Publication of startling statistics nearly a decade ago about the extent of preventable medical errors has directed attention to the "culture of safety" in health care organizations (Institute of Medicine, 2000). Subsequent research has sought to identify opportunities for improving safety outcomes by studying patterns of variation in what has been termed "safety climate" (Flin, Burns, Mearns, Yule, & Robertson, 2006). Climate and culture are not synonymous, although they are often used interchangeably (Zohar, 1980). Climate has been "defined as a perceptually based description of what the organization is like in terms of practices, policies, procedures, and routines, while culture helps define the underlying reasons and mechanisms for why these things occur in an organization based on fundamental ideologies, assumptions, values, and artifacts" (Ostroff, Kinicki, & Tamkins, 2003). Thus, climate refers to shared perceptions related to a given, specific area of interest, such as safety (Schneider & Bowen, 1993), whereas culture refers to employees' fundamental ideology and orientation (Trice & Beyer, 1993) and explains why an objective like safety is pursued in the manner exhibited within a particular organization (Schein, 1992).
Limited research has examined organizational characteristics that may affect safety climate in hospitals (Zohar & Luria, 2004). In particular, we know little about how the organizational context could be modified to improve safety climate. A better understanding of this relationship could reveal, for example, whether aspects of general organizational culture predispose some hospitals to better safety climate.
Theory and Conceptual Framework
Drawing on expanding evidence linking safety outcomes to climate measures in health care and other industries (e.g., Clarke, 2006; Hofmann & Mark, 2006), we assumed that a strong safety climate is beneficial for patient safety. We conceived of safety climate both as a property of organizations as a whole and as varying among groups within organizations (Gaba, Singer, & Rosen, 2007). Following organizational psychology theory which suggests that general organizational context shapes specific aspects of climate (Wallace, Popp, & Mondore, 2006), we examined organizational culture and its relationship to patient safety climate in 92 U.S. hospitals. In this way, we explored the potential for basic assumptions, values, and beliefs to play a role in safety climate.
In this study, organizational culture was operationalized using the competing values framework (CVF; Quinn & Rohrbaugh, 1983; Figure 1). The CVF framework posits four organizational culture dimensions. A group culture emphasizes teamwork, cohesiveness, mentorship, and participation and distributes rewards equally among members. An entrepreneurial culture is characterized by innovation, by risk taking, by focus on growth, and by rewards for individual initiative. It should be noted that "risk taking" in this context does not imply taking risks with respect to patient safety but rather with patient care processes, often with the explicit intent of improving some aspect of patient safety. A hierarchical culture values predictable operations, which it achieves through structure, rules, policies, and procedures; rewards are allocated according to rank. Finally, a production-oriented culture is rational, with a focus on rewards for goal accomplishment. According to the CVF, the overall culture of an organization will reflect some particular mix of these four dimensions. Thus, the CVF framework allows for the simultaneous consideration of potentially competing organizational characteristics and provides a means to encapsulate concisely the complex nature of organizational culture.
Working within the CVF framework, we considered likely relationships between levels of organizational culture and safety climate. Organizations with higher levels of group culture were hypothesized to have higher levels of safety climate (Hypothesis 1). We based this prediction on previous findings that strong groups are characterized by the psychological safety that encourages the openness about mistakes and concerns necessary for organizations to learn and to improve (Edmondson, 1999). The participation, the inclusion, and the shared decision making inherent in group culture have promoted collaboration and learning from peers (Cameron & Quinn, 1999; Shortell et al., 1995). Collegiality has also facilitated the implementation of processes related to improved patient safety (Kaissi, Kralewski, Dowd, & Heaton, 2007). Thus, we expected that group-oriented culture would be reflected in the policies, procedures, practices, and routines related to safety-the safety climate-in an organization. More group-oriented cultures have also been positively associated with a variety of better outcomes (Cameron & Quinn, 1999; Carman et al., 1996; Meterko, Mohr, & Young, 2004; Shortell et al., 1995, 2000; Zazzali, Alexander, Shortell, & Burns, 2007).
Higher levels of entrepreneurial culture were also hypothesized to be associated with higher levels of safety climate (Hypothesis 2). The dynamic and complex nature of health care requires hospitals to design innovative solutions to problems, to incorporate new technologies, and to adopt new routines safely and effectively. Employees in hospitals with a culture that emphasizes initiative, adaptability, and resilience-particularly when balanced by some degree of hierarchical control-may have expanded opportunities to observe experimentation aimed at improving safety and speaking up when an action or rule could compromise the safety of a patient. More entrepreneurial cultures have also been positively related to better outcomes (Cameron & Quinn, 1999; Carman et al., 1996; Meterko et al., 2004; Shortell et al., 1995, 2000; Zazzali et al., 2007).
By contrast, higher levels of hierarchical culture were hypothesized to be associated with lower levels of safety climate (Hypothesis 3). Although the standardization that comes with strong hierarchy can be beneficial (Adler, Goldoftas, & Levine, 1999), strong hierarchy can impede incorporation of frontline expertise into decisions and hamper sharing of valuable information, stifling safety awareness and learning (Carroll, Rudolph, & Hatakenaka, 2002). One key feature of other organizations with strong safety records (high-reliability organizations [HROs]) is an ability to "flatten the hierarchy" and to promote information flow (Roberts, 1990). Without explicit practices and policies that decentralize power, employees in hospitals that emphasize rules and standard procedures may also feel less empowered to speak up or to take action when confronted with a safety issue. Finally, organizations with higher levels of hierarchical culture have been most negatively related to performance measures (Cameron & Quinn, 1999; Carman et al., 1996; Meterko et al., 2004; Shortell et al., 1995, 2000; Zazzali et al., 2007).
Like hierarchical cultures, we hypothesized that higher levels of production-oriented culture will be associated with lower levels of safety climate (Hypothesis 4). In health care, a prime challenge to achieving safe climates is overt or covert pressure to put production and efficiency ahead of safety. Managing production pressure has also been important for achieving safe climates in other industries (Reason, 1990). Hospitals with less production-oriented cultures are likely to use practices and routines designed to take pressure off employees and to reinforce the importance of safety, such as time-outs for groups to reflect before and after procedures. Conversely, production pressure has been shown to impede safety climate and improvement in the operating room (Gaba, Howard, & Jump, 1994). More production-oriented cultures have also been negatively related to performance measures (Cameron & Quinn, 1999; Carman et al., 1996; Meterko et al., 2004; Shortell et al., 1995, 2000; Zazzali et al., 2007).
The previous hypotheses emphasize the influences of each of the organizational culture dimensions individually. In practice, however, hospitals will have mixtures of these dimensions. Some mixes of culture types might confer advantages that could lead to better safety climate and outcomes. For example, although safety can be enhanced by open communication and shared decision making, these values may be strengthened by the presence of some hierarchy, in the form of rules and guidelines, which could beneficially address organizations' need for authority and accountability and minimize unproductive and erratic variation in practice. To explore this, we investigated the mix of organizational culture associated with the highest safety climate.
Sample hospitals came from a stratified random sample of 92 U.S. hospitals, representing three size categories and all four U.S. census regions. They resembled U.S. hospitals except as dictated by our recruitment strategy, which sought equal representation of small (0-99 beds), medium (100-249 beds), and large (250+ beds) hospitals. Thus, sample hospitals were larger than the U.S. average. In addition, hospitals from the West were overrepresented in the sample. However, sample hospitals had similar rates of safety events, measured by the AHRQ Patient Safety Indicators, as all U.S. hospitals.
Questionnaires assessing perceptions of safety climate and organizational culture were administered to 35,340 individuals, including all senior managers, all physicians, and a 10% random sample of all other hospital staff at study hospitals between March 2004 and May 2005. Survey administration and follow-up procedures are reported elsewhere (Singer, Falwell, Gaba, & Baker, 2008). All questionnaires included measures of safety climate; a random one third of these also included measures of organizational culture. We received 18,361 safety climate surveys (52%) and 5,637 organizational culture surveys (42%). The overall response varied among hospitals and work groups (Singer et al., 2008, 2009). However, supplementary analysis confirmed that hospitals with low response rates did not represent extremes in our distribution of safety climate or organizational culture measures. In addition, differences in response patterns by survey wave did not suggest bias in response patterns. We adjusted responses to account for sampling and known response rate differences by job type (Singer et al., 2003).
Workers' perceptions of safety climate were measured using the 2004 Patient Safety Climate in Healthcare Organizations (PSCHO) survey (available on request). This instrument was selected from among several instruments (Colla, Bracken, Kinney, & Weeks, 2005; Flin et al., 2006; Singla, Kitch, Weissman, & Campbell, 2006) because it was designed to assess safety climate among all hospital employees, not just clinical staff or staff in specific units; its reliability and validity have been established; and it has been used extensively elsewhere (Cooper, 2006; Ginsburg, Norton, Casebeer, & Lewis, 2005; Hartmann et al., 2008; Singer et al., 2003, 2008). The PSCHO survey consisted of 38 questions about safety climate topics drawn from literature on HROs, plus six demographic questions. Each of the safety climate items used a 5-point Likert scale with a neutral midpoint. Psychometric analysis of response patterns, which assessed both convergent and discriminant validity, supported the construction of eight valid and reliable dimensions (Singer et al., 2007). Three organizational dimensions were senior managers' engagement with patient safety, the extent to which organizational resources are perceived as sufficient for safety, and a measure of the hospital's overall emphasis on safety. Two work-unit safety climate dimensions were informal unit safety norms and formal recognition and support for safety efforts. Two interpersonal dimensions were fear of shame associated with needing to ask for help and fear of blame for having made a mistake. One additional dimension was a self-reported measure of the incidence of unsafe care. Cronbach's alpha reliability coefficients for the safety climate dimensions ranged from .58 (fear of shame) to .89 (senior managers' engagement; Table 1).
We summarized results from the PSCHO survey by computing the fraction of respondents answering in ways that indicated low levels of safety climate. We referred to this fraction as the percent problematic response (PPR). Higher PPR indicates a lower level of safety climate. Debate continues regarding the most appropriate way to measure the strength and the uniformity of safety climate (Klein & Kozlowski, 2000); calculating PPR was one method (Gaba, Singer, & Rosen, 2007) used in previous research (Hartmann et al., 2008; Singer et al., 2003, 2008). Studies of HROs suggest that achieving highly reliable results requires consistent, prosafety perceptions among workers (Gaba, Singer, Sinaiko, & Bowen, 2003; Roberts, 1990). We prefer to use PPR rather than mean, positive, or standard deviation measures of safety climate because it highlights areas where safety attitudes are not uniformly positive.
For each respondent, we calculated the PPR for the eight separate multi-item safety climate dimensions as the average of item PPR. We also computed the average PPR for the 38 survey questions as a summary statistic, which we referred to as safety climate overall.
Organizational culture was assessed using the CVF as operationalized by Zammuto and Krakower (1991 [Z&K]; available on request). Survey methods have been questioned as a valid measure of organizational culture (Ashkanasy, Broadfoot, & Falkus, 2000; Schein, 1992; Trice & Beyer, 1993), which traditionally has been studied using ethnographic methods. However, although admittedly controversial (Scott, Mannion, Davies, & Marshall, 2003), the Z&K measure and the CVF are well established (Ostroff et al., 2003), have yielded findings similar to qualitative research (Zammuto & Krakower, 1991), and have proven useful for understanding the culture of health care organizations (Cameron & Quinn, 1999; Carman et al., 1996; Meterko et al., 2004; Shortell et al., 1995, 2000; Zazzali et al., 2007). Nevertheless, we acknowledge that the Z&K survey measured perceptions of dominant organizational behavior, which may or may not have measured culture per se. Compared with qualitative approaches, a survey also has the advantage of efficient implementation across large numbers of organizations.
The Z&K measure is structured around five key organizational features including, for example, the chief basis for distributing rewards. For each of these five features, four characterizations of an organization were presented, one representing each cultural type of the CVF. Respondents distributed 100 points across the culture characterizations to indicate the extent to which each description resembled their own organization. Cronbach's alpha reliability coefficients for the organizational culture types in our study were .48 for the production-oriented culture dimension, .55 for entrepreneurial, .70 for hierarchical, and .77 for group. We included in our models dimensions with relatively low reliability because of their theoretical interest. However, results related to production-oriented and entrepreneurial culture should be interpreted cautiously.
Characteristics of individuals and their jobs that may affect safety climate, including level of supervisory responsibility, age, gender, time at institution, professional discipline, and work area (emergency department, intensive care unit, operating room/postanesthesia care unit, medical/surgical ward, and others), served as controls in all models. These were drawn from individual responses to the PSCHO survey.
We also recognized that structural characteristics of hospitals, such as size, tax status, teaching status, region, urban location, nurse staffing levels, and financial status, may affect patient safety. We thus included these variables as additional controls in our analysis. Most of the hospital characteristics used in this study were derived from the American Hospital Association 2004 Annual Survey of Hospitals. For hospital size, we included both number of hospital beds and its square in our models because visual inspection suggested a curvilinear relationship between size and safety climate. As our measure of nurse staffing, we calculated the ratio of total full-time equivalent nurse hours per patient day. For financial status, we relied on the Dun & Bradstreet percentile rankings of hospital credit scores in 2004.
Hierarchical linear models examined the relationship between hospitals' organizational culture and patient safety climate, using individual-level data (Snijders & Bosker, 1999). Consistent with our conceptualization of safety climate as a property of both groups and organizations, we performed three-level random intercept analysis, which accounted for the nesting of individuals within work areas within hospitals while allowing for variation both within hospitals between work areas and between hospitals. A chi-square test comparing two- and three-level models with linear regressions found significant differences among both work areas and hospitals and confirmed appropriateness of using three-level models, χ2(2) = 630.86, p < .001.
We estimated hierarchical linear models in which safety climate and its eight dimensions were the dependent variables and measures of organizational culture were the independent variables of interest. Due to the ipsative nature of the organizational culture measures, only one culture type was included in any given model as in prior research with this instrument (Zazzali et al., 2007). Therefore, for each of the nine dependent variables, we first estimated a baseline model including only the control variables using our full sample of respondents. We then added each of the four culture types in turn to this basic model, applying these to the subsample of individuals who responded to the questionnaire version including both the safety climate and the organizational culture components. Thus, we examined 45 models (5 models for each of the nine dependent variables). Analyses were performed using STATA-10.
Next, we compared deviance differences between models to approximate information provided by an adjusted R2 (Snijders & Bosker, 1999). Hierarchical regression models do not permit direct assessment of the variance in the dependent variable explained by independent variables in the way that Ordinary Least Squares regressions do. Deviance differences allow assessment of model fit to the data, albeit in relative terms.
To explore what might be considered an "optimal" mix of general organizational culture types implied by our data, we compared the average culture-type scores of five hospitals with the highest safety climate overall to those with the lowest safety climate overall. First, we aggregated safety climate and organizational culture responses from the individual level to the hospital level. Aggregation was justified by one-way analysis of variance models, which assessed within-group versus between-group variance for safety climate overall and for each organizational culture dimension. The intraclass correlation coefficients of .027 for safety climate overall evaluated at the hospital level based on 197 respondents per hospital and of .030 to .122 for the organizational culture dimensions based on 61 respondents per hospital were all statistically significant (p = .000) Next, we graphically compared average organizational culture scores for the two groups of hospitals using a quadrant map that has been applied previously to the CVF measures (Zazzali et al., 2007). Then, we compared the mean scores for each culture type between the five highest and lowest safety climate hospitals using a t statistic to test for significance of the differences.
Respondents' scored their hospitals as having a hierarchical organizational culture the most (average = 31.6 points) and as having an entrepreneurial culture the least (average = 15.7 points; Table 1). Thus, the average respondent worked in a hospital with a culture that emphasized rules but also encouraged participation and teamwork and attended less to productivity and least to risk taking. The average PPR for safety climate overall was 17.1%. Additional characteristics of respondents are available from the authors on request.
Relationship of Organizational Culture and Safety Climate
Five regression models predicting safety climate overall are presented. Results for the remaining 40 regression models, providing more detail regarding the relationship of organizational culture dimensions with specific aspects of safety climate, are available from the authors on request.
Relationships between organizational culture and safety climate were generally strong (Table 2, columns 2-5). Higher group culture was associated with higher safety climate overall and for each safety climate dimension individually (Hypothesis 1). Overall, a one-point-higher score for group culture correlated with a .24 percentage point lower PPR. Group culture was most highly correlated with organizational resources and work-unit support for safety, with an effect size of .42 percentage points for both. Higher entrepreneurial culture was also related to higher safety climate overall and for all but the two interpersonal dimensions (fear of shame and fear of blame; Hypothesis 2). A one-point-higher score for entrepreneurial culture related to .28 percentage point lower PPR overall and .63 percentage point lower PPR for work-unit support for safety (the strongest effect for an individual safety climate dimension). Higher hierarchical culture related to lower safety climate overall and for all dimensions except fear of shame (Hypothesis 3). A one-point-higher score for hierarchical culture related to .30 percentage point higher PPR overall and .62 percentage point higher PPR for work-unit support for safety. Higher production-oriented culture was related to lower safety climate overall, for the three organizational dimensions and the provision of safe care, but not the work-unit or interpersonal safety climate dimensions (Hypothesis 4).
Comparison of Model Fit
Statistics assessing the fit of our models to the data suggested substantial improvement in fit when the organizational culture variables were included relative to the model including only controls (Table 2). The organizational culture variables accounted for more than threefold improvement in deviance measures of model fit compared with models with controls alone.
Optimal Mix of Organizational Culture Type
To explore the role of culture-type mix, we examined five hospitals in our sample with the highest and five with the lowest safety climate scores overall. Mean PPR for safety climate overall was 11.5 among the highest safety climate hospitals and 24.6 among the lowest safety climate hospitals (p = .000). Figure 2 is a graphical depiction of the average culture-type mixtures in these two groups. The results suggest that the optimal safety climate includes a mix of general organizational culture types. The five hospitals with the highest levels of safety climate scored highest on group culture (40.1), followed by hierarchical culture (24.6), production-oriented culture (20.0), and entrepreneurial culture (15.3). The pattern among the five hospitals with the lowest levels of safety climate was also consistent with regression results, with the highest score on hierarchical culture (36.7) and considerably lower scores on group (26.9), production-oriented (22.4), and entrepreneurial (13.9) dimensions. Differences between levels of group and hierarchical culture present in high and low safety climate hospitals were statistically significant at p < .05.
We found that patient safety climate was better when individuals also perceived that their hospital emphasized more group participation and less hierarchy. The association between higher group culture and better safety climate was not surprising, given that teamwork is necessary in patient care and problem-solving activities to maintain a safe environment. That more entrepreneurial culture may also relate positively to safety climate implies that some innovation and adaptability may be necessary for organizational learning and process change. Our finding that better safety climate was related to lower hierarchical culture suggests that high levels of bureaucracy may have a dampening effect on communication and information flow, which can be an important impediment to safety climate. In addition, better safety climate may relate to a lower production orientation, implying that demand for efficiency-at least to the extent that it comes at the expense of safety-could impede safety climate.
Results are relatively consistent across safety climate dimensions. However, organizational culture is most consistently related to features of safety climate that pertain to organizations and least consistently related to interpersonal dimensions of safety climate. The latter may be more a function of individual differences relative to institutional characteristics in comparison with other safety climate dimensions.
The graphical comparison of the distribution of cultural-type scores in hospitals with the highest and lowest levels of safety climate suggests that the relationship between culture types and safety climate may be complicated. The optimal mix probably weights group orientation most heavily. Relatively high levels of hierarchical culture observed among hospitals with the highest safety climate suggest that it may be important to couple strong teamwork with entrepreneurial initiatives and adaptability with sufficient standard operating procedures and managerial control to achieve appropriate uniformity and performance of clinical processes.
These results have implications for the design and effectiveness of hospitals. Our comparison of organizational culture in hospitals with different levels of safety climate and related findings in other industries (Zohar, 2002) suggests that promoting group-oriented cultures and reducing hierarchical ones may be desirable. Reducing production pressure by improving workload prediction and planning and through policies and procedures for handling unpredictable workload changes is a known strategy, also consistent with our findings (Gaba et al., 1994). There is also evidence that senior managers do not perceive safety climate in the same way that frontline workers do, and this may hamper their ability to appreciate and to support the changes required to optimize patient safety (Singer et al., 2008). Interventions for improving senior managers' awareness of frontline safety hazards may address this concern (Frankel et al., 2008; Tucker, Singer, Hayes, & Falwell, 2008). Even in hospitals where senior managers are engaged, physician independence and focus on individual performance can pose significant challenges to efforts to promote group-oriented behavior.
Several strategies could be used to improve teamwork and group orientation. For example, teamwork might be improved through multidisciplinary team training, including use of simulation techniques that provide experiential learning opportunities and allow individuals to "walk in someone else's shoes" to gain understanding and appreciation for other roles and perspectives. Similarly, greater application of continuous quality improvement tools such as plan-do-study-act cycles could be encouraged. These tools emphasize working effectively in groups, use of effective team-management techniques, consensus-driven decision making, and broad participation of stakeholders, potentially fostering more group culture (Shortell et al., 1995). Human resource practices addressing selection, orientation, training, performance appraisal, and reward systems could be designed to reinforce work in teams. Finally, policies might attack antigroup behaviors, such as tolerating abusive conduct toward fellow workers and ensuring no blame is attached to those who report safety or quality problems.
Likewise, organizations with excessively hierarchical cultures could develop strategies to ameliorate detrimental effects. HROs, such as nuclear powered aircraft carriers, have developed practices that allow hierarchy to transform from rigid centralized control in some circumstances to flexible, distributed control in others (Roberts, 1990). Specific techniques include using decision-making algorithms and policies to distribute authority, assigning relatively high responsibility and accountability to low-level employees, and explicitly giving safety veto power to those nearest to a process regardless of rank.
Although this study shares limitations with other cross-sectional analyses, it provides some useful insights for improving patient safety climate. Our findings can be interpreted as good news for hospitals in their efforts to improve patient safety. They imply that characteristics of organizations that are relatively mutable-at least in comparison with structural characteristics such as size or to market conditions as reflected in nurse staffing ratios and hospital financial status-are strongly related to safety climate. They also suggest that organizational culture explains more of the variance in safety climate among hospitals than structural characteristics do. Although difficult to achieve, hospital leaders can change organizational culture over time (Schein, 1992). Altering the mix of organizational culture seems to be a potentially useful strategy for promoting safety climate and ultimately patient safety. Our results suggest that hospitals may be able to increase safety climate by cultivating improvement-oriented teamwork and openness to innovation, leavening these with enough hierarchy to keep things under control. The lessons of HROs (which operate at high production and tempo while still achieving the most highly reliable results) suggest that a production orientation should be tempered by specific practices targeted to ensure safety.
Several limitations of our study are worth noting. First, despite a fairly representative sample of U.S. hospitals, reasonable response rates, compensation for expected and actual differences in nonresponse by job category through oversampling and weighting adjustments, and lack of systematic differences in responses among survey waves, the possibility of selection bias remains. Second, obtaining data from a single survey raises concern regarding endogeneity, that is, that the relationship found between safety climate and organizational culture was exaggerated. In practice, common method bias could inflate or deflate the apparent relationship (Spector, 2006). Also, the simplicity and distinctiveness of survey items related to safety climate as compared with culture and the observed variation in safety climate results by type of organizational culture mitigate this concern. Third, although we have argued that organizational culture and safety climate are related yet distinct features of organizations, we are unable to confirm discriminant validity between these measures. The ipsative nature of the organizational culture-type scale precludes traditional factor analysis.
This study provides the first empirical evidence of a link between safety climate and organizational culture. Others have found relationships between both structural characteristics and organizational culture and other outcomes of interest in hospitals and physician organizations (Cameron & Quinn, 1999; Carman et al., 1996; Meterko et al., 2004; Shortell et al., 1995, 2000; Zazzali et al., 2007). However, none have examined the link between these characteristics of organizations and safety climate. The results of our study suggest that general organizational culture is important to organizations' climate of safety. Transforming hospital culture may be a powerful tool to advance patient safety. Future research should seek to establish more persuasive evidence of the link between safety climate and safety performance and to identify situations in which selected processes, such as implementation of health information technology, moderate this relationship.
The authors thank Tobias Rathgeb for research assistance and the individuals and hospitals of the Patient Safety Consortium who participated in this study. Financial support for this research was provided by the Agency for Healthcare Research and Quality RO1 HSO13920. Preliminary results were presented at the Academy Health Annual Research Meeting, June 5, 2007, Orlando, Florida. Approval from all relevant institutional review boards was granted before conducting this study.
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Keywords:© 2009 Lippincott Williams & Wilkins, Inc.
hospital characteristics; organizational culture; patient safety; safety climate; survey