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Safety culture as a healthcare construct

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Palmieri, P. A., & Peterson, L. T. (2009). Safety culture as a healthcare construct. Presented at the Annual Meeting of the Academy of Management (August 9): Chicago, Illinois, USA. Nominated for Best Paper Award, Healthcare Management Division.

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Safety Culture as a Healthcare Construct Patrick A. Palmieri Center for American Education Lori T. Peterson Nance College of Business Administration Presented at the 2009 Annual Meeting of the Academy of Management, Chicago, Illinois (August 9, 2009). Best Paper Award Nominee, Health Care Division.
Funding Sources for Our Work Patrick Albert Palmieri Duke Health Technology Solutions Information Technology Fellowship Duke University Doctoral Scholarship National Institutes of Health (NIH) Roadmap for Medical Research, (Individual T-32 Summer Research Award). Project: Organizational Safety Culture Survey Reliability and Validity (Palmieri, PI). Duke University Clinical and Translational Science Institute (Califf, PI). Lori T. Peterson Texas Tech University Rawls College of Business Center for Health Innovation, Education, and Research
Paper Aims Analyze the theoretical underpinnings of safety culture Examine the psychometric performance properties of the measurement instruments Provide an assessment about the state of safety culture research in healthcare
Presentation Aims Summarize the state of healthcare to support the need for safety culture research Identify the disciplinary origination (theoretical influences) for the safety culture concept Describe the contemporary safety culture framework Discuss the findings from our review Recommend aims and goals for future safety culture work
INTRODUCTION
It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm Florence Nightingale, 1863, Notes on Hospitals
Healthcare is Dangerous Flawed systems (e.g. Zhan & Miller, 2003) Faulty processes (e.g. Reason, Carthey, & de Leval, 2001) Poor interactions (e.g. Cook, Render, & Woods, 2000) Substandard performance (e.g. Benner et al. 2006) Inadequate training (e.g. Bohmer & Edmondson, 2001) Poor management practices (e.g. Konteh et al., 2008) Anatomy and Physiology of Error in Adverse Healthcare Events Palmieri, DeLucia, Peterson, Ott, & Green (2008)
Safety Culture Focus Institute of Medicine recommends that healthcare organizations: Develop safety cultures Routinely assess safety culture Establish comprehensive patient safety plans to improve error detection Reduce opportunities for error by redesigning care systems IOM, 2000, 2004a, 2004b
Definition of Safety Culture A global organizational property that can be defined as: The organizational inputs of individual and group attitudes, perceptions, and values about workplace behaviors and system processes that collectively contribute to safe and reliable organizational outputs. (Cox and Flin 1998 and others)
THEORETICAL INFLUENCES
Theoretical Influences Sociology Normal Accident Theory Psychology High Reliability Theory Human Factors and Ergonomics (HF/E) Aviation Framework
Sociology Safety is an emergent property of culture (Smirich 1983) Reflect the collective history of individual contributions to group (Perrow 1970) Culture is not easily changed (Perrow & Langton, 1994; Sagan, 1994) Resistant to direct management intervention (Mears & Flin, 1999) Safety linked to reduced complexity & coupling Inflexible policies and procedures, and poorly designed processes and systems (Perrow, 1999)
Psychology Similar to Sociology except: Cultures readily change Exist for the purpose of manipulation (Schein, 1991) Individual focused Collective mindfulness of employees (Weick & Roberts, 1993; Weick & Sutcliffe, 2006) Management practices and interventions
Human Factors & Ergonomics Emphasis on application not theory production Derived from deductive methodologies Critical incident (Flanagan, 1954; Woods & Chattuck, 2000) Critical decision (Carlisle, 1986) Note: Aviation research related to behavioral markers is incomplete, early in development, and not psychometrically validated (Yule at al., 2006)
CONSTRUCTS & FRAMEWORK
Research Assumptions Four assumptions guide the majority of safety culture research: 1. Safety focused cultures produce better outcomes 2. Improved safety performance are produced by positive safety cultures 3. Organizations can improve culture by making safety a priority 4. Management practices influence employee safety performance
Safety Culture Characteristics Four cultural characteristics permit the organization of work to support safety 1. Learning 2. Reporting 3. Justice and Fairness 4. Flexibility (e.g. Reason, 1998b)
Safety Culture Framework Frameworks and models undefined No arrows, no lines connecting boxes Possible antecedents Error reporting (Piotrowski & Hinshaw, 2002) Non-punitive climate (Dekker, 2007) Trust (Dirks & Ferrin, 2002) Management involvement and practices (Thomas et al., 2005; Wong, Helsinger, & Petry, 2002) System and processes perspective (Barach & Johnson, 2006)
FINDINGS
Basic Conceptual Issues Unsystematic, fragmented, and underspecified in theoretical terms (Pidgeon ,1998; Zhan et al., 2002) Considerable disagreement among safety experts about the definition of safety culture and how this is operationalized (Flin et al., 2000; Guldenmund, 2000; Hale, 2000; Wiegmann et al., 2004) Culture & climate terms often used interchangeably e.g. Cox and Flin, 1998, Colla et al., 2005) ( Safety culture research provides management with data for benchmarking and trends analysis (Mearns, Flin, & Whitaker, 2001)
Healthcare Safety Culture The applicability of safety culture as a universal concept across disciplines and specialties within healthcare as well as the relationship to specific safety performance measures remains questionable and unsettled . Flin et al., 2006
RECOMMENDATIONS
Theoretical Framework Only the lack of theoretical grounding, scarcity of conceptual framework, and the presence of a dimension related to leadership and management practices was common across the reviews. e.g. Flin et al., 2000; Guldenmund, 2000; Colla et al., 2005; Scott et al., 2003a
Measurement Instruments Merely developing more measurement scales and re-testing climate-behavior relationships will hold back scientific progress. Zohar, 2008
Research Methods Measuring individual perceptions within studies designed to analyze data at the group or organizational level is theoretically incompatible Hoffman & Stetzer, 1996; Zohar, 2003
Psychometric Properties The science is limited by the inadequate attention to establishing suitable psychometric properties, such as reporting essential validity and reliability standards Colla et al., 2005; Flin et al., 2006; Flin, 2007
Conclusion We agree Safety culture is a concept whose time has come and we should develop a clearer theoretical understanding of these organizational issues to create a principled basis for more effective culture- enhancing practices. Reason (1998b) but we also believe Inadequate theoretical frameworks and the associated instrument and methodological issues limit further development as a translational science where interventions might be designed, implemented, and tested as methods to improve outcomes.
Contact Information Patrick A. Palmieri palmieripa@gmail.com Lori A. Peterson ltpeterson@gmail.com CITATION: Palmieri, P. A., & Peterson, L. T. (2009). Safety culture as a healthcare construct. Presented at the Annual Meeting of the Academy of Management (August 9): Chicago, Illinois, USA.

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Safety culture as a healthcare construct

  • 1. Safety Culture as a Healthcare Construct Patrick A. Palmieri Center for American Education Lori T. Peterson Nance College of Business Administration Presented at the 2009 Annual Meeting of the Academy of Management, Chicago, Illinois (August 9, 2009). Best Paper Award Nominee, Health Care Division.
  • 2. Funding Sources for Our Work Patrick Albert Palmieri Duke Health Technology Solutions Information Technology Fellowship Duke University Doctoral Scholarship National Institutes of Health (NIH) Roadmap for Medical Research, (Individual T-32 Summer Research Award). Project: Organizational Safety Culture Survey Reliability and Validity (Palmieri, PI). Duke University Clinical and Translational Science Institute (Califf, PI). Lori T. Peterson Texas Tech University Rawls College of Business Center for Health Innovation, Education, and Research
  • 3. Paper Aims Analyze the theoretical underpinnings of safety culture Examine the psychometric performance properties of the measurement instruments Provide an assessment about the state of safety culture research in healthcare
  • 4. Presentation Aims Summarize the state of healthcare to support the need for safety culture research Identify the disciplinary origination (theoretical influences) for the safety culture concept Describe the contemporary safety culture framework Discuss the findings from our review Recommend aims and goals for future safety culture work
  • 6. It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm Florence Nightingale, 1863, Notes on Hospitals
  • 7. Healthcare is Dangerous Flawed systems (e.g. Zhan & Miller, 2003) Faulty processes (e.g. Reason, Carthey, & de Leval, 2001) Poor interactions (e.g. Cook, Render, & Woods, 2000) Substandard performance (e.g. Benner et al. 2006) Inadequate training (e.g. Bohmer & Edmondson, 2001) Poor management practices (e.g. Konteh et al., 2008) Anatomy and Physiology of Error in Adverse Healthcare Events Palmieri, DeLucia, Peterson, Ott, & Green (2008)
  • 8. Safety Culture Focus Institute of Medicine recommends that healthcare organizations: Develop safety cultures Routinely assess safety culture Establish comprehensive patient safety plans to improve error detection Reduce opportunities for error by redesigning care systems IOM, 2000, 2004a, 2004b
  • 9. Definition of Safety Culture A global organizational property that can be defined as: The organizational inputs of individual and group attitudes, perceptions, and values about workplace behaviors and system processes that collectively contribute to safe and reliable organizational outputs. (Cox and Flin 1998 and others)
  • 11. Theoretical Influences Sociology Normal Accident Theory Psychology High Reliability Theory Human Factors and Ergonomics (HF/E) Aviation Framework
  • 12. Sociology Safety is an emergent property of culture (Smirich 1983) Reflect the collective history of individual contributions to group (Perrow 1970) Culture is not easily changed (Perrow & Langton, 1994; Sagan, 1994) Resistant to direct management intervention (Mears & Flin, 1999) Safety linked to reduced complexity & coupling Inflexible policies and procedures, and poorly designed processes and systems (Perrow, 1999)
  • 13. Psychology Similar to Sociology except: Cultures readily change Exist for the purpose of manipulation (Schein, 1991) Individual focused Collective mindfulness of employees (Weick & Roberts, 1993; Weick & Sutcliffe, 2006) Management practices and interventions
  • 14. Human Factors & Ergonomics Emphasis on application not theory production Derived from deductive methodologies Critical incident (Flanagan, 1954; Woods & Chattuck, 2000) Critical decision (Carlisle, 1986) Note: Aviation research related to behavioral markers is incomplete, early in development, and not psychometrically validated (Yule at al., 2006)
  • 16. Research Assumptions Four assumptions guide the majority of safety culture research: 1. Safety focused cultures produce better outcomes 2. Improved safety performance are produced by positive safety cultures 3. Organizations can improve culture by making safety a priority 4. Management practices influence employee safety performance
  • 17. Safety Culture Characteristics Four cultural characteristics permit the organization of work to support safety 1. Learning 2. Reporting 3. Justice and Fairness 4. Flexibility (e.g. Reason, 1998b)
  • 18. Safety Culture Framework Frameworks and models undefined No arrows, no lines connecting boxes Possible antecedents Error reporting (Piotrowski & Hinshaw, 2002) Non-punitive climate (Dekker, 2007) Trust (Dirks & Ferrin, 2002) Management involvement and practices (Thomas et al., 2005; Wong, Helsinger, & Petry, 2002) System and processes perspective (Barach & Johnson, 2006)
  • 20. Basic Conceptual Issues Unsystematic, fragmented, and underspecified in theoretical terms (Pidgeon ,1998; Zhan et al., 2002) Considerable disagreement among safety experts about the definition of safety culture and how this is operationalized (Flin et al., 2000; Guldenmund, 2000; Hale, 2000; Wiegmann et al., 2004) Culture & climate terms often used interchangeably e.g. Cox and Flin, 1998, Colla et al., 2005) ( Safety culture research provides management with data for benchmarking and trends analysis (Mearns, Flin, & Whitaker, 2001)
  • 21. Healthcare Safety Culture The applicability of safety culture as a universal concept across disciplines and specialties within healthcare as well as the relationship to specific safety performance measures remains questionable and unsettled . Flin et al., 2006
  • 23. Theoretical Framework Only the lack of theoretical grounding, scarcity of conceptual framework, and the presence of a dimension related to leadership and management practices was common across the reviews. e.g. Flin et al., 2000; Guldenmund, 2000; Colla et al., 2005; Scott et al., 2003a
  • 24. Measurement Instruments Merely developing more measurement scales and re-testing climate-behavior relationships will hold back scientific progress. Zohar, 2008
  • 25. Research Methods Measuring individual perceptions within studies designed to analyze data at the group or organizational level is theoretically incompatible Hoffman & Stetzer, 1996; Zohar, 2003
  • 26. Psychometric Properties The science is limited by the inadequate attention to establishing suitable psychometric properties, such as reporting essential validity and reliability standards Colla et al., 2005; Flin et al., 2006; Flin, 2007
  • 27. Conclusion We agree Safety culture is a concept whose time has come and we should develop a clearer theoretical understanding of these organizational issues to create a principled basis for more effective culture- enhancing practices. Reason (1998b) but we also believe Inadequate theoretical frameworks and the associated instrument and methodological issues limit further development as a translational science where interventions might be designed, implemented, and tested as methods to improve outcomes.
  • 28. Contact Information Patrick A. Palmieri palmieripa@gmail.com Lori A. Peterson ltpeterson@gmail.com CITATION: Palmieri, P. A., & Peterson, L. T. (2009). Safety culture as a healthcare construct. Presented at the Annual Meeting of the Academy of Management (August 9): Chicago, Illinois, USA.