Objective
The purpose of this study was to determine the effect of an obstetrics patient safety program on staff safety culture.
Study Design
We implemented (1) obstetrics patient safety nurse, (2) protocol-based standardization of practice, (3) crew resource management training, (4) oversight by a patient safety committee, (5) 24-hour obstetrics hospitalist, and (6) an anonymous event reporting system. We administered the Safety Attitude Questionnaire on 4 occasions over 5 years (2004-2009) to all staff members that assessed teamwork and safety cultures, job satisfaction, working conditions, stress recognition, and perceptions of management.
Results
We observed significant improvements in the proportion of staff members with favorable perceptions of teamwork culture (39% in 2004 to 63% in 2009), safety culture (33% to 63%), job satisfaction (39% to 53%), and management (10% to 37%). Individual roles (obstetrics providers, residents, and nurses) also experienced improvements in safety and teamwork, with significantly better congruence between doctors and nurses.
Conclusion
Safety programs can improve workforce perceptions of safety and an improved safety climate.
Safety culture is defined as the integration of safety thinking and practices into clinical activities. This includes development of systems for data collection and reporting, the reduction of tendencies to place blame on individuals, and a focus on real or potential system latencies. Improvement of patient safety, in terms of risk and outcomes, in a healthcare system depends on the building of a patient safety culture; some investigators have argued that the key to quality improvement may lie in this type of organizational change.
For Editors’ Commentary, see Table of Contents
Safety climate is the quantitative description of the safety culture. Safety climate can be assessed in several ways that include examination of adverse events (outcomes measures), analysis of adherence to practices (process measures), or calibration of healthcare teams’ attitudes about issues relevant to safety. Many patient safety programs have shown significant reductions in adverse outcomes; however, less is known of the impact of such efforts on staff safety perceptions and attitudes.
With the hypothesis that a multifaceted approach to enhance the overall safety culture would reduce the rate of adverse outcomes, we partnered with our hospital (Yale–New Haven Hospital) and our malpractice carrier (MCIC Vermont, Inc, New York, NY) to assess and improve our safety climate. The goal of this program was to improve patient safety and the safety culture, decrease patient injury, and decrease liability losses through a program that identified and initiated cultural changes and specific risk-reduction clinical practices. We reported the details of the incremental reduction in adverse outcomes, as measured by the obstetrics Adverse Outcomes Index, over a 3-year period in a previous publication.
Simultaneously, we aimed to determine the effect of a comprehensive obstetrics patient safety program on staff perceptions of safety and teamwork that was measured by the Safety Attitude Questionnaire (SAQ), which is a standardized and validated questionnaire that measures staff attitudes towards safety and quality in the workplace.
Materials and Methods
We sequentially introduced multiple patient safety interventions from December 2002 to November 2006 at a university-based obstetrics service at Yale–New Haven Hospital. The details of this program have been previously described. Briefly, the effort involved the initiation of the following interventions:
Outside expert review
In 2002, 2 independent consultants (a maternal–fetal medicine physician and a nurse specialist/leader) initiated an outside expert review. This site visit culminated in a review and recommendations that focused on principles of patient safety, evidence-based practice, and consistency with standards of professional and governing bodies.
An obstetrics patient safety nurse
An obstetrics patient safety nurse was responsible for data collection (which was begun prospectively in September 2004) on a “case occurrence” basis. This nurse also led educational efforts (team training, electronic fetal monitoring certification), directed the anonymous event reporting system, and initiated and led adverse event reviews.
Protocol and guideline
Protocol and guideline development began in 2004; the aim was to codify and standardize existing practices.
Reporting system
An anonymous, computerized event reporting system (Peminic, Inc, Princeton, NJ) was initiated in 2004 and allowed any hospital worker to report events that may have caused or could cause harm to a patient/visitor.
An obstetrics hospitalist/Yale on-call attending
An obstetrics hospitalist/Yale on-call attending physician position was implemented in 2004 to provide a consistent system of inpatient coverage and resident supervision. This coverage was provided by a Maternal-Fetal Medicine specialist 24 hours a day, 7 days a week.
Obstetrical Patient Safety Committee
This multidisciplinary committee (physicians, nurses, administrators) was initiated in 2004 was responsible for quality assurance and quality improvement reviews and, in particular, addressed the need for protocols and policies to improve safety and efficiency.
The SAQ
The SAQ is a tool that was adapted from the aviation field and is used for the assessment of healthcare employee perception of teamwork and safety.
Team training
Started in 2005, team training was a continuing series of crew resource management seminars that were based on seminars of airline and defense industries. Four-hour classes included videos, lectures, and role-playing and integrated obstetrics staffing domains (physicians, nurses, administrators, assistants). Seminars were organized as a 1-time training opportunity for existing staff members. New employees who were hired after the initial set of seminars received training shortly after beginning work. Crew resource management techniques have been reinforced since that time through obstetrics simulations in an on-site simulation facility. Completion of the crew resource management seminar was a condition for employment and/or clinical privileges.
Electronic fetal monitoring certification
Electronic fetal monitoring certification, which began in 2005, involves dissemination and review of National Institute of Child Health and Human Development guidelines, a review of tracings, the allocation of study guides, and voluntary review sessions and culminates in a standardized, certified examination. All medical staff members and employees who are responsible for fetal monitoring interpretation were obligated to take this examination. New employees who were hired after the initial effort were required to take this examination within 1 year of employment; a passing score was required within 18 months. There was a 100% pass rate among physicians and midwives and a 98% pass rate on first attempt among nurses over the time of this study.
Workforce safety climate
Workforce safety climate was assessed with the obstetrics SAQ. This anonymous survey helps to detect perceived systemic weaknesses and differences of opinion over time or between employee groups (eg, staff, nursing, physicians) that result from a professional education that is marked by differing languages/vocabularies and contrasting perspectives. The survey consists of a series of statements to which the respondent is able to answer with agreement or disagreement, with a 5-point Likert scale (disagree/never, disagree/rarely, neutral/sometimes, agree/most of the time, agree/always). Agreement with a statement, for instance, is concluded when a respondent answers either “most of the time” or “always.” The survey involves 58 questions and takes approximately 10 minutes to complete. Sample questions include: “I would feel safe being treated here as a patient,” “The physicians and nurses here work together as a well-coordinated team,” and “Morale in this unit/clinical area is high.”
The SAQ has been validated in nonobstetrics healthcare settings. Favorable scores are associated with shorter lengths of stay, fewer medication errors, lower ventilator-associated pneumonia rates, lower bloodstream infection rates, and lower risk-adjusted mortality rates. Furthermore, having favorable scores in 4 of 6 safety domains is associated with lower nurse turnover.
The SAQ was administered on 4 occasions (2004-2009) to all Labor & Birth Unit staff members (includes attending obstetricians, nurse midwives, pediatricians, neonatologists, anesthesiologists, residents, nurses, surgical technicians, aides, and social workers) to survey patient safety culture. The SAQ measures caregiver assessments of safety and quality within 6 climate domains: (1) teamwork culture (perceived quality of collaboration between personnel), (2) safety culture (perceptions of a strong and proactive organizational commitment to safety), (3) job satisfaction (positivity about the workplace), (4) working conditions (perceived quality of the work environment and logistical support), (5) stress recognition (acknowledgement of how performance is influenced by stressors), and (6) perceptions of management (approval of managerial action). Demographic characteristics of respondents were not assessed.
Sexton has published standards for the determination of the clinical significance of SAQ results. Differences of ≥10% over time or between groups are considered clinically significant. Overall scores that show 80% agreement that the teamwork climate is favorable are considered the target for change; <60% indicates an area of higher risk. We also analyzed responses between 2004 and 2009 and between caregiver groups (physicians/midwives, residents, nurses) with chi-square testing.
This project was reviewed by the Chair of the Yale University Human Investigations Committee and was deemed a quality assurance activity and thus not required to undergo review by the Committee.
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