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By Robert J. Wolosin, PhD

In theory, a hospital's safety culture ought to be related to its service quality--how well it deals with the service expectations of its patients, reflected in their satisfaction. Similar practices (e.g., open communication among staff members) and values (e.g., patient- and family-centered care), contribute to both patient safety and patient satisfaction. Nurses who are satisfied and engaged, and who can spend sufficient time at the bedside, will presumably know their patients and their patients' vulnerabilities better, and have the time and energy to ward off potential harms. At the same time, such nurses are in a better position to address patients' and families' psychosocial needs-a consistently powerful driver of patient satisfaction (Donabedian, 1988; Gerteis, Edgman-Levitan, Daley & Delbanco 1993; Press, 2005).

There are reports of empirical connections between patient safety and patient satisfaction in the published literature. A recent study examined inpatients' reports of service "incidents"-deficiencies in service quality such as waits/delays, poor communication, poor care coordination, lack of respect for personal preferences, or environmental issues. Roughly 40% of patients reported at least one incident, and reporting of incidents was associated with diminished patient satisfaction. (Weingart, et al., 2006) A review of seven quantitative studies of the relationship between nursing leadership and patient outcomes found significant associations between positive leadership behaviors and both increased patient satisfaction and reduced adverse events (Wong and Cummings, 2007).

This study examines the relationship between employee ratings of hospital safety culture and patient ratings of service quality from the same hospitals. As consumers of any particular hospital's services, patients and employees encounter the hospital from differing standpoints. Fundamentally, patients see themselves as temporary inhabitants of the hospital. Their purpose is getting better and going home, while employees have a longer-term perspective, with investments in the hospital workplace as well as in their own careers.

It is hypothesized that hospitals with a strong culture of patient safety, as rated by employees, will be the same hospitals whose patients experience high levels of service quality.

Method
Two survey instruments were used to gather data for this study. The Press Ganey Inpatient Survey is structured around a typical hospital visit, starting with admission. It inquires about important hospital events, processes, and people, as well as how well the patient's psychosocial needs were addressed. Patients make quality ratings on a 5-point, balanced, modified Likert scale. Patients receive and return surveys through the mail, beginning approximately one week post hospital discharge. This instrument has been described in detail elsewhere (Gesell, Clark et al., 2005; Kaldenberg, Mylod and Drain, 2003).

Press Ganey's Safety Culture Survey was adapted from an instrument developed by the Agency for Healthcare Research and Quality (AHRQ) in 2004. It assesses hospital's culture of safety by inquiring into the individual/group values, attitudes, perceptions, and patterns of behavior of the staff. Overall ratings of job satisfaction, loyalty, personal safety as a patient, and safety culture were added to supplement the AHRQ measure. Psychometric properties of this instrument are available from the author.

The Safety Culture survey is based on the premise that patient safety depends heavily on employee practices within hospital units. These practices include open communication across staff levels, teamwork within and between units, a non-punitive response to errors, and the ability to learn from errors. Employees rate these practices as well as estimate how frequently various types of mistakes are made and the number of event reports they submit. Employees also assign a grade to their unit's safety, on a scale from Excellent to Failing. The survey is typically administered on-site, handed out to employees and returned to the hospital, which sends completed surveys to Press Ganey for processing and reporting.

Forty-four Press Ganey Associates acute-care hospital clients have already used both the Inpatient Survey and the Safety Culture Survey. For this analysis, surveys returned between October, 2006, and August, 2007, were analyzed. Together, they represent evaluations of 53,784 patients and 20,057 hospital personnel.

Results
The scatterplot, above, shows average safety culture and service quality ratings, aggregated by hospital. Thus, each point depicts one of the 44 hospitals in the sample; each hospital's patient-rated average service quality score is plotted on the horizontal axis, its corresponding employee-rated safety culture score is shown on the vertical axis. Axis scales reflect differing ranges of scores attained in the two surveys. With some exceptions, most of the points fall relatively close to the regression line running from the lower left to the upper right of the graph. The two scores correlated r = .57 (p < .001). nearly one-third of the variation in hospital overall safety culture ratings can be explained by patient satisfaction in the same hospitals.

Comments and Caveats
Hospitals whose employees rate as having a culture of patient safety tend to be hospitals that meet or exceed patient expectations for service. The strength of the relationship, though moderate, indicates that there is no necessary competition between the two goals. This fact should be heartening for patient safety advocates who must justify their requests for resources in the context of other demands. It is apparently not the case that devoting resources to patient safety activities will be detrimental to service quality.

Two caveats are in order: First, because the current study used data from clients who hired a consulting firm so as to improve their practices, the data are subject to selection bias. Second, would-be respondents can choose not to respond, resulting in a potential for non-response bias. These issues are discussed at length in Gesell, Clark, Mylod, et al. (2005) in the context of hospital-level correlations of service and clinical quality.

Robert Wolosin is a research product manager at Press Ganey Associates in South Bend, Indiana. He may be contacted at rwolosin@pressganey.com.

References
Donabedian, A. (1988). The quality of care: How can it be assessed? JAMA, 260, (12) 1743-1748.

Gerteis M, Edgman-Levitan S, Daley J, Delbanco T.T. (Eds.) (1993). Through the patient's eyes: Understanding and promoting patient-centered care. San Francisco: Jossey-Bass.

Gesell, S.B, Clark, P.A., Mylod, D.E., et al. (2005). Hospital-level correlation between clinical and service quality performance for heart failure treatment. Journal for Healthcare Quality

Kaldenberg , D., Mylod, D., Drain, M. (2003). Patient-derived information: Satisfaction with care in acute and post-acute care environments. In N. Goldfield, M.

Pine, & J. Pine (Eds.), Measuring and managing health care quality (pp. 469-489). New York: Aspen Publishers.

Press I. (2005). Patient satisfaction: Understanding and managing the experience of care. 2nd edition. Chicago: Health Administration Press.

Weingart S.N., Pagoviceh O., Sands D.Z., et al. (2006, April). Patient-reported service quality on a medicine unit. International Journal of Quality in Health Care 18(2): 95-101.