Taipei Medical University School of Healthcare Administration. Master s Thesis

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1 Taipei Medical University School of Healthcare Administration Master s Thesis Measuring the Current Patient Safety Culture in the Gambian Public Hospitals Graduate Student: Momodou Barrow Adviser: Professor Nai-Wen Kuo, Ph.D. M.P.H May, 2012

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5 Acknowledgements All thanks and praises be to the almighty Allah (Glory be to him alone) for the numerous blessings that he has bestowed upon me during the course of the entire master program and this project. I must express my sincere gratitude to the following people whose love, guidance and encouragement enabled me to complete this work: Firstly, sincere thanks go to my thesis Adviser, Professor Nai-Wen Kuo Ph.D. M.P.H, who helped me throughout this piece of work, from the formulation of the research framework until the very end. He offered continuous support and opened his door to me for comments and suggestions. Also not forgetting the faculty and staff of the school of healthcare administration for the great moments we had over the cause of my study in TMU. I really learned a lot from the lectures and instructors and I know that the lessons learnt will help me in my future career. Thank you. I would also like to thank the Taiwan International Cooperation and Development Fund (ICDF) for providing me with a scholarship to study at Taipei Medical University. My special thanks and appreciation goes to all my family members for their maximum patience and sacrifice during this period of my absence. Thank you. iv

6 Abstract Title: Measuring the Current Patient Safety Culture in the Gambian Public Hospitals Author: Momodou Barrow Thesis Advised By: Professor Nai-Wen Kuo, Ph.D., M.P.H Background: Patient safety is crucial to the quality of patient care and remains a challenge for countries at all levels of development. There is popular acknowledgement of the importance of establishing patient safety culture in healthcare organizations. As a result, assessing patient safety culture in healthcare organizations has become a common activity to improve patient safety. The aim of this study was to examine the current patient safety culture from the perspective of healthcare workers in the Gambian public hospitals and to draw comparisons. Methods: A cross-sectional survey was conducted using a Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire which has 12 dimensions. Overall, we distributed 235 questionnaires and received 211 respondents. The data was collected between July and September SAS 9.2 version was used for the statistical analysis of the survey data that included descriptive as well as inferential statistics. Results: The overall mean positive response rate for the Gambia was 52% which is 11% lower than the Agency for Healthcare Research and Quality (AHRQ) benchmark report of 63%. The results show that healthcare workers in the Gambia seem to have lower perceptions about patient safety culture. All 12 of the dimensions pertaining to patient safety culture were found to have a significant relationship with patient safety culture in the Gambia. Physicians are more likely to give a negative opinion and less likely to give a positive opinion about the factors of patient safety culture. The dimension with the highest positive mean score was Teamwork within units while the dimension with lowest positive mean score was Frequency of event reporting. Conclusions: Healthcare workers appear to have a lower perception of patient safety culture compared to AHRQ 2012 benchmark report. Training of healthcare workers on patient safety and broad based research including all categories of healthcare organizations are highly recommended in order to improve patient safety culture. Key words: Patient safety culture, The Gambia, Benchmark data, HSOPSC Questionnaire v

7 Tables of Content Acknowledgements... iv Tables of Content... vi List of Tables... viii List of Figures... ix CHAPTER I INTRODUCTION... 1 Background... 1 Statement of the problem... 3 Significance of the study... 4 The objectives of the study... 5 CHAPTER II LITERATURE REVIEW... 6 The concept of patient safety culture... 6 Perceptions on patient safety culture in health care organizations... 6 Adverse event reporting and culture of patient safety... 7 Leadership and patient safety culture... 8 Non-punitive response to errors and patient safety culture... 8 Communication openness and feedback in a patient safety culture... 9 Learning and continuous improvement and patient safety culture Teamwork and patient safety culture Patient safety culture measuring tools Summary of literature review CHAPTER III METHODS Theoretical Framework Operational Definitions of variables The dependent Variable Independent Variables Controlling variables Research Hypotheses Study Design Study setting Data collection tool and techniques vi

8 Study Sample HSOPSC Questionnaire Reliability Validity Ethical considerations Data analysis CHAPTER IV RESULTS Demographic characteristics of the study respondents Descriptive statistics of survey s items of the HSOPSC Descriptive statistics of the patient safety culture dimensions Hospital grade and number of events reported Comparisons of PSC composite-level mean positive response rates in the Gambia and the AHRQ 2012 benchmark data Comparisons of PSC composite-level average positive response rates across the three hospitals The relationship between the independent variables and patient safety culture The impact of independent and controlling variables on patient culture in the Gambia.. 48 CHAPTER V DISCUSSION CONCLUSIONS Recommendations Limitations of the study References Appendix 1: Research questionnaire Appendix 2: Respondent information sheet Appendix 3: Coding table Appendix 4: Ethical approval vii

9 List of Tables Table Table Table Table Table Table Table Table viii

10 List of Figures Figure Figure ix

11 CHAPTER I INTRODUCTION Background In recent years, the world has realized the impact of patient safety problems in health care organizations and has been responding with great endeavor to tackle the issue (Johnstone & Kanitsaki, 2008). The World Health Organization has defined patient safety as as the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum. World Health Organization [WHO], (2009). In 1999, a landmark report of the Institute of Medicine, To Err is Human : Building a Safer Health System was released, and patient safety came to the forefront of the world`s attention (Kohn, Corrigan & Donaldson,1999). The report revealed that an estimated 44,000 to 98,000 people die every year from medical errors that occur in US hospitals, more than those that die from motor vehicle accidents, breast cancer, and AIDS combined (Brickell & Carla, 2011). The media coverage of the report was swift and widespread, resulting in a sudden public awareness of the problem (Ransom, Joshi, & Nash, Ransom, 2010). The public expressed shock and the issue attracted the concern of policy makers, healthcare administrators and researchers, and consequently, our understanding of patient safety continues to increase. It has become well recognized globally that hospitals and other healthcare organisations are not as safe as they should be (Marciano et al., 2010). In October 2004, the WHO launched the World Alliance for Patient Safety (WHO, 2009).The Alliance described patient safety as a global issue affecting countries at all levels of development. Patient safety problems are believed to be hidden in health care organizations, especially in developing countries where less is still known about the impact of the problem. It is likely that millions of patients globally suffer from injuries, disabilities or even death due to medical errors. The WHO reported an adverse event rate of about 10 percent (WHO, 2009), which would mean that one in every ten patients seeking healthcare suffers an adverse event. Gandhi et al., (2003) reported that 25 percent of patients in ambulatory care practices experience adverse drug events. Commonwealth Fund studies in 2002 revealed that 25 percent of patients across four countries reported that they had experienced some form of medical error in the past two years (Blendon et al., 2003). 1

12 Resolution of the Fifty-fifth World Health Assembly, passed in May 2002, called upon member states to pay the closest possible attention to the problem of patient safety (WHO, 2009). Developing a patient safety culture was one of the recommendations made by the Institute of Medicine to assist health care organizations in improving patient safety (Jardali et al., 2011). Patient safety culture is typically defined as the shared attitudes, beliefs, values and assumptions that underlie how people perceive and act upon safety issues within their organization (Lee et al., 2010). It has been advocated that an organization s safety culture is a fundamental factor that influences system safety. Therefore, current efforts to improve patient safety focus on system problems, rather than individual culpability, by promoting a culture of patient safety (Garbutt et al., 2008). Establishing a culture of patient safety and embedding it within all levels of an organization is vital. There is now a substantial body of evidence demonstrating the benefits of patient safety culture for both patients and health care organizations; because all constituencies win when patient safety improves. It is believed that as patient safety culture improves, patient safety improves, employee satisfaction improves, organizational citizenship improves, patient satisfaction improves, quality of care improves, malpractice costs decrease, and the overall reputation and financial security of the organization is assured (Krause & Hadley, 2009). There is widespread acceptance that more work is required to improve patient safety globally. Currently however, in Africa, there is insufficient awareness of patient safety and a lack of data to measure the scale of patient safety problems and its impact on healthcare organizations (Ente, Odongkara, & Mpora, 2010). International assistance will be vital in tackling the following challenges: resource shortages, lack of awareness, the low priority given to patient safety, and staff attitudes. Medical errors are an inevitable and a sad reality of medical practice (Garbutt et al., 2008). However, establishing patient safety culture in health care organizations has been shown to be a potential strategy for improving patient safety. Therefore, many health care organizations have become interested in assessing their patient safety culture using the Hospital Survey on Patient Safety Culture questionnaire (HSOPSC).This is a validated instrument developed by the Agency for Healthcare Research and Quality (AHRQ). It has good reliability and validity (Chen & Li, 2010) and has been translated into seventeen languages and used in over thirty countries (Haugen et al., 2010). 2

13 This study seeks to measure the current patient safety culture in Gambian hospitals using HSOPSC, and to make comparisons with the AHRQ 2012 benchmark database (AHRQ 2012). The findings of this study will provide policy makers and healthcare professionals with more understanding of the current patient safety culture in Gambian hospitals, with the ultimate aim of identifying opportunities for improvement and establishing a baseline for assessing future improvement efforts. Statement of the problem The World Health Organization (WHO) estimates that tens of millions of patients worldwide endure disabling injuries or death each year that can be attributed directly to unsafe medical practices and care (Bodur & Filiz 2010). Dr. Lucian Leape, in a retrospective review of Harvard Medical Practices, 1991, found that medical errors and adverse events were occurring far more frequently than was reported and were contributing to unnecessary deaths (Brennan et al, 1991). For instance, a Harvard Medical Study of an acute care hospital in 1984 found an adverse event rate of 3.8%. Similarly, in 1992, a study on quality in Australian acute care hospitals found the rate to be 16.6%. Furthermore, studies conducted in acute care hospitals in UK ( ), Denmark (1998), New Zealand (1998), and Canada (2001) found the adverse event rates to be 11.7%, 9.0%,12.9%, and 7.5% respectively (WHO 2004). Adverse events exert a high toll in financial losses, as well. In the UK, consequent additional hospital stays alone cost about 2 billion per year, and paid litigation claims cost the National Health Service around 400 million annually (WHO, 2004). The total national cost of preventable adverse medical events in the USA, including lost income, disability and medical expenses, is estimated at between US$ 1.7 billion and US$ 2.9 billion annually. Added to these costs is the erosion of trust, confidence, and satisfaction among the public and health care providers (WHO, 2004). This is a global phenomenon affecting all countries at all levels of development. In developed countries information technologies are increasingly being used in healthcare to improve patient safety. Studies have shown that Computerized Physician Order Entry (CPOE), especially when combined with Decision Support System (DSS), improves patient safety (Ball & Douglas, 2002). Uunfortunately, many resource constrained countries lack such technologies. 3

14 Thus, such countries are left with no choice but to establish a patient safety culture in health care organisations in order to achieve patient safety and quality of patient care. Significance of the study Patient safety is critical to health care quality which remains a developmental challenge, especially for developing countries. According to the Institute for Health Care Research and Improvement (IHCRI), health care quality includes six factors: Safe - patients should not be harmed by the care that is intended to help them Timely - unnecessary waits and harmful delays should be reduced Effective - care should be based on sound scientific knowledge Efficient - care shouldn't be wasteful Equitable - care shouldn't vary in quality because of patient characteristics Patient-centered - care should be responsive to individual preferences, needs, and values. Therefore, achieving quality of care and patient safety are challenges for health care organizations (Kuo, Borycki, Kushniruk, & Lee, 2010). In order to effectively improve all these aspects of healthcare quality, it is believed that establishing a culture of patient safety within health care organizations is the best strategy. This belief has led to a growing interest in patient safety culture among policy makers, healthcare managers, practitioners, and researchers. A study conducted in United States 2008 showed a positive correlation between patient safety culture and patient satisfaction (Mardon, 2008). This study seeks to assess, for the first time, the current patient safety culture in the Gambian public referral hospitals from the perspective of healthcare professionals. The findings will be beneficial to healthcare workers, managers, health policy makers, and future researchers in terms of improving patient safety and the image of the health care organizations. This research will also help in minimizing the knowledge deficit that exists with regards to patient safety in the Gambia. 4

15 The objectives of the study The overall aim of the study is to measure the current patient safety culture in the Gambian hospitals from the perspective of healthcare workers with the following specific objectives: 1. To assess the attitudes and perceptions of healthcare workers towards patient safety culture. 2. Make comparisons of scores in the Gambian hospitals with benchmark data. 3. To explore the factors related to patient safety culture in the Gambian hospitals. 5

16 CHAPTER II LITERATURE REVIEW The concept of patient safety culture The concept of safety culture originated from the research of safety in hazardous industries (Chen & Li, 2010; Sorra & Dyer, 2010). Much of what is known about patient safety culture is based on an extensive literature search by experts taking their reference from industries such as the aviation industry, shipping, and nuclear industry. Over the past decades, these industries have significantly improved their level of safety. A study on aviation safety found an association between cultures of safety and reduced pilot error (Pronovost et al., 2003). Multiple and varied definitions of safety culture have emerged in the literature. It has been observed that some studies use the terms patient safety climate and culture interchangeably. There has been considerable debate about the relationship between safety culture and safety climate. It is now generally accepted that the two concepts are closely related and that safety climate consists of the surface elements of the safety culture (Fleming, 2005). When using questionnaires to study group-level perceptions, the most appropriate term to use is climate. Climates are more readily measurable aspects of safety culture (Sexton et al., 2006). Safety culture is generally defined as a product of individual and group values, attitudes, perceptions, competencies and patterns of behavior that determine the commitment, the style, and proficiency of an organization's health and safety management (Fleming, 2005). Safety climate, on the other hand, is defined as shared perceptions regarding the events, practices and procedures, as well as the kind of behavior that gets rewarded, supported, and expected in a particular organizational setting (Alahmadi, 2010). Perceptions on patient safety culture in health care organizations The current thinking on patient safety recognizes the growing need for establishing a patient safety culture in health care organizations to improve patient safety and quality of care. Establishing an environment of patient safety may be challenging because it is associated with a change of behavior. The perception one may draw from the literature is that, once a health care organization succeeds in changing the perceptions of frontline healthcare workers towards patient safety, it can be assured of having the most reliable and effective strategy for achieving quality of patient care. 6

17 Positive patient safety culture reduces adverse events (Mardon, 2008). Empirical studies have found that, fewer medical errors tend to occur in hospitals that embrace a culture of patient safety (Navon et al., 2005). A culture of patient safety is recursive in nature, in that it influences the behavior of healthcare workers. The behavior of healthcare workers, in turn, influences the safety culture of the organization. A positive safety culture guides the many discretionary behaviors of healthcare workers toward viewing patient safety as one of their highest priorities (Smits, Dingelhoff, Wagner, Wal, & Groenewegen, 2008). Adverse event reporting and culture of patient safety It is widely believed that people can learn from their past mistakes and if the lessons learned are shared, more people become aware. If people can learn from the experiences of others, then they would become more effective in preventing similar mistakes. An effective safety event reporting system is an essential part of a comprehensive patient safety culture (Cochrane et al., 2009). A study in Lebanon found event reporting to be a major predictor of a positive patient safety culture in health care organizations (El-Jardali, Dimassi, Jamal, Jaafar, & Hemadeh, 2011). Hospitals with a patient safety culture are transparent and fair with staff when incidents occur, learn from mistakes, and, rather than blaming individuals, look at what went wrong in the system (Cox & Cox, 1991). A study of pediatricians in the United States indicated willingness among them to report errors to hospitals, but the belief that current reporting systems are inadequate and struggle with error disclosure (Gerbutt et al., 2007). Hospitals should improve their reporting systems and encourage staff to report adverse events and even near-misses because this could help prevent future errors and improve patient safety. Kaldjian et al. (2008) found that most respondents agreed that reporting errors improves the quality of care for future patients. Advocates of patient safety have called strongly for the removal of blame and shame from the reporting of medical errors (Kaldjian et al, 2008). Health care organizations should even seek to reward error reporting. Interest is also increasing in encouraging health care organizations to report these events to central entities such as government patient safety institutions to improve patient safety throughout the healthcare system (Gerbutt et al., 2010). 7

18 Leadership and patient safety culture Managerial commitment to safety was identified as the most strongly positive attribute of a patient safety culture (Hughes, Chang, & Mark, 2009). If the staffs in any health care organization are to believe that patient safety is a priority, the message must come from the Chief Executive Officer (CEO), supervisors, and the board (Ransom, Joshi, & Nash, Ransom, 2010). It is absolutely vital that this message be visible and consistent, not only through memos, but by directly visiting staff and discussing patient safety (Ransom, Joshi, & Nash, Ransom, 2010). This Therefore, the commitment of health care organizations leadership to patient safety issues is essential for an optimal patient safety culture. The leaders communicate the importance of patient safety in the priorities they set, the decisions they make about resource allocation, and the patient safety-related employee feedback they provide (Pronovost et al., 2003). Engagement between the leadership and the staff will not only promote teamwork, but also improve confidence among staff to improve patient safety culture (Pronovost et al., 2003). Once the ordinary staff in the health care organization have identified themselves with the message from the top management, the process of changing the existing culture can be very simple. Characteristics of a strong and proactive safety culture include the commitment of the leadership to discussing and learning from errors by documenting and analyzing adverse events, as well as encouraging and practicing teamwork (Pronovost et al., 2003). Non-punitive response to errors and patient safety culture Health care organizations need to trust their employees and technically establish a nonpunitive environment. This can encourage staff to discuss errors openly with their colleagues. Common sense should lead us to understand that humans by nature are prone to errors, despite the aim of healthcare workers to provide the best patient care possible. Therefore, health care organizations should make the environment conducive to facilitate error reporting, ensuring that healthcare workers are free of shame and blame as the result of a mistake. The Institute of Medicine states that if there is a safety culture environment where adverse events can be reported without people being blamed and shamed, that will provide an opportunity for staff to learn from their mistakes and, if possible, to make improvements to prevent future human and system errors, thus promoting patient safety (Smits, et al., 2008). 8

19 The way health care organizations respond to errors is critical to an optimal safety culture. The Swiss Cheese Model gives a better picture about the causes of medical error. According to this model, health care organizations conduct different types of activities aimed at giving quality care to the patient. There are, however, potential hazards, as well as potential loopholes, that can allow harm to reach the patient (Thomas, 2005). Hospitals do their best to implement systems of barriers to prevent potential harm from reaching the patient. In the event any harm reaches the patient, it should be seen as a result of the system s failure and not that of the individual. Systems must be created to prevent or catch inevitable human errors before they result in harm (Duke University, 2005). If the health care organization takes the habit of blaming and shaming individuals for an error, mistakes may be concealed. It may, however, be viewed as a real test of a non-punitive environment in a culture of patient safety when a member of staff makes a very serious mistake that results in patient harm. Some would argue that disciplinary action needs to be taken. Taking disciplinary action against staff of any kind would not help improve patient safety. Patient safety can be best improved within a non-punitive environment that places more value on reporting adverse events, so that solutions can be found, than in pursuing the blaming or suing of staff. It is believed that medical errors are symptoms of a diseased system (Sexton et al., 2005). Error prevention efforts must therefore be directed mainly at the weaknesses in the system. This indicates that health care organizations should focus on continuous systems improvement in order to effectively minimize errors. Experts believe that medical errors must be investigated within the framework of healthcare organizational systems (Sexton et al., 2005). That means that after an error occurs, instead of rushing to blame the staff, health care organizations should investigate in order to identify weaknesses in the systems or processes and address these immediately. Communication openness and feedback in a patient safety culture Studies have indicated that a lack of proper communication among healthcare workers is one of the leading causes of adverse events (Dingley, Daugherty, Derieg, & Persing, (2009). Jasti, et al. 1999, also indicated that communication failures can compromise optimal patient care and are one of the most common root causes of medical error and adverse events. Many other studies have highlighted the lack of open communication within health care organizations as 9

20 critical to causing adverse events. It is therefore vital for health care organizations to continuously remove all barriers to open communication such as blaming, shaming, and a lack of feedback mechanisms. Healthcare managers need to provide feedback to healthcare workers about errors and listen to the concerns of staff. This will encourage staff to speak up about near misses and adverse events. A study conducted by Evens et al., 2006 found that almost two thirds of respondents believed a lack of feedback was the greatest deterrent to reporting. This indicates that when staffs are not getting any feedback from the management after reporting an adverse event, they will begin to question the necessity of sending any future reports. The management should therefore analyze the reports and give feedback to the staff and discuss how to continuously improve the system. Learning and continuous improvement and patient safety culture Organizational learning and continuous improvement are crucial to patient safety culture because they enhance awareness and skills. Hospitals should therefore continue efforts to create learning environments in which error discussions are valued and those who discuss their own errors are respected. An environment with an effective learning culture where people constantly and consistently seek to bring about improvement is very important. A study conducted by Gerbutt et al. (2010) found that a key motivator of physicians willingness to report was their confidence that the errors reported would be used to make improvements. Management should use such data to prepare proper guidelines on patient safety awareness for staff through continuous education. A survey of 1,082 U.S. physicians found that most of them wanted to be trained in new skills to prevent common errors. Health care organizations must learn about actual and potential errors (Gerbutt et al., 2010). New methods to improve patient safety must be disseminated to healthcare workers and implemented (Gerbutt et al., 2010). Continuous education within the the healthcare organization can facilitate staff awareness concerning new methods as well as enhance skills to effectively deal with patient safety issues and also facilitates a forum where all issues concerning patient safety can be improve. 10

21 Teamwork and patient safety culture When people work in teams they tend to help each other identify errors and prevent unnecessary hazards from reaching the patient. Teamwork has great potential for preventing errors compared to working individually. It facilitates valuable contributions and encourages participation in decision-making from staff. It fosters collaboration in terms of the strengthening of shared goals and the creation of mutual respect and trust among team members (Manser, 2008). The aviation industry has been using a concept called crew resource management which has greatly helped in reducing accidents and made the industry one of the safest nowadays. The improvements in aviation safety are attributed to improved crew coordination, communication, and decision-making (Pronovost et al., 2003). The concept of team resource management, similar to the concept of crew resource management in the aviation industry has recently gained ground within health care organizations as a means of improving safety culture. Efforts to improve a safety culture have to be a continuous and sustained process. Salas et al. (2003) found that patient safety depends on teamwork. It is not just about people coming together, but about the willingness to cooperate over shared goals such as maintaining health status and avoiding medical error (Salas, Sims, Klein, & Burke, 2003). A well-structured teamwork environment creates shared mental models among the team members that produce a shared perception of a situation, an understanding of team structure and team tasks and roles. Helmreich described employees in a safe culture as being guided by an organizationwide commitment to safety where safety standards are upheld on a personal and a team level (Pronovost et al., 2003). Teamwork in a safety culture can promote adaptive coordination; for instance, dynamic task allocation when new members join the team, and increased information exchange and planning in critical situations. It can also promote openness of communication, quality of communication, and specific communication practices. Patient safety culture measuring tools The increasing need for assessing patient safety culture has led to the development of numerous instruments for specifically measuring patient safety in the healthcare industry. These include the Safety Attitudes Questionnaire, the Stanford Instrument (Singer, Gaba, Sinaiko, Howard & Park, 2003), and the Hospital Survey on Patient Safety Culture (Sorra & Neiva, 2004; 11

22 Sorra & Dyer, 2010). The availability of different varieties of instruments raises the question: which instrument is the best? Not surprisingly, there is not one best instrument, as they all have strengths and weaknesses (Sorra & Dyer, 2010). However, the Agency for Healthcare Research and Quality (AHRQ) encourages health care organizations to conduct safety culture surveys using HSOPSC, with its high reliability and validity. This instrument is the most recent, and has been used in over 31 countries, such as the United States, Saudi Arabia, Canada, the United Kingdom, Belgium, Denmark, Norway and Taiwan. According to Fleming (2010), the HSOPSC has much strength, such as good psychometric properties, cross-country comparisons are possible and comprehensive coverage of safety culture. Summary of literature review Patient safety culture can be described as a relatively new area and the current thinking for improving patient safety in health care organizations is mainly focused on creating a culture of patient safety. Many tools have been developed for the evaluation of this culture. It is believed that the impact of a positive patient safety culture in changing behavior among healthcare workers is stronger than any rules or regulations. It was found that mistakes can still occur even among a collection of the best employees. However, a culture of patient safety usually influences the entire system and improves patient safety. A strong patient safety-oriented leadership will foster a spirit of teamwork that will encourage event reporting without fear of blame and shame among staff. This will support learning and continuous improvement through open communication and feedback mechanisms. Subsequently, the overall perceptions of staff regarding patient safety will improve, especially among the frontline staff. 12

23 CHAPTER III METHODS Theoretical Framework This study constructs a theoretical framework from the assumption that several factors influence a culture of patient safety culture in health care organizations. The twelve dimensions of the hospital survey on patient safety culture form the basis of this conceptual framework in relation to patient safety culture. We also take into consideration some demographic and professional characteristics of health workers. Figure 3.1 Patient safety culture theoretical framework 13

24 Operational Definitions of variables The dependent Variable Patient safety culture (PSC) This is the dependent variable in this study that measures health workers attitudes, beliefs, values, and assumptions that underlie how they perceive and act upon safety issues within their hospitals. Patient safety culture scores were created for each respondent by calculating the mean percentage of positive responses from the study data measured on 5-point Likert scales (from 1 meaning strongly disagree to 5 meaning strongly agree). Negatively worded questions were reversed coded for data analysis. Independent Variables Communication openness The communication openness domain refers to whether staff freely speaks up if they see something that may negatively affect patient care, feel free to question those with more authority and afraid to speak up if something does not seem right. It was measured by asking respondents to evaluate these issues on 5-point Likert scales (from1 meaning strongly disagree to 5 meaning strongly agree). Negatively worded questions were reversed coded for data analysis. Feedback and communication The feedback and communication about errors domain measures whether staffs are informed about errors that happen, given feedback about changes put into place based on event reports, and discuss ways to prevent errors occurring again. These issues were measured on a 5- point Likert scale with 1 representing never to 5 representing always. Teamwork within hospital units The teamwork within hospital units domain measures whether staff supports one another treats each other with respect and work together as a team. These dimensions were measured on a 5-point scale with 1 representing strongly disagree to 5 representing strongly agree. Negatively worded items were reversed coded for data analysis. 14

25 Hand-offs and transitions This domain refers to patient care and patient information transfer across hospital units and during shift changes. This domain was measured on the following sub-dimensions; problems during patient transfer from one unit to another, loss of patient care information, and problems in information exchanges between units. A 5-point Likert scale was used and negatively worded statements were reversed coded for data analysis. Management support for patient safety This domain measures whether hospital management provides a work climate that promotes patient safety and shows if patient safety is a top priority or is only of interest after an adverse event occurs. These sub-dimensions were asked using a 5-point Likert scale and negatively worded items were reversed coded in the data set for analysis. Non-punitive responses to error This domain measures whether staff feel free to report adverse events and that their mistakes are not held against them. These sub-dimensions were measured using a 5-point Likert scale and negatively worded statements were reversed coded in the data set for analysis. Organizational learning and continuous improvement This domain refers to whether staffs are doing things to improve patient safety by learning from their mistakes and evaluate the effectiveness of new interventions put in place. It was measured by using a 5-point Likert scale and negatively worded statements were reversed coded for data analysis. Overall perceptions of patient safety This domain refers to how staff thinks about work procedures and systems in preventing errors in hospital units as well as how they deal with work pressure in relation to preventing medical errors. These sub-dimensions were measured on a 5-point Likert scale and negatively worded statements were reverse coded in the data set for analysis. 15

26 Staffing This domain refers to whether there are enough staffs and appropriate working hours to handle the workload. These sub-dimensions were measured on a 5-point Likert scale and negatively worded statements were reverse coded in the data set for analysis. Supervisor/manager expectations and actions promoting safety This domain refers to whether leadership consider staff suggestions, praise staff for following patient safety procedure for improving patient safety and do not encourage faster work by taking short cuts These sub-dimensions were measured on a 5-point Likert scale and negatively worded statements were reverse coded in the data set for analysis. Teamwork across hospital unit This domain refers to whether hospital units cooperate, coordinate with one another and encourage teamwork among staff from other units to provide the best care for patients. It was measured on a five 5-point Likert scale and negatively worded statements were reverse coded in the data set for analysis. Frequency of events reported This domain refers to how often staff report all types of mistakes, such as latent errors, accidents, and near misses. It is measured on a 5-point Likert scale with 1 representing never to 5 representing always. Controlling variables The following control variables were used in this study: Gender This referred to male and female respondents. Age This referred to the age category to which a respondent belongs (<30, 31-40, 41-50, >50 years). 16

27 Educational level This referred to the level of education obtained by the respondent. It was categorized into the following: Junior school or less, Senior High school, College, and University. Years of work in the current hospital This referred to the duration of service within the current hospital. It was categorized into the following: Less than 1 year, 1 to 5 years, 6 to 10 years, 11 to 15 years, 16 to 20 years and 21 years or more. Number of hours worked per week This referred to the total weekly number of hours the staff worked. It was categorized into the following: Less than 20 hours per week, 20 to 39 hours per week, 40 to 59 hours per week, 60 to 79 hours per week, 80 to 99 hours per week, 100 hours per week or more. Patient Access This referred to whether the staff had interaction with patients or not. Research Hypotheses Hypothesis 1: Overall perceptions of patient safety have a relationship with patient safety culture Hypothesis 2: Frequency of event reporting has a relationship with patient safety culture Hypothesis 3: Supervisors/managers expectations and actions in promoting patient safety affect patient safety culture Hypothesis 4: Organizational learning and continuous improvement affect patient safety culture Hypothesis 5: Teamwork within units affects patient safety culture Hypothesis 6: Management support for patient safety affects patient safety culture Hypothesis 7: Communication and feedback about errors is associated with patient safety culture Hypothesis 8: Non-punitive response to error affects patient safety culture Hypothesis 9: Staffing affects patient safety culture in the Gambian hospitals Hypothesis 10: Hand-offs and transitions affect patient safety culture 17

28 Hypothesis11: Teamwork across hospital units affects patient safety culture Hypothesis12: Communication openness affects patient safety culture Hypothesis 13: Age affects patient safety culture Hypothesis 14: Gender has an impact on patient safety culture Hypothesis 15: Educational levels affect patient safety culture Hypothesis 16: Years of service in the current hospital affects patient safety culture Hypothesis 17: Number of hours worked per week affects patient safety culture Hypothesis 18: Patient access affects patient safety culture Study Design The study adopted a cross-sectional survey design which was conducted to assess the current patient safety culture in Gambian hospitals from the perspective of healthcare professionals. Data was collected between July and September 2011 and was used to examine the objectives and the hypotheses outlined in this study. Study setting The Gambia is situated on the Atlantic coast of West Africa, at the interface of the Sudan Savannah and Northern Guinea Savannah zones (Ceesay et al., 2008). Three hospitals were randomly selected from the four public referral hospitals currently fully operational in the Gambia. The three selected hospitals are as follows: Royal Victoria Teaching Hospital (RVTH), the major referral hospital in the capital Banjul with 540 beds Bansang Hospital, a rurally based hospital 200 km from capital with 160 beds. AFPRC General Hospital, a rurally based hospital 100km from capital with 250 beds. 18

29 Figure 3.2 Map of the Gambia showing the location of the three hospitals Data collection tool and techniques The Hospital Survey on Patient Safety Culture (HSOPSC) questionnaire developed by the Agency for Healthcare Research and Quality (AHRQ) was used for this study. It is a self-administered questionnaire and each respondent was given a printed copy with a cover letter explaining the purpose of the study. Study Sample Inclusion and Non-inclusion Criteria To ensure representation of frontline clinical healthcare workers, those frontline staff that consented to take part in the study were always selected, including physicians, nurses, pharmacy assistants and laboratory staff. Hughes, Chang & Mark s (2009) study indicated that frontline clinicians are in the best position to provide information about patient safety culture. Untrained staff was not included in this study. Sampling The study used a convenience sampling method. The questionnaires were given to health workers who were found on duty during the data collection period for completion. The sample 19

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