Safety culture as a healthcare construct
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- 1.Safety Culture as aHealthcare ConstructPatrick A. PalmieriCenter for American EducationLori T. PetersonNance College of Business AdministrationPresented at the 2009 Annual Meeting of the Academy ofManagement, 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 5. INTRODUCTION 6. It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harmFlorence 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 systemsIOM, 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) 10. THEORETICAL INFLUENCES 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 individualcontributions 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 poorlydesigned processes and systems (Perrow, 1999) 13. PsychologySimilar 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 theoryproduction Derived from deductive methodologies Critical incident (Flanagan, 1954; Woods & Chattuck, 2000) Critical decision (Carlisle, 1986)Note: Aviation research related to behavioral markersis incomplete, early in development, and notpsychometrically validated (Yule at al., 2006) 15. CONSTRUCTS & FRAMEWORK 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 bypositive safety cultures 3. Organizations can improve culture by makingsafety a priority 4. Management practices influence employee safetyperformance 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) 19. FINDINGS 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 CultureThe applicability of safety culture as a universal concept across disciplines and specialties within healthcare aswell as the relationship to specific safety performance measures remains questionable and unsettled . Flin et al., 2006 22. RECOMMENDATIONS 23. Theoretical FrameworkOnly the lack of theoretical grounding, scarcity of conceptualframework, 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 moremeasurement scales and re-testingclimate-behavior relationships will hold back scientific progress.Zohar, 2008 25. Research MethodsMeasuring individual perceptions withinstudies designed to analyze data at thegroup or organizational level istheoretically incompatible Hoffman & Stetzer, 1996; Zohar, 2003 26. Psychometric PropertiesThe science is limited by theinadequate 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. ConclusionWe 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 InformationPatrick A. Palmieripalmieripa@gmail.comLori A. Petersonltpeterson@gmail.comCITATION: Palmieri, P. A., & Peterson, L. T. (2009). Safety culture as ahealthcare construct. Presented at the Annual Meeting of the Academy ofManagement (August 9): Chicago, Illinois, USA.