1173 C OPYRIGHT Ó 2015
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Orthopaedic Surgeons’ View on Strategies for Improving Patient Safety Stein J. Janssen, MD, Teun Teunis, MD, Thierry G. Guitton, MD, PhD, David Ring, MD, PhD, and James H. Herndon, MD, MBA Investigation performed at the Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Background: Many strategies have been introduced to improve safety in health care, but it is not clear that these efforts have reduced errors. This study assessed the experienced safety culture and preferred means of improving safety among orthopaedists. Methods: Members of the Science of Variation Group and Ankle Platform were invited to complete an eighty-ninequestion survey. Outcomes measured were the modified Patient Safety Climate in Healthcare Organizations (PSCHO) questionnaire, which measures safety as perceived by hospital personnel, and the degree of enthusiasm expressed for seventeen means of improving safety. Results: The questionnaire was completed by 387 (92%) of the 422 participants. The rate of problematic responses, those implying a lack of safety climate, in the modified PSCHO questionnaire was 18%. In multivariable linear regression analysis, working in a non-teaching hospital (b, 3.7; 95% confidence interval [95% CI], 1.3 to 6.2; p = 0.003), having a safety program (b, 4.8; 95% CI, 0.74 to 8.8; p = 0.020), and male sex (b, 3.7; 95% CI, 0.079 to 7.3; p = 0.045) were associated with higher perceived safety as measured by the PSCHO questionnaire. The majority of participants were very enthusiastic about making safety everyone’s responsibility (75%), promoting better communication (80%), standardizing procedures (58%), and standardizing equipment and supplies (63%) to improve safety. Conclusions: We found a high problematic response rate concerning the perceived safety climate among surgeons, but there was a high rate of enthusiasm for means of improving safety. Knowledge of the variation in perceived safety and the enthusiasm for strategies to improve safety among surgeons can serve as a starting point for cultural change.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
H
igh-reliability organizations succeed in avoiding catastrophes. The medical profession is attempting to build on quality and safety advances made in such organizations via increasing use of checklists1,2. There is debate about whether these efforts reduce medical errors and improve outcomes3,4. However, we know from the aviation and manufacturing industries the importance of culture to improve safety3,5. An organization’s culture is the product of individual and group values, norms, attitudes, competencies, and behavior1,3,6.
High-reliability organizations adopt a culture of safety by expecting to err, creating continuous awareness of processes that are and are not working, being reluctant to accept simple or incomplete explanations for problems, deferring to the expertise of people who have the most developed knowledge of the task regardless of hierarchy, and adapting quickly and effectively to changes7. Knowledge about what influences doctors’ attitudes toward safety might help to improve the hospital safety culture.
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2015;97:1173-86
d
http://dx.doi.org/10.2106/JBJS.N.01235
1174 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 97-A N U M B E R 14 J U LY 15, 2 015 d
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ON
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TABLE I Results on Modified PSCHO Questionnaire Response* Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
I am provided adequate resources (personnel, budget, and equipment) to provide safe patient care.
14 (3.6)
51 (13)
54 (14)
191 (49)
77 (20)
Loss of experienced personnel has negatively affected my ability to provide high-quality patient care.
24 (6.2)
89 (23)
85 (22)
154 (40)
35 (9)
Good communication flow exists down the chain of command regarding patient safety issues.
16 (4.1)
55 (14)
84 (22)
182 (47)
50 (13)
Good communication flow exists up the chain of command regarding patient safety issues.
15 (3.9)
54 (14)
92 (24)
183 (47)
43 (11)
Senior management does not hesitate to temporarily restrict clinicians who are under high personal stress.
57 (15)
132 (34)
129 (33)
52 (13)
17 (4.4)
Senior management reacts well to unexpected changes to its plan.
33 (8.5)
116 (30)
131 (34)
91 (24)
16 (4.1)
In my unit, there is significant peer pressure to discourage unsafe patient care.
19 (4.9)
45 (12)
84 (22)
171 (44)
68 (18)
5 (1.3)
63 (16)
71 (18)
185 (48)
63 (16)
13 (3.4)
88 (23)
101 (26)
140 (36)
45 (12)
5 (1.3)
34 (8.8)
71 (18)
217 (56)
60 (16)
Statement
My unit uniformly prescribes performance standards to ensure patient safety. My unit follows a specific process to review performance against defined training goals. Individuals in my unit are willing to report behavior that is unsafe for patient care. In my unit, disregarding policy and procedure is rare.
6 (1.6)
38 (10)
73 (19)
222 (57)
48 (12)
17 (4.4)
60 (16)
85 (22)
179 (46)
46 (12)
9 (2.3)
70 (18)
101 (26)
157 (41)
50 (13)
People in leadership positions set the example for compliance with policies and procedures that promote safe patient care.
12 (3.1)
46 (12)
85 (22)
182 (47)
62 (16)
Senior management provides a positive climate that promotes patient safety.
14 (3.6)
46 (12)
91 (24)
175 (45)
61 (16)
Senior management provides adequate safety backups to catch possible human errors during high-risk patient care activities.
8 (2.1)
55 (14)
116 (30)
168 (43)
40 (10)
This facility has a reputation for high-quality performance.
3 (0.78)
9 (2.3)
70 (18)
200 (52)
105 (27)
Staff are provided with the necessary training to safely provide patient care.
9 (2.3)
26 (6.7)
72 (19)
225 (58)
55 (14)
Supervisors conduct adequate reviews and updates of patient safety practices.
13 (3.4)
55 (14)
105 (27)
176 (45)
38 (9.8)
Senior management is successful in communicating its patient safety goals to hospital or clinic personnel.
16 (4.1)
47 (12)
106 (27)
175 (45)
43 (11)
Senior management has a clear picture of the risks associated with patient care.
24 (6.2)
57 (15)
85 (22)
177 (46)
44 (11)
Patient safety decisions are made at the proper levels by the most qualified people. My unit closely monitors performance to ensure clinicians are qualified.
My unit does a good job of managing risk to ensure patient safety.
2 (0.52)
17 (4.4)
60 (16)
242 (63)
66 (17)
My unit takes the time to identify and assess risks to patient safety.
2 (0.52)
25 (6.5)
73 (19)
226 (58)
61 (16)
Staff is genuinely concerned about patient safety.
4 (1)
7 (1.8)
35 (9)
199 (51)
142 (37)
*The values are given as the number of participants, based on a total of 387 participants, with the percentage in parentheses.
1175 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 97-A N U M B E R 14 J U LY 15, 2 015 d
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TABLE II Specific Statements Regarding Patient Safety Response* Statement Perceived patient safety in general Healthcare is not as safe as it should be.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
15 (3.9)
67 (17)
72 (19)
174 (45)
59 (15)
There is not enough emphasis on patient safety.
25 (6.5)
113 (29)
90 (23)
128 (33)
31 (8)
A culture of safety does not exist in medicine.
72 (19)
184 (48)
71 (18)
47 (12)
9 (2.3)
45 (12)
80 (21)
212 (55)
41 (11)
14 (3.6)
106 (27)
96 (25)
145 (37)
26 (6.7)
I would feel safe as a patient. We lack explicit and consistent standards for patient safety.
13 (3.4)
Specific statements about patient safety Increased workload increases the likelihood of error.
7 (1.8)
64 (17)
58 (15)
153 (40)
105 (27)
Patient safety is only discussed behind closed doors.
36 (9.3)
146 (38)
77 (20)
99 (26)
29 (7.5)
A culture of blame exists and precludes patient safety.
19 (4.9)
96 (25)
92 (24)
131 (34)
49 (13)
The hospital leadership structure precludes patient safety. Errors result from disorganized systems of care that lack clear lines of accountability.
24 (6.2) 4 (1)
136 (35) 46 (12)
120 (31) 71 (18)
86 (22) 195 (50)
21 (5.4) 71 (18)
The greatest threat to patient safety is human error.
6 (1.6)
58 (15)
84 (22)
169 (44)
70 (18)
14 (3.6)
72 (19)
76 (20)
144 (37)
81 (21)
2 (0.52)
13 (3.4)
38 (10)
219 (57)
115 (30)
I am aware of the strategies for improving patient safety.
1 (0.26)
16 (4.1)
50 (13)
240 (62)
80 (21)
It is my primary responsibility to ensure patients are safe.
3 (0.78)
4 (1)
23 (5.9)
176 (45)
181 (47)
174 (45)
174 (45)
30 (7.8)
4 (1)
5 (1.3)
27 (7)
70 (18)
99 (26)
158 (41)
33 (8.5)
195 (50) 236 (61)
158 (41) 119 (31)
22 (5.7) 21 (5.4)
7 (1.8) 4 (1)
5 (1.3) 7 (1.8)
Patient safety is a system problem, not an individual problem. Personal statements on safety I create an environment where people feel free to speak up when an error might occur.
I never make errors. The potential for litigation influences my behavior in dealing with errors. I am too busy to worry about patient safety. Working in a safe environment is boring.
*The values are given as the number of participants, based on a total of 387 participants, with the percentage in parentheses.
We assessed the opinions of orthopaedic surgeons on the current patient safety culture and their enthusiasm for various means of improving safety to explore the opportunities for cultural change. We hypothesized that surgeon characteristics were not associated with the safety culture as perceived by the surgeon and preferred means of improving patient safety. Also, we assessed the view of surgeons on the perceived preventability of specific adverse events, which stakeholders were responsible for safety, and surgeon factors deemed important in improving safety. Materials and Methods Study Design, Setting, and Participants
T
his survey study was approved by our institutional review board. All 8,9 members of the Science of Variation Group (an international collaboration of 691 upper-extremity surgeons) and the Ankle Platform (an international collaboration of 350 lower-extremity surgeons) were invited to complete this eighty-nine-question survey on patient safety (see Appendix). The questionnaire was developed in SurveyMonkey (Palo Alto, California), an online survey tool. Invitations to participate were sent in early 2014. At two and four weeks, we sent a reminder. Both collaborations aim to study
variation in the definition and treatment of human illness without financial incentives. The methodology of our study was based on an article regarding controlling health-care costs published in the Journal of the American Medical 10 Association by Tilburt et al. . That study assessed the attitudes of 3897 U.S. physicians toward addressing health-care costs.
Outcome Measures Baseline characteristics (sex, practice location, years in practice, specialization) were extracted from the member databases of both platforms. Additionally, we included age, type of practice, compensation, presence of a safety program, presence of a government-mandated safety program, and presence of a safety champion at the respondent’s institution. We administered six questionnaires in the following order: (1) the modified Patient Safety Climate in Healthcare Organizations (PSCHO) ques11-14 tionnaire , (2) responsibilities of different entities in improving safety, (3) degree of enthusiasm for potential means of improving safety, (4) general safety statements, (5) importance of personal factors in improving safety, and (6) statements focusing on adverse events (see Appendix). These questionnaires have not been validated. The perceived safety culture, as measured by the PSCHO questionnaire, and enthusiasm for potential means of improving patient safety were our primary outcomes.
1176 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 97-A N U M B E R 14 J U LY 15, 2 015 d
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TABLE III Multivariable Linear Regression Analysis of Surgeon Characteristics Associated with Safety Climate as Perceived by Participants (N = 387) According to Their PSCHO Score b Coefficient*†
P Value
3.7 (0.079 to 7.3)
0.045‡
Surgeon Characteristic Male sex Practice location Asia (reference) United States and Canada
20.19 (23.9 to 3.5)
0.26
Europe
22.3 (25.9 to 1.4)
0.92
Other
0.13 (25.3 to 5.0)
0.96
Years in practice None to five years (reference) Six to ten years Eleven to twenty years Twenty-one to thirty years
21.1 (23.7 to 1.5) 0.045 (22.5 to 2.6) 20.32 (23.6 to 2.9)
0.41 0.97 0.85
Primary practice clinic Teaching hospital (reference) Non-teaching hospital
3.7 (1.3 to 6.2)
0.003‡
Salary plus bonus
0.95 (21.7 to 3.5)
0.41
Salary only
1.8 (20.77 to 4.4)
0.12
Compensation Billing (reference)
No (reference) Unknown
ON
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FOR
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questionnaire was based on the U.S. Institute of Medicine report To Err Is 15 Human: Building a Safer Health System and the World Health Organization 16 report WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives . The degree of enthusiasm was dichotomized into “not or somewhat enthusiastic” and “very enthusiastic” for analysis. Participants were given the opportunity to provide five additional means of improving safety. These suggestions were categorized by two investigators (S.J.J. and T.T.). Consensus on the categories was reached by discussion after independently analyzing and assigning themes to a subset of fifty suggestions. After this consensus, both investigators analyzed the remaining suggestions.
Additional Questionnaires We developed nineteen additional statements to further explore the view of surgeons on safety using the 5-point Likert scale ranging from “strongly disagree” to “strongly agree” (see Appendix). The questions on responsibilities of different stakeholders in improving patient safety assessed the responsibility of the government, health insurance companies, patients, physician professional societies, individual practicing surgeons, hospitals and health systems, employers, pharmaceutical and device 10 manufacturers, and trial lawyers . We explored the importance of personal factors in improving safety: psychomotor skills, scientific knowledge, expertise, communication, leadership, behavior, attitude, and workload or capacity balance. Finally, the surgeons’ responsibility for preventing the following adverse events was examined: wrong-site surgery, retained foreign bodies, surgical site infections, thromboembolic complications, pressure ulcers, and medication errors.
Statistical Analysis
Safety program in practice Yes
O R T H O PA E D I C S U R G E O N S ’ V I E W P AT I E N T S A F E T Y
4.8 (0.74 to 8.8) 20.36 (26.0 to 5.2)
0.020‡ 0.90
*The b regression coefficient indicates the difference in the PSCHO score in one group compared with another. †The values are given as the beta coefficient, with the 95% CI in parentheses. ‡These p values indicate significance.
Modified PSCHO Questionnaire The PSCHO questionnaire is a validated and widely used questionnaire assessing the safety climate of health-care organizations as perceived by hospital 11-14 personnel . This forty-two-question scale was modified to twenty-four 13 questions and used by Kadzielski et al. . Questions focus on availability of resources, communication, training, monitoring, reporting, and responding to errors. Responses to every question are recorded on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree.” The responses “strongly disagree” and “disagree” (problematic) were assigned a value of 21, “neither agree nor disagree” was assigned a value of 0 (neutral), and “agree” and “strongly agree” (positive) were assigned a value of 1. Question 2 was scored inversely because of its reversed nature. The median PSCHO score was 12 points and scores ranged from 218 to 24 points (the possible range was 224 to 24 points, with a higher score indicating a safer climate as perceived by the participants). We validated the questionnaire by assessing internal consistency (Cronbach alpha of 0.93) and exploratory factor analysis (one factor explained 79% of the variance).
Enthusiasm for the Potential Means of Improving Patient Safety We formulated seventeen questions assessing the degree of enthusiasm for potential means of improving safety on a 3-point Likert scale: “not enthusiastic,” “somewhat enthusiastic,” and “very enthusiastic.” The content of this
In multivariable linear regression analysis, we assessed which surgeon characteristics were independently associated with the response variable of the modified PSCHO score. Linear regression analysis provides a b regression coefficient that indicates the difference in outcome score (PSCHO) in one group compared with another. A two-sided p value of
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Orthopaedic Surgeons’ View on Strategies for Improving Patient Safety Stein J. Janssen, MD, Teun Teunis, MD, Thierry G. Guitton, MD, PhD, David Ring, MD, PhD, and James H. Herndon, MD, MBA Investigation performed at the Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Background: Many strategies have been introduced to improve safety in health care, but it is not clear that these efforts have reduced errors. This study assessed the experienced safety culture and preferred means of improving safety among orthopaedists. Methods: Members of the Science of Variation Group and Ankle Platform were invited to complete an eighty-ninequestion survey. Outcomes measured were the modified Patient Safety Climate in Healthcare Organizations (PSCHO) questionnaire, which measures safety as perceived by hospital personnel, and the degree of enthusiasm expressed for seventeen means of improving safety. Results: The questionnaire was completed by 387 (92%) of the 422 participants. The rate of problematic responses, those implying a lack of safety climate, in the modified PSCHO questionnaire was 18%. In multivariable linear regression analysis, working in a non-teaching hospital (b, 3.7; 95% confidence interval [95% CI], 1.3 to 6.2; p = 0.003), having a safety program (b, 4.8; 95% CI, 0.74 to 8.8; p = 0.020), and male sex (b, 3.7; 95% CI, 0.079 to 7.3; p = 0.045) were associated with higher perceived safety as measured by the PSCHO questionnaire. The majority of participants were very enthusiastic about making safety everyone’s responsibility (75%), promoting better communication (80%), standardizing procedures (58%), and standardizing equipment and supplies (63%) to improve safety. Conclusions: We found a high problematic response rate concerning the perceived safety climate among surgeons, but there was a high rate of enthusiasm for means of improving safety. Knowledge of the variation in perceived safety and the enthusiasm for strategies to improve safety among surgeons can serve as a starting point for cultural change.
Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. It was also reviewed by an expert in methodology and statistics. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
H
igh-reliability organizations succeed in avoiding catastrophes. The medical profession is attempting to build on quality and safety advances made in such organizations via increasing use of checklists1,2. There is debate about whether these efforts reduce medical errors and improve outcomes3,4. However, we know from the aviation and manufacturing industries the importance of culture to improve safety3,5. An organization’s culture is the product of individual and group values, norms, attitudes, competencies, and behavior1,3,6.
High-reliability organizations adopt a culture of safety by expecting to err, creating continuous awareness of processes that are and are not working, being reluctant to accept simple or incomplete explanations for problems, deferring to the expertise of people who have the most developed knowledge of the task regardless of hierarchy, and adapting quickly and effectively to changes7. Knowledge about what influences doctors’ attitudes toward safety might help to improve the hospital safety culture.
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2015;97:1173-86
d
http://dx.doi.org/10.2106/JBJS.N.01235
1174 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 97-A N U M B E R 14 J U LY 15, 2 015 d
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TABLE I Results on Modified PSCHO Questionnaire Response* Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
I am provided adequate resources (personnel, budget, and equipment) to provide safe patient care.
14 (3.6)
51 (13)
54 (14)
191 (49)
77 (20)
Loss of experienced personnel has negatively affected my ability to provide high-quality patient care.
24 (6.2)
89 (23)
85 (22)
154 (40)
35 (9)
Good communication flow exists down the chain of command regarding patient safety issues.
16 (4.1)
55 (14)
84 (22)
182 (47)
50 (13)
Good communication flow exists up the chain of command regarding patient safety issues.
15 (3.9)
54 (14)
92 (24)
183 (47)
43 (11)
Senior management does not hesitate to temporarily restrict clinicians who are under high personal stress.
57 (15)
132 (34)
129 (33)
52 (13)
17 (4.4)
Senior management reacts well to unexpected changes to its plan.
33 (8.5)
116 (30)
131 (34)
91 (24)
16 (4.1)
In my unit, there is significant peer pressure to discourage unsafe patient care.
19 (4.9)
45 (12)
84 (22)
171 (44)
68 (18)
5 (1.3)
63 (16)
71 (18)
185 (48)
63 (16)
13 (3.4)
88 (23)
101 (26)
140 (36)
45 (12)
5 (1.3)
34 (8.8)
71 (18)
217 (56)
60 (16)
Statement
My unit uniformly prescribes performance standards to ensure patient safety. My unit follows a specific process to review performance against defined training goals. Individuals in my unit are willing to report behavior that is unsafe for patient care. In my unit, disregarding policy and procedure is rare.
6 (1.6)
38 (10)
73 (19)
222 (57)
48 (12)
17 (4.4)
60 (16)
85 (22)
179 (46)
46 (12)
9 (2.3)
70 (18)
101 (26)
157 (41)
50 (13)
People in leadership positions set the example for compliance with policies and procedures that promote safe patient care.
12 (3.1)
46 (12)
85 (22)
182 (47)
62 (16)
Senior management provides a positive climate that promotes patient safety.
14 (3.6)
46 (12)
91 (24)
175 (45)
61 (16)
Senior management provides adequate safety backups to catch possible human errors during high-risk patient care activities.
8 (2.1)
55 (14)
116 (30)
168 (43)
40 (10)
This facility has a reputation for high-quality performance.
3 (0.78)
9 (2.3)
70 (18)
200 (52)
105 (27)
Staff are provided with the necessary training to safely provide patient care.
9 (2.3)
26 (6.7)
72 (19)
225 (58)
55 (14)
Supervisors conduct adequate reviews and updates of patient safety practices.
13 (3.4)
55 (14)
105 (27)
176 (45)
38 (9.8)
Senior management is successful in communicating its patient safety goals to hospital or clinic personnel.
16 (4.1)
47 (12)
106 (27)
175 (45)
43 (11)
Senior management has a clear picture of the risks associated with patient care.
24 (6.2)
57 (15)
85 (22)
177 (46)
44 (11)
Patient safety decisions are made at the proper levels by the most qualified people. My unit closely monitors performance to ensure clinicians are qualified.
My unit does a good job of managing risk to ensure patient safety.
2 (0.52)
17 (4.4)
60 (16)
242 (63)
66 (17)
My unit takes the time to identify and assess risks to patient safety.
2 (0.52)
25 (6.5)
73 (19)
226 (58)
61 (16)
Staff is genuinely concerned about patient safety.
4 (1)
7 (1.8)
35 (9)
199 (51)
142 (37)
*The values are given as the number of participants, based on a total of 387 participants, with the percentage in parentheses.
1175 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 97-A N U M B E R 14 J U LY 15, 2 015 d
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TABLE II Specific Statements Regarding Patient Safety Response* Statement Perceived patient safety in general Healthcare is not as safe as it should be.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
15 (3.9)
67 (17)
72 (19)
174 (45)
59 (15)
There is not enough emphasis on patient safety.
25 (6.5)
113 (29)
90 (23)
128 (33)
31 (8)
A culture of safety does not exist in medicine.
72 (19)
184 (48)
71 (18)
47 (12)
9 (2.3)
45 (12)
80 (21)
212 (55)
41 (11)
14 (3.6)
106 (27)
96 (25)
145 (37)
26 (6.7)
I would feel safe as a patient. We lack explicit and consistent standards for patient safety.
13 (3.4)
Specific statements about patient safety Increased workload increases the likelihood of error.
7 (1.8)
64 (17)
58 (15)
153 (40)
105 (27)
Patient safety is only discussed behind closed doors.
36 (9.3)
146 (38)
77 (20)
99 (26)
29 (7.5)
A culture of blame exists and precludes patient safety.
19 (4.9)
96 (25)
92 (24)
131 (34)
49 (13)
The hospital leadership structure precludes patient safety. Errors result from disorganized systems of care that lack clear lines of accountability.
24 (6.2) 4 (1)
136 (35) 46 (12)
120 (31) 71 (18)
86 (22) 195 (50)
21 (5.4) 71 (18)
The greatest threat to patient safety is human error.
6 (1.6)
58 (15)
84 (22)
169 (44)
70 (18)
14 (3.6)
72 (19)
76 (20)
144 (37)
81 (21)
2 (0.52)
13 (3.4)
38 (10)
219 (57)
115 (30)
I am aware of the strategies for improving patient safety.
1 (0.26)
16 (4.1)
50 (13)
240 (62)
80 (21)
It is my primary responsibility to ensure patients are safe.
3 (0.78)
4 (1)
23 (5.9)
176 (45)
181 (47)
174 (45)
174 (45)
30 (7.8)
4 (1)
5 (1.3)
27 (7)
70 (18)
99 (26)
158 (41)
33 (8.5)
195 (50) 236 (61)
158 (41) 119 (31)
22 (5.7) 21 (5.4)
7 (1.8) 4 (1)
5 (1.3) 7 (1.8)
Patient safety is a system problem, not an individual problem. Personal statements on safety I create an environment where people feel free to speak up when an error might occur.
I never make errors. The potential for litigation influences my behavior in dealing with errors. I am too busy to worry about patient safety. Working in a safe environment is boring.
*The values are given as the number of participants, based on a total of 387 participants, with the percentage in parentheses.
We assessed the opinions of orthopaedic surgeons on the current patient safety culture and their enthusiasm for various means of improving safety to explore the opportunities for cultural change. We hypothesized that surgeon characteristics were not associated with the safety culture as perceived by the surgeon and preferred means of improving patient safety. Also, we assessed the view of surgeons on the perceived preventability of specific adverse events, which stakeholders were responsible for safety, and surgeon factors deemed important in improving safety. Materials and Methods Study Design, Setting, and Participants
T
his survey study was approved by our institutional review board. All 8,9 members of the Science of Variation Group (an international collaboration of 691 upper-extremity surgeons) and the Ankle Platform (an international collaboration of 350 lower-extremity surgeons) were invited to complete this eighty-nine-question survey on patient safety (see Appendix). The questionnaire was developed in SurveyMonkey (Palo Alto, California), an online survey tool. Invitations to participate were sent in early 2014. At two and four weeks, we sent a reminder. Both collaborations aim to study
variation in the definition and treatment of human illness without financial incentives. The methodology of our study was based on an article regarding controlling health-care costs published in the Journal of the American Medical 10 Association by Tilburt et al. . That study assessed the attitudes of 3897 U.S. physicians toward addressing health-care costs.
Outcome Measures Baseline characteristics (sex, practice location, years in practice, specialization) were extracted from the member databases of both platforms. Additionally, we included age, type of practice, compensation, presence of a safety program, presence of a government-mandated safety program, and presence of a safety champion at the respondent’s institution. We administered six questionnaires in the following order: (1) the modified Patient Safety Climate in Healthcare Organizations (PSCHO) ques11-14 tionnaire , (2) responsibilities of different entities in improving safety, (3) degree of enthusiasm for potential means of improving safety, (4) general safety statements, (5) importance of personal factors in improving safety, and (6) statements focusing on adverse events (see Appendix). These questionnaires have not been validated. The perceived safety culture, as measured by the PSCHO questionnaire, and enthusiasm for potential means of improving patient safety were our primary outcomes.
1176 TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 97-A N U M B E R 14 J U LY 15, 2 015 d
d
d
TABLE III Multivariable Linear Regression Analysis of Surgeon Characteristics Associated with Safety Climate as Perceived by Participants (N = 387) According to Their PSCHO Score b Coefficient*†
P Value
3.7 (0.079 to 7.3)
0.045‡
Surgeon Characteristic Male sex Practice location Asia (reference) United States and Canada
20.19 (23.9 to 3.5)
0.26
Europe
22.3 (25.9 to 1.4)
0.92
Other
0.13 (25.3 to 5.0)
0.96
Years in practice None to five years (reference) Six to ten years Eleven to twenty years Twenty-one to thirty years
21.1 (23.7 to 1.5) 0.045 (22.5 to 2.6) 20.32 (23.6 to 2.9)
0.41 0.97 0.85
Primary practice clinic Teaching hospital (reference) Non-teaching hospital
3.7 (1.3 to 6.2)
0.003‡
Salary plus bonus
0.95 (21.7 to 3.5)
0.41
Salary only
1.8 (20.77 to 4.4)
0.12
Compensation Billing (reference)
No (reference) Unknown
ON
S T R AT E G I E S
FOR
IMPROVING
questionnaire was based on the U.S. Institute of Medicine report To Err Is 15 Human: Building a Safer Health System and the World Health Organization 16 report WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives . The degree of enthusiasm was dichotomized into “not or somewhat enthusiastic” and “very enthusiastic” for analysis. Participants were given the opportunity to provide five additional means of improving safety. These suggestions were categorized by two investigators (S.J.J. and T.T.). Consensus on the categories was reached by discussion after independently analyzing and assigning themes to a subset of fifty suggestions. After this consensus, both investigators analyzed the remaining suggestions.
Additional Questionnaires We developed nineteen additional statements to further explore the view of surgeons on safety using the 5-point Likert scale ranging from “strongly disagree” to “strongly agree” (see Appendix). The questions on responsibilities of different stakeholders in improving patient safety assessed the responsibility of the government, health insurance companies, patients, physician professional societies, individual practicing surgeons, hospitals and health systems, employers, pharmaceutical and device 10 manufacturers, and trial lawyers . We explored the importance of personal factors in improving safety: psychomotor skills, scientific knowledge, expertise, communication, leadership, behavior, attitude, and workload or capacity balance. Finally, the surgeons’ responsibility for preventing the following adverse events was examined: wrong-site surgery, retained foreign bodies, surgical site infections, thromboembolic complications, pressure ulcers, and medication errors.
Statistical Analysis
Safety program in practice Yes
O R T H O PA E D I C S U R G E O N S ’ V I E W P AT I E N T S A F E T Y
4.8 (0.74 to 8.8) 20.36 (26.0 to 5.2)
0.020‡ 0.90
*The b regression coefficient indicates the difference in the PSCHO score in one group compared with another. †The values are given as the beta coefficient, with the 95% CI in parentheses. ‡These p values indicate significance.
Modified PSCHO Questionnaire The PSCHO questionnaire is a validated and widely used questionnaire assessing the safety climate of health-care organizations as perceived by hospital 11-14 personnel . This forty-two-question scale was modified to twenty-four 13 questions and used by Kadzielski et al. . Questions focus on availability of resources, communication, training, monitoring, reporting, and responding to errors. Responses to every question are recorded on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree.” The responses “strongly disagree” and “disagree” (problematic) were assigned a value of 21, “neither agree nor disagree” was assigned a value of 0 (neutral), and “agree” and “strongly agree” (positive) were assigned a value of 1. Question 2 was scored inversely because of its reversed nature. The median PSCHO score was 12 points and scores ranged from 218 to 24 points (the possible range was 224 to 24 points, with a higher score indicating a safer climate as perceived by the participants). We validated the questionnaire by assessing internal consistency (Cronbach alpha of 0.93) and exploratory factor analysis (one factor explained 79% of the variance).
Enthusiasm for the Potential Means of Improving Patient Safety We formulated seventeen questions assessing the degree of enthusiasm for potential means of improving safety on a 3-point Likert scale: “not enthusiastic,” “somewhat enthusiastic,” and “very enthusiastic.” The content of this
In multivariable linear regression analysis, we assessed which surgeon characteristics were independently associated with the response variable of the modified PSCHO score. Linear regression analysis provides a b regression coefficient that indicates the difference in outcome score (PSCHO) in one group compared with another. A two-sided p value of
