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The Correlation Between Neonatal Intensive Care Unit Safety Culture and Quality of Care

Profit, Jochen MD, MPH*†; Sharek, Paul J. MD†‡§; Cui, Xin PhD, MPH*†; Nisbet, Courtney C. RN, MS†§; Thomas, Eric J. MD, MPH; Tawfik, Daniel S. MD; Lee, Henry C. MD, MS*†; Draper, David PhD**; Sexton, J. Bryan PhD††‡‡

doi: 10.1097/PTS.0000000000000546
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Objectives Key validated clinical metrics are being used individually and in aggregate (Baby-MONITOR) to monitor the performance of neonatal intensive care units (NICUs). The degree to which perceptions of key components of safety culture, safety climate, and teamwork are related to aspects of NICU quality of care is poorly understood. The objective of this study was to test whether NICU performance on key clinical metrics correlates with caregiver perceptions of safety culture.

Study Design Cross-sectional study of 6253 very low-birth-weight infants in 44 NICUs. We measured clinical quality via the Baby-MONITOR and its nine risk-adjusted and standardized subcomponents (antenatal corticosteroids, hypothermia, pneumothorax, healthcare-associated infection, chronic lung disease, retinopathy screen, discharge on any human milk, growth velocity, and mortality). A voluntary sample of 2073 of 3294 eligible professional caregivers provided ratings of safety and teamwork climate using the Safety Attitudes Questionnaire. We examined NICU-level variation across clinical and safety culture ratings and conducted correlation analysis of these dimensions.

Results We found significant variation in clinical and safety culture metrics across NICUs. Neonatal intensive care unit teamwork and safety climate ratings were correlated with absence of healthcare-associated infection (r = 0.39 [P = 0.01] and r = 0.29 [P = 0.05], respectively). None of the other clinical metrics, individual or composite, were significantly correlated with teamwork or safety climate.

Conclusions Neonatal intensive care unit teamwork and safety climate were correlated with healthcare-associated infections but not with other quality metrics. Linkages to clinical measures of quality require additional research.

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

From the *Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine and Lucile Packard Children's Hospital;

California Perinatal Quality Care Collaborative;

Center for Quality and Clinical Effectiveness, Lucile Packard Children's Hospital;

§Division of General Pediatrics, Department of Pediatrics, Stanford University, Palo Alto, California;

University of Texas at Houston - Memorial Hermann Center for Healthcare Quality and Safety, University of Texas Medical School, Houston, Texas;

Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University School of Medicine; Stanford;

**Department of Applied Mathematics and Statistics, Baskin School of Engineering University of California, Santa Cruz, California; and

††Department of Psychiatry, Duke University School of Medicine, and

‡‡Duke Patient Safety Center, Duke University Health System, Durham, North Carolina.

Correspondence: Jochen Profit, MD, MPH, Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, MSOB Rm x115, 1265 Welch Rd, Stanford, CA 94305 (e-mail: profit@stanford.edu).

The authors disclose no conflict of interest.

This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01 HD084679-01, co-PI: J.B.S. and J.P., and K24 HD053771-01, PI: E.J.T.).

J.P. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

J.P. acquired funding for this study, conceptualized and designed the study, selected data for inclusion in analyses, analyzed the data, assisted with interpretation of the results, drafted the initial manuscript, and approved the final manuscript as submitted. P.J.S. helped conceptualize and design the study, was the local lead for CPQCC NICUs, helped select data for inclusion in the survey and analyses, assisted with interpretation of the results, revised the manuscript, and approved the final manuscript as submitted. X.C. assisted with designing the analysis and interpretation of the results, revised the manuscript, and approved the final manuscript as submitted. C.N. coordinated data collection among CPQCC member NICUs, de-identified data, assisted with interpretation of the results, revised the manuscript, and approved the final manuscript as submitted. E.J.T. helped acquire funding, conceptualized and designed the study, selected data for inclusion in the survey and analyses, assisted with interpretation of the results, revised the manuscript, and approved the final manuscript as submitted. D.S.T. helped with interpretation of the results, revision of the manuscript, and approved the final manuscript as submitted. H.C.L. helped with conceptualizing the paper, designing the analysis, and interpreting the results. He revised the manuscript and approved the final manuscript as submitted. D.D. created the statistical methodology underlying the Baby-MONITOR, helped with interpreting the results and revising the manuscript, and approved the final manuscript as submitted. J.B.S. helped acquire funding for this study, conceptualized and designed the study, selected data for inclusion in the survey and analyses, and assisted with interpretation of the results. He revised the initial manuscript and approved the final manuscript as submitted.

What's Known: Establishing a strong culture of safety is a health policy priority. Teamwork and safety climate, two well-established dimensions of safety culture, vary significantly among NICUs. The contribution of this variation to differences in NICU quality of care delivery is unknown.

What This Study Adds: NICU teamwork and safety climate correlated significantly with healthcare-associated infections. However, other metrics of quality of care did not correlate. Caution should be applied in equating efforts to improve safety culture with expectations for better quality of care delivery.

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