version was tested in three health care districts (n = 1298). The empirical model created with factor analysis produced 8 dimensions when the original measurement model had 13 dimensions (Pietikäinen 2008). We decided to revise the measurement model (by modifying both the underlying dimensions as well as the survey questions) 4
5 TUKU 1 The survey was piloted in three Finnish hospital districts (n = 1298) in Likert-type questions. Measurement model: five psychological and 13 organizational dimensions. The psychological part was adapted from the CULTURE-survey constructed originally for nuclear industry by Reiman and Oedewald (2004). Factor analysis of the organizational part produced eight dimensions. For example, questions addressing hypothesized dimensions of change management, managements safety activity and safety communication formed one factor. Also a new factor labelled crisis mode was formed from several negatively worded questions. Seven of the dimensions had Cronbach s alphas over.70. Six of the dimensions also showed statistically significant differences between the three hospitals (p <.001). The empirically formed organizational dimensions were labelled as follows: 1) knowledge management and systematicalness of the hospital unit, 2) management actions to guarantee patient safety and control change, 3) crisis mode, 4) supervisory activity, ) cooperation and information flow at the hospital, 6) management of third parties, 7) management system, and 8) practices of organizational learning. Of these, only the dimensions 4, 6, 7 and 8 concurred with the measurement model.
6 Development of the TUKU questionnaire 2 The TUKU 2 survey that was constructed in 2009 had 9 organisational dimensions. The survey was tested in one health care district (n = 1707). Several findings about the dimensions were made and a revised TUKU 3 was made TUKU 3 has 4 psychological dimensions 9 organisational dimensions, with a new dimension hazard control added 6
7 Organizational functions Safety leadership The hospital has a long-term plan to ensure patient safety The hospital s management style shows that patient safety is a central value Supervisor safety activities Supervisors take into account suggestions from staff to improve patient safety If you are worried about an issue at work, it is easy to discuss it with your superior Work conditions management We have enough staff to manage the amount of work we have We have adequate facilities for taking care of the patients Work process management The organisation s work processes and practices support day-to-day cooperation The flow of information between different departments in the hospital is adequate Proactive safety development We have functioning practices for learning from incidents We actively develop our operations to improve patient safety in our hospital Hazard control The tools we use to prevent adverse patient related events (checklists, double checks, etc.) work well we have quality control and supervisory systems that contribute to patient safety Change management The effects of change on patient safety are carefully evaluated Competence management The people working in our hospital have the knowledge and skills they need to do their job well Management of third parties Staff employed by a different organisation (e.g. locum doctors and other agency staff) 7 who work in our hospital are competent
8 Psychological factors Safety motivation Patient safety is a central guiding value in my own work Mindfulness I actively seek to identify risk factors linked to patient safety Sense of control I sometimes have to rush my work I do not always have opportunities to perform my work with sufficient care Sense of personal responsibility I feel personally responsible for the well-being of our patients It bothers me if patients aren t feeling well 8
9 Pilot study on the functioning of the TUKU 3 questionnaire Case study in a Finnish hospital unit The survey was a part of a larger scale evaluation of patient safety culture at the unit n=123, response rate 40. 9
10 Factor solution, psychological dimensions (GLS, rotation Direct Oblimin, 67. % of variance explained, eigen values > 1, Bartlett s Test of Sphericity p <.001, KMO 0.77) FACTOR QUESTIONS RELIABILITY MEAN SCORE Safety motivation Sense of responsibility Mindfulness Lack of control In addition to the four scales, the questionnaire includes control variables: - The perceived significance of one s own work - The perceived clarity of work community s expectations - Felt patient safety worry - Felt concern about other personnel s commitment to patient safety - Climate (in hospital and in one s own work group) - Fear of admitting mistakes 10
11 Factor solutions, organizational dimensions (GLS, rotation Direct Oblimin, 70.8 % of variance explained, eigen values > 1, Bartlett s Test of Sphericity p <.001, KMO 0.91) FACTOR QUESTIONS RELIABILITY MEAN SCORE Work conditions management Work process management Supervisory activity Change management Hazard control Systematic safety development
12 Dimensions TUKU 2 measurement model, TUKU 3 measurement models and TUKU 3 pilot empirical model TUKU 2 measurement model TUKU 3 measurement model Safety management system Safety management and leadership Leadership Supervisor safety actions TUKU 3 pilot empirical model Management of information flow Work process management Supervisor safety actions Management of cooperation Work conditions management Systematic safety development Management of resources Proactive safety development Hazard control Competence management Hazard control Work process management Organizational learning Competence management Work conditions management Management of change Management of change Management of change Management of third parties Sense of control Management of third parties Sense of control? Sense of control Safety motivation Safety motivation Sense of personal responsibility Mindfulness Climate, safety worry, job satisfaction, reporting, blaming Safety motivation Sense of personal responsibility Mindfulness Climate, safety worry, job satisfaction, reporting, blaming Sense of personal responsibility 12 Mindfulness Climate, safety worry, job satisfaction, reporting, blaming
13 The reliability of the organizational dimensions according to the measurement model FACTOR Work conditions management Work process management Supervisory activity (ID) Change management (ID) Hazard control Proactive safety development Safety leadership Competence management QUESTIONS RELIABILITY
14 The background theory for the questionnaire is VTT s DISC (Design for integrated safety culture) model (Reiman & Oedewald 2009) Change management Risk analyses of changes Monitoring of incremental changes Management of third parties Supervision Audits Induction Supervisory activity Feedback Competence management Training Recruitment Responsibility for the safe functioning of the entire system is taken Organization is mindful in its practices Safety leadership Safety communication Safety policy and management expectations Safety is a genuine value in the organisation which reflects to decision making and daily activities Safety culture Activities are organised in a manageable way Work conditions management Rules and instructions Resources Tools Hazard management Human performance tools Risk analyses Hazards and core task requirements are understood thoroughly Safety is understood as a complex and systemic phenomenon Work practices Communication Cooperation Strategic management Investments Pro-active safety development Monitoring safety culture Learning from incidents Setting and following up on development targets Work process management 14
15 Responsibility for the safe functioning of the entire system is taken Organization is mindful in its practices Safety is a genuine value in the organisation which reflects to decision making and daily activities Criteria for good patient safety potential Activities are organised in a manageable way Hazards and core task requirements are understood thoroughly Safety is understood as a complex and systemic phenomenon 1
16 Discussion The survey is one data gathering method in our evaluation methodology Survey results should always be complemented with other types of data Feedback and discussion with personnel about the results is important Topics for further research The relation of survey results to adverse events, Methodology for utilizing survey results in organizational development work, Following of trends in patient safety culture development, and measuring the effectiveness of improvement efforts Optimizing the lenght of the survey 16
17 References Reiman, T. & Oedewald, P. (2004). Measuring maintenance culture and maintenance core task with CULTURE-questionnaire a case study in the power industry. Safety Science 42 (9), Reiman, T. & Oedewald, P. (2008). Turvallisuuskriittiset organisaatiot Onnettomuudet, kulttuuri ja johtaminen. Helsinki: Edita. Reiman, T. & Oedewald, P. (2009). Evaluating safety critical organizations. Focus on the nuclear industry. Swedish Radiation Safety Authority, Research Report 2009:12. Reiman, T., Pietikäinen, E. & Oedewald, P. (2010). Multilayered approach to patient safety culture. Quality and Safety in Health Care, 19, 1- doi: /qshc
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