ARQH: What Is Your Organization’s Patient Safety Culture?

March / April 2011


What Is Your Organization’s Patient Safety Culture?

Ask any frontline clinician or healthcare support staff if they can identify the components that make up a “culture of patient safety,” and you might get a vague answer in response. But ask those same health providers if they feel they can speak up to report patient safety concerns without fearing retribution, and you’re likely to get very specific responses.

Just as all organizations have a culture that reflects how they do what they do, so do healthcare organizations. Patient safety culture is generally defined by researchers as the values, beliefs, and perceptions that surround the behavior of people working in a hospital or a health system (Singer et al., 2009). An organization’s patient safety culture exerts a powerful influence on many endeavors, including its efforts to identify behaviors, assumptions, or omissions that can lead to medical errors.

Academic organizations, notably Johns Hopkins University (JHU), and Federal research agencies, such as the Agency for Healthcare Research and Quality (AHRQ), have led the field in developing evidence-based surveys that help organizations measure their patient safety culture. As more organizations put these tools into practice, new findings highlight the significant potential to extend patient safety improvement from the unit level to the entire organization. At the same time, findings from countries outside the United States suggest that culturally unique values and behaviors need to be factored for a true reflection of safety culture.

A Safety Program to Reduce Infections
By now, most healthcare organizations are familiar with the evidence-based methods pioneered by JHU researchers and practiced in hospital intensive care units in Michigan to reduce catheter-related bloodstream infections and ventilator-associated pneumonia (Pro-
novost et al., 2006). In the Michigan initiative, known as the Keystone Project, interventions have reduced the median rate of these infections to zero, a rate that has held steady for 3 years. The project is now being expanded on a national scale through the U.S. Department of Health and Human Services, with funding from AHRQ and other major federal health agencies (Department of Health and Human Services, 2009).

A central feature of the Keystone Project is the comprehensive unit-based safety program, or CUSP, which consists of steps that help providers enhance their awareness of and alter behaviors to promote patient safety. CUSP works with providers to identify hazards, learn from defects, partner with executive leadership, and implement communication and teamwork at the unit level. (More information and training materials are available at

Expanding Safety from the Unit to the Entire Organization
While specific interventions can improve the patient safety culture of a hospital unit, can they positively influence the entire organization?
To test this theory, JHU researchers put a series of hospital-wide interventions into place in 144 of its clinical units between 2006 and 2008. In addition to CUSP, interventions included an electronic event-reporting system; training on science safety at departmental grand rounds; and communications tools, such as a newsletter to share lessons from adverse events and describe effective interventions (Paine et al., 2010).

Outcomes were assessed using the Safety Attitudes Questionnaire, which seeks feedback from frontline providers about safety climate, teamwork climate, job satisfaction, stress recognition, working conditions, and perceptions of hospital-level and unit-level management. Meeting the safety culture goal required units to meet or exceed the 60% minimum positive score or improve it by 10 points or more.
Using the hospital-wide interventions improved patient safety climate scores significantly, the study found. For safety climate, which sought feedback on statements such as: “I would feel safe being treated here as a patient,” 82% of units achieved the culture goal in 2008, compared to 55% in 2006. Teamwork climate showed a similar level of improvement (83% in 2008 vs. 61% in 2006). Improvements were seen in all areas except stress recognition.

Despite the overall improvement in safety climate, the research team concluded that methods to investigate errors, define interventions, and evaluate risk reduction “remain immature.” This will require hospitals to make greater use of systems and human factors engineers.

Comparing Patient Safety Culture across Hospitals
In response to requests from hospitals interested in comparing patient safety culture results, AHRQ established a comparative database for the Hospital Survey on Patient Safety Culture (HSOPSC). The 2011 database report (Sorra et al., 2011) presents results from 1,032 U.S. hospitals with 472,397 hospital staff respondents. Results show that:

  • Smaller hospitals (6 to 24 beds) have higher patient safety culture scores than hospitals with 300 beds or more.
  • Rehabilitation units have higher scores than other units, and emergency departments tend to have the lowest scores.
  • Administration/management perceive the patient safety culture of their organization more highly than all other staff.

Areas of strength across hospitals were “teamwork within units” (80% positive) and “supervisor/manager expectations and actions promoting patient safety” (75% positive). Areas for improvement were in “non-punitive response to error” (44% positive) and “handoffs and transitions” (45% positive).

Changing culture takes time, and the database findings support this conclusion. For 512 hospitals that administered the survey more than once, trends showed average score increases of only 2 percentage points after 20 months. These results, while sobering, can enable hospitals to set more realistic expectations about the level of effort and time it takes to achieve culture change.

Patient Safety Culture:
A Global Challenge

Elements of patient safety culture—teamwork, management support, working conditions, and so on—transcend geographic and cultural boundaries. Yet findings from a new study of patient safety culture conducted between 2006 and 2008 at 42 hospitals in Taiwan caution against sweeping generalizations (Chen et al., 2010).

Study authors used AHRQ’s HSOPSC to measure 12 dimensions of patient safety culture among 788 physicians, nurses, and non-clinical staff (AHRQ, 2004). The dimensions include:

  • Seven unit-level aspects of safety culture, such as teamwork, communications, staffing, and non-punitive response to error.
  • Three hospital-level aspects of safety culture, including hospital management support for patient safety, teamwork across units, and hospital handoffs.
  • Two outcome variables, including overall perceptions of safety and frequency of event reporting.

Respondents at Taiwan hospitals gave their organization an overall positive rating of patient safety culture of 64%, slightly higher than the AHRQ data average of 61%, according to study findings. The dimension that received the highest positive response was “teamwork within units” (93% for supervisors, 94% for non-supervisors), while “staffing” received the lowest (42% for supervisors, 37% for non-supervisors). Other dimensions with low positive scores were “non-punitive response to error” (52% for supervisors, 41% for non-supervisors), and “hospital handoffs and transitions” (54% for supervisors, 45% for non-supervisors).

Although authors’ analysis of the findings confirmed that the HSOPSC is a good fit to assess patient safety culture in Taiwan, they caution that questionnaires developed in one cultural setting cannot always be directly translated and used in another.

In particular, findings in the areas of communication openness and non-punitive response to error “may be partly explained by the differences in organizational behavior between cultural settings.” Most of the respondents in Taiwan hospitals are “shy of speaking up or asking questions when something which does not seem right has happened,” the authors said.

American culture praises direct communication and speaking up as ways to raise safety concerns, but other cultures may use different ways to communicate safety concerns that may be more effective in their culture. Within some safety culture dimensions, differences in scores across countries may not reflect true differences in patient safety culture, but instead may reflect distinct cultural norms. Research that addresses cultural norms is needed to better understand how group dynamics and individual attitudes affect patient safety culture across countries.

In slightly more than a decade, the contribution of a positive patient safety culture on safer care has evolved from a theory to an evidence-based national demonstration program to reduce the incidence of HAIs and save billions of dollars in preventable healthcare expenditures.

Much work remains to be done, of course. The recent study at JHU highlights the myriad interventions needed, even at a sophisticated academic medical center, to translate safety culture gains from one unit to an entire organization. Despite these interventions, safety culture is deeply embedded in organizations and is slow to respond to improvement efforts. Culture change can be achieved through sustained improvements in safety practices and outcomes. And as the Taiwan hospital study findings indicate, attempts to directly implement interventions that are successful in one country may need adaptation to make sure they are equally successful elsewhere.

Nonetheless, assessing an organization’s patient safety culture remains a critical first step for healthcare organizations of all sizes. Feedback provides organizations with the specific data needed to build or expand a culture where patient safety can flourish. The coming decade is certain to differentiate those organizations that commit their energy and resources to this important goal.

Carolyn Clancy is director of the Agency for Healthcare Research and Quality, Rockville, Maryland. She is a general internist and holds an academic appointment at George Washington School of Medicine in Washington, DC. She may be contacted at

Agency for Healthcare Research and Quality. Hospital Survey on Patient Safety Culture. (2010). Retrieved February 7, 2011, from

Chen, I. C., Li, H. H. Measuring patient safety culture in Taiwan using the Hospital Survey on Patient Safety Culture (HSOPSC). (2010). BMC Health Services Research, 10, 152.

Paine, L., Rosenstein, B.J., Sexton, J.B., Kent, P., Holzmueller, C.G., Pronovost, P.J. (2010). Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study. Quality & Safety in Health Care, 19, 547-554.

Pronovost, P., Needham, D., Berenholtz, S., Sinopoli, D., Chu, H., Cosgrove, S., et al. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 355, 2725-2732.

Singer, S., Lin, S., Falwell, A., Gaba, D., & Baker, L. (2009). Relationship of safety climate and safety performance in hospitals. Health Services Research, 44, 399-421.

Sorra J, Famolaro T, Dyer N, et al. (2011) Hospital Survey on Patient Safety Culture 2011 Comparative Database Report. (Prepared by Westat, Rockville, MD under Contract No. HHSA 290299710024C). Rockville, MD: Agency for Healthcare Research and Quality; April 2011. AHRQ Publication No. 11- 0048.

U.S. Department of Health & Human Services. HHS Action Plan to Prevent Healthcare-Associated Infections. (2009). Retrieved February 7, 2011, from