Achieving a Climate for Patient Safety
Achieving a Climate for Patient Safety
Objective Despite many initiatives, advances in patient safety remain uneven in part because poor relationships among health professionals have not been addressed. The purpose of this study was to determine whether relationships between health professionals contributed to a patient safety climate, after implementation of an intervention to improve inter-professional collaboration.
Design/Setting This was a secondary analysis of data collected to evaluate the Interprofessional Model of Patient Care (IPMPC) at The Ottawa Hospital in Ontario, Canada, which consists of five sites. A series of generalized estimating equation models were generated, accounting for the clustering of responses by site.
Participants Thirteen health professionals including physicians, nurses, physiotherapists and others (n = 1896) completed anonymous surveys about 1 year after the IPMPC was introduced.
Intervention The IPMPC was implemented to improve interdisciplinary collaboration.
Main Outcome Measures Reliable instruments were used to measure collaboration, respect, inter-professional conflict and patient safety climate.
Results Collaboration (β = 0.13; P = 0.002) and respect (β = 1.07; P = 0.03) were significant independent predictors of patient safety climate. Conflict was an independent and significant inverse predictor of patient safety climate (β = −0.29; P = 0.03), but did not moderate linkages between collaboration and patient safety climate or between respect and patient safety climate.
Conclusions Through the IPMPC, all health professionals learned how to collaborate and build a patient safety climate, even in the presence of inter-professional conflict. Efforts by others to foster better work relationships may yield similar improvements in patient safety climate.
Advances in patient safety remain uneven, and progress has been slow despite considerable research and changes to healthcare policy and practice. The importance of establishing a climate of patient safety in healthcare organizations has taken on added urgency now that hospital accreditation in the USA requires an assessment of safety climate, defined as a perception of organizational commitment to patient safety. Accreditation Canada requires that organizations create a culture that supports a safe and healthy work environment, thus focusing more on patient safety culture, defined as the shared values, attitudes and norms to which organizational members, in varying degrees, direct their attention as they act to minimize patient harm while caring for patients. Patient safety climate and culture are not synonymous, with safety climate representing a surface layer view of the deeper, more entrenched patient safety culture.
There have been multiple success stories of initiatives contributing to greater patient safety, but there have been numerous disappointments as well. Closer examination of these successes and disappointments reveals that relationships among health professionals were unnoticed in many of the failed attempts to improve patient safety, inhibiting the development of a patient safety climate. Although patient safety climate is an organizational attribute, the organization consists of health professionals who work independently or in small groups to provide patient care. Collaborative relationships lead to effective inter-professional practice, which is the key to establishing a patient safety climate and the future in healthcare systems, because no one discipline has all of the knowledge needed to promote patient safety and input from all disciplines is required.
We conducted a secondary data analysis to answer this research question: how do relationships, exemplified by health professionals' perceptions of inter-professional collaboration, respect and inter-professional conflict, contribute to a climate of patient safety?
Relationships among health professionals have been commonly conceptualized in the literature as non-technical skills (e.g. task management, teamwork and decision-making), social capital (e.g. social interactions and personal relationships) or networks (e.g. relationships between people). Relationships between various health professional groups contribute to or inhibit the development of a patient safety climate and have been shown to contribute to patient safety directly as well as indirectly. For example, a patient safety project team and international panel of experts recently came up with an evidence-based list of 22 patient safety strategies that should be adopted by healthcare providers. Strategies were divided into two groups: those that the panel 'strongly encouraged' and others that were merely 'encouraged'. Preoperative and other checklists were on the list of strongly encouraged strategies, whereas team training was on the list of encouraged strategies, which somehow seems to ignore the fact that it is not the checklist itself that contributes to patient safety but the communication between care providers (the team) who complete it.
Inter-professional collaboration has been defined as a process in which interdependent professionals engage collectively to meet patients' needs. Interventions to improve inter-professional collaboration may affect patient outcomes such as length of stay but have been labeled as promising rather than proven in a recent review, because while one study showed a significant decrease in the length of stay, another showed no difference. Respect has been characterized as a moral principle and recognizes the value of patients as persons unconditionally. Mutual respect is a core component of relational coordination and has been found to be a significant contributor to important patient outcomes for surgical patients. Disrespect has been identified as a threat to patient safety, because it inhibits collaboration as well as compliance with practices that promote patient safety. Inter-professional conflict among physicians, nurses and other health professionals may occur because of overlapping competencies and blurred role boundaries between various health professions. Teamwork and effective communication, which are important contributors to patient safety, depend on collaboration that can be jeopardized when conflict arises and is not appropriately managed. Moreover, conflict, if left unresolved, contributes to the lack of respect as well. Thus, unresolved conflict may act as a moderator, indirectly influencing patient safety climate through the lack of collaboration and respect. We developed and tested a model, proposing relationships between concepts based on our review of the literature. Figure 1 displays our model, which posits that inter-professional collaboration and respect will have direct positive impacts on patient safety and also be moderated by inter-professional conflict, which is posited to have a direct negative effect on patient safety climate. Plus signs in the model indicate positive relationships, whereas minus signs indicate inverse relationships.
(Enlarge Image)
Figure 1.
A model of relationships and patient safety climate
Several hospitals in Ottawa, Ontario, Canada, merged in 1998 to form The Ottawa Hospital (TOH). Today, TOH is a multi-site academic health center with >6000 health professionals deployed in 5 campuses over 110 units/services. The Inter-Professional Model of Patient Care (IPMPC) was an intervention implemented in 2006 to improve interdisciplinary collaboration. Representatives from all health disciplines developed a set of 22 guiding principles to provide the needed organizational structures and processes for inter-professional collaboration and organize the delivery of patient care among all healthcare professionals. The guiding principles are divided into: (i) the care environment and community linkages (10 guiding principles, e.g. 'the patient and family will have their individual beliefs and values recognized and respected by all healthcare providers') and (ii) inter-professional teamwork (12 guiding principles, e.g. 'healthcare providers will collaborate and provide support to foster team spirit and teamwork'). Research ethics approval for the IPMPC was granted by the Ottawa Hospital Research Institute, the University of Western Ontario and the University of Ottawa.
Each nursing unit constituted its own multi-disciplinary team consisting of a clinical nurse manager and health professional co-chair, as well as a representative from each discipline including a physician/surgeon. All 103 nursing unit teams were required to reflect on the guiding principles and decide whether each principle was met, partially met or not met. Then, each team developed and carried out an action plan specific to its needs; the roll out and implementation of the IPMPC was unique to each team. Support for the roll out of the IPMPC came in the form of education workshops, a series of online, self-directed learning modules, a public awareness campaign for patients and families and a network of advocates within TOH to promote inter-professional care.
As part of the evaluation of the IPMPC, all healthcare disciplines completed anonymous surveys, which contained instruments to measure collaboration, respect, conflict and patient safety climate (among others). The extent to which these concepts interact to contribute to a patient safety climate has not been studied. Yet, given the importance of these relational characteristics to patient safety as described earlier, leaders need this information so that they can develop organizational processes to foster those characteristics that are most influential to a climate of patient safety.
Abstract and Introduction
Abstract
Objective Despite many initiatives, advances in patient safety remain uneven in part because poor relationships among health professionals have not been addressed. The purpose of this study was to determine whether relationships between health professionals contributed to a patient safety climate, after implementation of an intervention to improve inter-professional collaboration.
Design/Setting This was a secondary analysis of data collected to evaluate the Interprofessional Model of Patient Care (IPMPC) at The Ottawa Hospital in Ontario, Canada, which consists of five sites. A series of generalized estimating equation models were generated, accounting for the clustering of responses by site.
Participants Thirteen health professionals including physicians, nurses, physiotherapists and others (n = 1896) completed anonymous surveys about 1 year after the IPMPC was introduced.
Intervention The IPMPC was implemented to improve interdisciplinary collaboration.
Main Outcome Measures Reliable instruments were used to measure collaboration, respect, inter-professional conflict and patient safety climate.
Results Collaboration (β = 0.13; P = 0.002) and respect (β = 1.07; P = 0.03) were significant independent predictors of patient safety climate. Conflict was an independent and significant inverse predictor of patient safety climate (β = −0.29; P = 0.03), but did not moderate linkages between collaboration and patient safety climate or between respect and patient safety climate.
Conclusions Through the IPMPC, all health professionals learned how to collaborate and build a patient safety climate, even in the presence of inter-professional conflict. Efforts by others to foster better work relationships may yield similar improvements in patient safety climate.
Introduction
Advances in patient safety remain uneven, and progress has been slow despite considerable research and changes to healthcare policy and practice. The importance of establishing a climate of patient safety in healthcare organizations has taken on added urgency now that hospital accreditation in the USA requires an assessment of safety climate, defined as a perception of organizational commitment to patient safety. Accreditation Canada requires that organizations create a culture that supports a safe and healthy work environment, thus focusing more on patient safety culture, defined as the shared values, attitudes and norms to which organizational members, in varying degrees, direct their attention as they act to minimize patient harm while caring for patients. Patient safety climate and culture are not synonymous, with safety climate representing a surface layer view of the deeper, more entrenched patient safety culture.
There have been multiple success stories of initiatives contributing to greater patient safety, but there have been numerous disappointments as well. Closer examination of these successes and disappointments reveals that relationships among health professionals were unnoticed in many of the failed attempts to improve patient safety, inhibiting the development of a patient safety climate. Although patient safety climate is an organizational attribute, the organization consists of health professionals who work independently or in small groups to provide patient care. Collaborative relationships lead to effective inter-professional practice, which is the key to establishing a patient safety climate and the future in healthcare systems, because no one discipline has all of the knowledge needed to promote patient safety and input from all disciplines is required.
We conducted a secondary data analysis to answer this research question: how do relationships, exemplified by health professionals' perceptions of inter-professional collaboration, respect and inter-professional conflict, contribute to a climate of patient safety?
Relationships among health professionals have been commonly conceptualized in the literature as non-technical skills (e.g. task management, teamwork and decision-making), social capital (e.g. social interactions and personal relationships) or networks (e.g. relationships between people). Relationships between various health professional groups contribute to or inhibit the development of a patient safety climate and have been shown to contribute to patient safety directly as well as indirectly. For example, a patient safety project team and international panel of experts recently came up with an evidence-based list of 22 patient safety strategies that should be adopted by healthcare providers. Strategies were divided into two groups: those that the panel 'strongly encouraged' and others that were merely 'encouraged'. Preoperative and other checklists were on the list of strongly encouraged strategies, whereas team training was on the list of encouraged strategies, which somehow seems to ignore the fact that it is not the checklist itself that contributes to patient safety but the communication between care providers (the team) who complete it.
Inter-professional collaboration has been defined as a process in which interdependent professionals engage collectively to meet patients' needs. Interventions to improve inter-professional collaboration may affect patient outcomes such as length of stay but have been labeled as promising rather than proven in a recent review, because while one study showed a significant decrease in the length of stay, another showed no difference. Respect has been characterized as a moral principle and recognizes the value of patients as persons unconditionally. Mutual respect is a core component of relational coordination and has been found to be a significant contributor to important patient outcomes for surgical patients. Disrespect has been identified as a threat to patient safety, because it inhibits collaboration as well as compliance with practices that promote patient safety. Inter-professional conflict among physicians, nurses and other health professionals may occur because of overlapping competencies and blurred role boundaries between various health professions. Teamwork and effective communication, which are important contributors to patient safety, depend on collaboration that can be jeopardized when conflict arises and is not appropriately managed. Moreover, conflict, if left unresolved, contributes to the lack of respect as well. Thus, unresolved conflict may act as a moderator, indirectly influencing patient safety climate through the lack of collaboration and respect. We developed and tested a model, proposing relationships between concepts based on our review of the literature. Figure 1 displays our model, which posits that inter-professional collaboration and respect will have direct positive impacts on patient safety and also be moderated by inter-professional conflict, which is posited to have a direct negative effect on patient safety climate. Plus signs in the model indicate positive relationships, whereas minus signs indicate inverse relationships.
(Enlarge Image)
Figure 1.
A model of relationships and patient safety climate
The Intervention
Several hospitals in Ottawa, Ontario, Canada, merged in 1998 to form The Ottawa Hospital (TOH). Today, TOH is a multi-site academic health center with >6000 health professionals deployed in 5 campuses over 110 units/services. The Inter-Professional Model of Patient Care (IPMPC) was an intervention implemented in 2006 to improve interdisciplinary collaboration. Representatives from all health disciplines developed a set of 22 guiding principles to provide the needed organizational structures and processes for inter-professional collaboration and organize the delivery of patient care among all healthcare professionals. The guiding principles are divided into: (i) the care environment and community linkages (10 guiding principles, e.g. 'the patient and family will have their individual beliefs and values recognized and respected by all healthcare providers') and (ii) inter-professional teamwork (12 guiding principles, e.g. 'healthcare providers will collaborate and provide support to foster team spirit and teamwork'). Research ethics approval for the IPMPC was granted by the Ottawa Hospital Research Institute, the University of Western Ontario and the University of Ottawa.
Each nursing unit constituted its own multi-disciplinary team consisting of a clinical nurse manager and health professional co-chair, as well as a representative from each discipline including a physician/surgeon. All 103 nursing unit teams were required to reflect on the guiding principles and decide whether each principle was met, partially met or not met. Then, each team developed and carried out an action plan specific to its needs; the roll out and implementation of the IPMPC was unique to each team. Support for the roll out of the IPMPC came in the form of education workshops, a series of online, self-directed learning modules, a public awareness campaign for patients and families and a network of advocates within TOH to promote inter-professional care.
As part of the evaluation of the IPMPC, all healthcare disciplines completed anonymous surveys, which contained instruments to measure collaboration, respect, conflict and patient safety climate (among others). The extent to which these concepts interact to contribute to a patient safety climate has not been studied. Yet, given the importance of these relational characteristics to patient safety as described earlier, leaders need this information so that they can develop organizational processes to foster those characteristics that are most influential to a climate of patient safety.
