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Assessing and improving safety climate in a large cohort of intensive care units*

Bryan Sexton, J. PhD; Berenholtz, Sean M. MD, MHS; Goeschel, Christine A. RN, MPA, MPS; Watson, Sam R. MSA, MT(ASCP); Holzmueller, Christine G. BLA; Thompson, David A. DScN, RN; Hyzy, Robert C. MD; Marsteller, Jill A. PhD, MPP; Schumacher, Kathy MSA, CPHQ; Pronovost, Peter J. MD, PhD, FCCM

doi: 10.1097/CCM.0b013e318206d26c
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Objectives: To evaluate the impact of a comprehensive unit-based safety program on safety climate in a large cohort of intensive care units participating in the Keystone intensive care unit project.

Design/Setting: A prospective cohort collaborative study to improve quality of care and safety culture by implementing and evaluating patient safety interventions in intensive care units predominantly in the state of Michigan.

Interventions: The comprehensive unit-based safety program was the first intervention implemented by every intensive care unit participating in the collaborative. It is specifically designed to improve the various elements of a unit's safety culture, such as teamwork and safety climate. We administered the validated Safety Attitudes Questionnaire at baseline (2004) and after 2 yrs of exposure to the safety program (2006) to assess improvement. The safety climate domain on the survey includes seven items.

Measurements and Main Results: Post-safety climate scores for intensive care units. To interpret results, a score of <60% was in the “needs improvement” zone and a ≥10-point discrepancy in pre-post scores was needed to describe a difference. Hospital bed size, teaching status, and faith-based status were included in our analyses. Seventy-one intensive care units returned surveys in 2004 and 2006 with 71% and 73% response rates, respectively. Overall mean safety climate scores significantly improved from 42.5% (2004) to 52.2% (2006), t = −6.21, p < .001, with scores higher in faith-based intensive care units and smaller-bed-size hospitals. In 2004, 87% of intensive care units were in the “needs improvement” range and in 2006, 47% were in this range or did not score ≥10 points or higher. Five of seven safety climate items significantly improved from 2004 to 2006.

Conclusions: A patient safety program designed to improve teamwork and culture was associated with significant improvements in overall mean safety climate scores in a large cohort of 71 intensive care units. Research linking improved climate scores and clinical outcomes is a critical next step.

From the Department of Psychiatry (JBS), Duke University Health System, Durham, NC; The Johns Hopkins University School of Medicine (SMB, CAG, CGH, DAT, PJP), Baltimore, MD; Michigan Health and Hospital Association Keystone Center (SRW), Lansing, MI; University of Michigan (RCH), Ann Arbor, MI; The Johns Hopkins Bloomberg School of Public Health (HAM), Baltimore, MD; and William Beaumont Hospital-Royal Oak (KS), Royal Oak, MI.

Supported, in part, for the period from October 2003 to September 2005, by the Agency for Healthcare Research and Quality (1UC1HS14246) and the Michigan Health and Hospital Association.

The work was performed at the Johns Hopkins University, the Michigan Health and Hospital Association Keystone Center, and hospitals participating in the collaborative. Dr. Sexton reports receiving honoraria for speaking at grand rounds, conferences and to associations, and non-financial interest with Pascal Metrics in that he created the Safety Attitudes Questionnaire (SAQ), but licensed the rights of the SAQ to them. He does not receive royalties from the SAQ. He does have permission to act as a paid consultant with Pascal Metrics, but has not does so yet. The SAQ is available for free on the internet for researchers, and those who wish may contract with Pascal Metrics to manage the survey administration for technical support and customer service. He also received honoraria/speaking fees and grant support from Harvard RMF, AHA HRET, Mayo Foundation, Michigan Hospital Association, New Jersey Hospital Association, Connecticut Hospital Association, Institute for Healthcare Improvement, Nationwide Childrens Hospital, St. Joseph's Mercy of Michigan grand rounds, and the National Patient Safety Foundation. Dr. Berenholtz reports receiving a grant/contract support from the Agency for Healthcare Research and Quality, Michigan Health & Hospital Association, National Institutes of Health, World Health Organization, and the Robert Wood Johnson Foundation. He received honoraria/speaking fees from Meritcare, the Samaritan Medical Center, and the University of Vermont, and has equity ownership in Docusys, Inc. Dr. Pronovost received a contract from the World Health Organization and a patent from the National Patent Safety Agency. Dr. Pronovost reports receiving grant/contract support from World Health Organization, the Agency for Healthcare Research and Quality, National Institutes of Health, and the National Patient Safety Foundation (U.K.), the Robert Wood Johnson Foundation, and The Commonwealth Fund for research relating to measuring and improving patient care; honoraria from various hospitals and health systems and the Leigh speaker's bureau to speak on quality and safety; consultancy with the Association for Professionals in Infection Control and Epidemiology, Inc.; and book royalties for authoring Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out. He also received a patent from the National Patient Safety Agency. He received a gift from the Sandler Foundation and honoraria/speaking fees from the Blue Cross Blue Shield Association of America. The remaining authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: bryan.sexton@duke.edu

© 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins