Patient safety culture

Defining patient safety culture

Organisational culture is a set of values, expectations, formal and informal practices, and behaviours that define the unique corporate environment. Culture is deeply ingrained in the fabric of organisational life; it determines how the organisation conducts its business, treats its employees, evaluates its leaders, serves its customers, and handles productivity and performance. A common interpretation of culture is ‘the way things are done around here’.

Safety culture is the aspects of organisational culture that relate to health and safety management. It is defined as ‘a product of individual and group values, attitudes, perceptions, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of an organisation’s health and safety management’.

Patient safety culture is focused on the aspects of organisational culture that relate to patient safety. It is defined as a pattern of individual and organisational behaviour, based upon shared beliefs and values that continuously seeks to minimise patient harm, which may result from the process of care delivery.
 

Why is patient safety culture important ?

Positive patient safety culture is related to better outcomes for patients and healthcare staff. Inquiries following patient harm highlight the potentially catastrophic impact of dysfunctional workplace cultures on patient care.

By systematically monitoring patient safety culture and acting on the findings, organisations can identify cultural issues early and make improvements before patient harm occurs. Our Clinical Governance Standard requires health service organisations to provide leadership in developing a culture of safety and quality improvement and demonstrate that this culture exists within the organisation.
 

How positive safety culture is achieved

Positive patient safety culture is achieved through strong leadership that drives and prioritises safety. The actions and attitudes of leaders and managers influence the perceptions, attitudes and behaviours of healthcare staff.

Leaders drive cultural change by demonstrating their own commitment to patient safety and setting examples through the decisions they make.

Positive patient safety culture can include:

• a shared understanding and appreciation of the importance of safety amongst healthcare staff
• constructive communication about patient safety
• mutual trust between leadership and staff
• engaged staff who are aware that things can go wrong
• acknowledgement at all levels that mistakes occur
• the ability to recognise, respond to, give feedback about, and learn from adverse events.

Patient safety culture is everyone's responsibility, but the ultimate responsibility for the culture of an organisation rests with the Chief Executive Officer and the governing body.
 

Measuring patient safety culture in hospitals

Patient safety culture can be measured through surveys of healthcare staff, focus groups, interviews, and ethnographic investigation. Surveys of healthcare staff are the most common way of measuring patient safety culture as staff are often the first to notice patterns of unsafe practices. The experience and perspectives of all hospital staff are important. Clinical and non-clinical staff observe different aspects of how the hospital works and have the potential to identify what is going well and what could be done better.

Patient safety culture measurement is most useful when combined with insights from other indicators of quality care such as complications, patient-reported experience and patient outcomes as well as other indicators of organisational culture such as staff wellbeing, satisfaction and retention. 

Australian Hospital Survey on Patient Safety Culture (A-HSOPS) 2.0

Our Australian Hospital Survey on Patient Safety Culture (A-HSOPS 2.0) provides hospitals with a staff survey to measure and improve on patient safety culture. We recommend that hospitals use this tool.

Hospitals can request access to A-HSOPS 2.0 by completing a quick online form and view the technical specifications for A-HSOPS 2.0. 

Request access to the Hospital Survey on Patient Safety Culture
 

Our patient safety culture measurement toolkit supports hospitals to collect, interpret, discuss and action results from the A-HSOPS 2.0 survey, and our templates help hospitals in implementing the A-HSOPS 2.0.

A-HSOPS 2.0 offers a survey that has been:

• assessed as a suitable validated survey for use in Australian hospitals
• modified for the Australian setting
• shortened to be user-friendly to promote uptake while keeping sufficient detail to be actionable
• piloted in the Australian hospitals and found to be valid and reliable for use.

Our patient safety culture measurement toolkit supports hospitals to collect, interpret, discuss and action results from the A-HSOPS 2.0 survey, and our templates help hospitals in implementing the A-HSOPS 2.0.

A-HSOPS 2.0 offers a survey that has been:

• assessed as a suitable validated survey for use in Australian hospitals
• modified for the Australian setting
• shortened to be user-friendly to promote uptake while keeping sufficient detail to be actionable
• piloted in the Australian hospitals and found to be valid and reliable for use. 

Structure

The survey includes a total of 35 questions. There are 26 items across nine composites, they are:

1. Supervisor, manager, or clinical leader support for patient safety (3 items)
2. Teamwork (3 items)
3. Communication/openness (3 items)
4. Reporting patient safety events (2 items)
5. Organisational learning- continuous improvement (3 items)
6. Communication about error (3 items)
7. Hospital management support for patient safety (3 items)
8. Response to error (3 items)
9. Handovers and information exchange (3 items).

The remaining nine questions are:

• Two overarching items (rating of patient safety for their unit/work area, and likelihood to recommend their unit/work area to a friend or family member)
• One open-ended item
• Six demographic items. 

Development and validation

A-HSOPS 2.0 is an Australian modification of the HSOPS 2.0 developed by the US Agency for Health Research released in 2019. HSOPS 2.0 is used internationally and is designed to measure staff opinions about patient safety issues, medical errors, and safety event reporting.

The survey was selected by the Safety Culture Measurement Expert Advisory Group as the most suitable survey for measurement of patient safety culture in both public and private Australian hospitals. It measures the most contemporary view and key aspects of patient safety culture, is easy to complete and can be implemented in a range of hospital types. The Commission developed the Australian version of the survey based on the advice of the expert advisory group and validated these modifications through cognitive testing. A-HSOPS 2.0 has been validated in nine hospitals from across Australia. The pilot included three private and six public hospitals.

Learn more about the development of the Australian Hospital Survey on Patient Safety Culture. 

Other tools used in Australia

In addition to the A-HSOPS 2.0, there are two other tools that are used in Australia. They are the:

• Safety Attitudes Questionnaire (SAQ) – short version
• Manchester Patient Safety Framework (MaPSAF).

Both tools have been used in Australian hospitals and provide a view of the key elements of patient safety culture. SAQ has been validated in South Australia and Victoria. MaPSAF, while resource intensive, provides an opportunity to measure, and improve on, patient safety culture concurrently. While the A-HSOPS 2.0 is recommended, hospitals may continue using these other tools to meet their needs or understand trends in patient safety culture over time. Information on each of these tools is provided below.

Safety Attitudes Questionnaire (SAQ)

The SAQ was developed in 2004 by researchers at the University of Texas in the US and continues to be widely used to measure patient safety culture. 

Structure

The full version of the questionnaire includes 60 items, of which 30 items are standard and identical across all settings. The generic SAQ Short-form version, includes the 30 standard items from the full SAQ, plus an additional six items, and three demographic items, providing a total of 39 items.

The survey is comprised of six factors:

1. Teamwork Climate
2. Safety Climate
3. Job Satisfaction
4. Perceptions of Management
5. Working Conditions
6. Stress Recognition. 

Validation and use in Australia

The Staff Survey on Patient Safety was developed by South Australia Health who worked with researchers to adapt the SAQ. This survey was used in a state-wide study in 2009^[i] and repeated in some SA Local Health Networks in 2013.

The modifications of the SAQ continue to be used in Australia to monitor patient safety culture and measure the impact of improvement projects. 

Manchester Patient Safety Framework (MaPSaF)

The MaPSaF was designed specifically for use in the UK’s National Health Service in 2009.^[ii] The MaPSaF provides a different approach to assessing patient safety culture. Rather than collecting information from a survey, the MaPSaf uses a card sorting activity and facilitated discussion to support units to understand their culture.

The implementation is ideally facilitated by a person within the healthcare organisation and teams who have a lead role in the patient safety agenda, rather than by a professional facilitator. The framework includes an improvement process that is designed to involve frontline staff in seven steps to assess and improve safety culture within their work unit. The seven steps are:

1. Safety culture
2. Lead and support staff
3. Integrated risk management
4. Promote incident reporting
5. Involve patients and the public
6. Learn and share lessons
7. Implement solutions. 

Structure

The framework is presented as a grid for organisations to assess themselves against five levels of maturity in nine or ten dimensions of safety culture. This allows the generation of a profile of the patient safety culture in terms of areas of relative strength and challenge, which can be used to identify issues for change and improvement.

The ten dimensions are:

1. Overall commitment to continuous improvement
2. Priority given to patient safety
3. System errors and individual responsibility /perception of causes of incidents
4. Recording incidents and best practice
5. Evaluating incidents and best practice
6. Learning and effecting change
7. Communication about safety issues
8. Personnel management and safety issues
9. Staff education and training about safety
10. Team working around safety issues.

The five levels of maturity are (E=most mature):

1. Pathological: why waste time on patient safety?
2. Reactive:  we take it seriously and do something after an incident
3. Bureaucratic or Calculative:  we have systems in place to manage patient safety
4. Proactive: we are always on the alert thinking about safety issues that might emerge
5. Generative: managing patient safety is an integral part of everything we do. 

Validation and use in Australia

The MaPSaF has been evaluated in a hospital setting overseas^[iii]. While MaPSaF has not been validated in Australia, it is widely used and well regarded in Australia as an integrated measurement and improvement strategy.