Control Mechanisms in Health Services

PU34CH22-Singer ARI ANNUAL REVIEWS 13 February 2013 23:6 Further Annu. Rev. Public Health 2013.34:373-396. Downloaded from www.annualreviews.org Access provided by Walden University on 09/29/19. For personal use only. Click here for quick links to Annual Reviews content online, including: • Other articles in this volume • Top cited articles • Top downloaded articles • Our comprehensive search Reducing Hospital Errors: Interventions that Build Safety Culture Sara J. Singer1 and Timothy J. Vogus2 1 Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts 02115; email: ssinger@hsph.harvard.edu 2 Owen Graduate School of Management, Vanderbilt University, Nashville, Tennessee 37203; email: timothy.vogus@owen.vanderbilt.edu Annu. Rev. Public Health 2013. 34:373–96 Keywords First published online as a Review in Advance on January 16, 2013 safety culture, safety climate, medical errors The Annual Review of Public Health is online at publhealth.annualreviews.org Abstract This article’s doi: 10.1146/annurev-publhealth-031912-114439 c 2013 by Annual Reviews. Copyright  All rights reserved Hospital errors are a seemingly intractable problem and continuing threat to public health. Errors resist intervention because too often the interventions deployed fail to address the fundamental source of errors: weak organizational safety culture. Control Mechanisms in Health Services

This review applies and extends a theoretical model of safety culture that suggests it is a function of interrelated processes of enabling, enacting, and elaborating that can reduce hospital errors over time. In this model, enabling activities help shape perceptions of safety climate, which promotes enactment of safety culture. We then classify a broad array of interventions as enabling, enacting, or elaborating a culture of safety. Our analysis, which is intended to guide future attempts to both study and more effectively create and sustain a safety culture, emphasizes that isolated interventions are unlikely to reduce the underlying causes of hospital errors. Instead, reducing errors requires systemic interventions that address the interrelated processes of safety culture in a balanced manner. 373 PU34CH22-Singer ARI 13 February 2013 23:6 INTRODUCTION Annu. Rev. Public Health 2013.34:373-396. Downloaded from www.annualreviews.org Access provided by Walden University on 09/29/19. For personal use only. Scholarly and practitioner interest in hospital errors—errors that result from poorly designed and managed systems and are attributable to the actions of multiple organizational participants who deviate from organizationally specified rules and procedures (50)—took hold more than a decade ago with the Institute of Medicine’s landmark report, To Err Is Human: Building a Safer Health System (74). However, despite a great deal of academic research and practitioner experimentation, hospital errors continue to present a seemingly intractable public health problem (78), the dimensions of which may be greater than initially imagined (18). Control Mechanisms in Health Services

A hospital’s inability to reduce these errors stems from their organizational (123) and systemic (134) nature, meaning that they are integrated into complex and interrelated structures and processes to which individuals throughout the hospital contribute. Their causes reside in the organization’s culture—its assumptions, values, attitudes, and patterns of behavior (130). Errors are intractable when a culture de-emphasizes safety and instead prioritizes competing concerns (e.g., cost, efficiency) that can produce errors (182). A safety culture consists of the shared values, attitudes, and patterns of behavior regarding safety (i.e., concern about errors and patient harm that may result from the process of care delivery) (124). Culture may vary within organizations and among their units and by professional disciplines. Safety climate, a related construct, refers to shared perceptions of existing safety policies, procedures, and practices (183). In other words, safety climate reflects the extent to which the organization values and rewards safety relative to other competing priorities as demonstrated through organizational policies and leader behavior (181). The expression of safety climate in specific and identifiable policies and practices means that it captures “surface features” of a safety culture (36). The goal of this review is to provide a public health and management audience with 374 Singer · Vogus an understanding of how a broad array of interventions may be combined to reduce hospital errors. Our review focuses specifically on hospital errors because this is where the bulk of intervention efforts have been directed and where the measurement of errors is most developed. To distinguish our review from other excellent recent reviews of interventions designed to reduce organizational errors in the health care context (34, 176), we focus explicitly on interventions that reduce errors by directly or indirectly impacting safety culture. This allows us to categorize these activities using a theoretical model that shows how interventions may work together to shape safety climate and safety culture in a process that reduces hospital errors over time. We focus on culture rather than errors themselves in recognition of the importance of culture as a basic mechanism through which patient safety is achieved (21). Control Mechanisms in Health Services

A deeper understanding of the cultural underpinnings of errors provides a more organizational and systemic foundation for reducing them. An Enabling, Enacting, and Elaborating Model of Safety Culture We focus on safety culture as the foundation upon which hospitals can reduce errors by preventing and learning from them (120). That is, a well-developed safety culture seeks to resolve the underlying causes of errors. To date, however, the ways in which interventions shape safety culture have been imprecisely specified. Our review employs a recently developed conceptual framework (164) to suggest that existing interventions tend to target one of three aspects of safety culture—enabling, enacting, or elaborating—that when taken together create a process with the potential to reduce hospital errors over time. Enabling refers to leader actions that emphasize safety, enacting includes frontline actions to surface and resolve threats to safety, and elaborating means systematically reflecting on and learning from performance (164). In turn, new enabling interventions may be selected on the basis of evolving needs and hospital culture. Thus, cycles of enabling, PU34CH22-Singer ARI 13 February 2013 23:6 Enabling Policies and practices that motivate the pursuit of safety Frontline interpretations of safety-related leader actions and organizational practices • Interpersonal processes (e.g., teamwork) • Reporting and voicing concerns • Coordinating at care transitions (hand overs) and across interdependent functions (checklists) Safety culture Safety culture Annu. Rev. Public Health 2013.34:373-396. Downloaded from www.annualreviews.org Access provided by Walden University on 09/29/19. For personal use only. Safety climate Safety culture Safety culture Fewer hospital errors Shared assumptions, values, attitudes, and patterns of behavior regarding safety that become embedded over time Elaborating Learning practices that reinforce safe behaviors Safety culture External actions: • Accreditation and advocacy • Surveys • Work hours rules Internal actions: • Leader behaviors and practices • HR practices • Technology (EMR) Enacting Frontline actions that improve patient safety • Learning-oriented interventions • Education (simulation) • Operational improvement (case-based analysis and frontline system improvement) • System monitoring (prospective, retrospective, concurrent) Figure 1 A cultural approach to reducing hospital errors. EMR, electronic medical record; HR, human resources. Adapted from Reference 164. enacting, and elaborating continue iteratively in an evolutionary process. In applying this model to a comprehensive set of interventions, we make two important refinements. First, we find that enabling occurs not only through hospital leaders but also through external actors (e.g., activists and quasi-regulatory agencies). Second, we posit that these enabling activities shape frontline workers’ perceptions of safety climate and thereby promote the enactment of safety culture. Figure 1 depicts our theoretical model, which highlights the interrelationships among interventions that enable, enact, and elaborate a culture of safety to reduce hospital errors. The arrows in this model indicate that climate and culture are dynamic processes. In this review, we organize disparate research on discrete interventions to reduce hospital errors and apply and extend an inte- grative model to highlight distinctions among the interventions’ objectives. Our primary contribution is the conceptual categorization of interventions and the identification of relationships among them. This is important because the fragmented nature of prior research on hospital errors provides an inadequate foundation for practitioners to pursue more than piecemeal solutions. Our analysis also provides researchers with a richer, theoretically grounded framework for understanding how interventions combine to reduce hospital errors. We offer practitioners a guide to more effectively creating and sustaining safety culture. Our review suggests that isolated interventions that enable, enact, or elaborate a culture of safety are unlikely to reduce the underlying causes of hospital errors. Instead, hospital errors require interventions that simultaneously address all three aspects of culture rather than only one. www.annualreviews.org • Reducing Hospital Errors 375 PU34CH22-Singer ARI 13 February 2013 Annu. Rev. Public Health 2013.34:373-396. Downloaded from www.annualreviews.org Access provided by Walden University on 09/29/19. For personal use only. Supplemental Material 23:6 This review represents a broad, albeit not comprehensive, review of research published in the management and health services literatures on interventions attempting to reduce hospital errors. More specifically, in ABI/ProQuest, R , and PubMed, we searched on PsycINFO the terms “safety” or “error” and “culture” in a set of leading management, psychology, health services, health care management, and medical journals (see Supplemental Appendix online. Follow the Supplemental Material link from the Annual Reviews home page at http://www.annualreviews.org), focusing on articles published during the most active period of research on hospital errors (between 2000 and early 2012). We identified 593 articles. By reviewing the abstracts of these articles, we derived a list of intervention types. Control Mechanisms in Health Services

We next assigned these intervention types to an element of the conceptual model so that each type of intervention was classified primarily as enabling, enacting, or elaborating a safety culture. We also looked for interventions that might not fit in the conceptual model. Then, the authors and a research assistant each reviewed a third of the papers to assign each one to the applicable intervention type or types. We conducted a second review to confirm the assignments. At each stage, the group discussed interventions or papers that raised questions and jointly resolved their classification. This allowed us to supplement and refine our list of intervention types and the relationships among them. Table 1 below summarizes the literature in each category (e.g., enabling) and subdomain (e.g., technology). We describe the interventions designed to promote each of the elements of the conceptual framework in turn. ENABLING Enabling a safety culture means motivating the goal of reducing hospital errors, directing attention to and prioritizing safety, and creating a context within which frontline caregivers can enact safer practices. In reviewing these interventions, two sets of mechanisms emerged: (a) external motivators, such as regulators and 376 Singer · Vogus advocacy organizations, and (b) internal motivators, such as leaders and organizational practices. External Motivators Researcher and practitioner interest in safety culture as a key source for reducing hospital errors took hold with the Institute of Medicine’s To Err Is Human (74) and subsequent reports. These early efforts to induce action tried to establish the scope of the problem (e.g., the number of deaths resulting from hospital errors) so as to motivate remedial actions (19, 74). The search for more accurate measures of the scope of the problem continues (18). Administrative data such as the Agency for Healthcare Research and Quality’s patient safety indicators (91) provide another source of data intended to fuel change; however, some evidence suggests that they do not predict individual hospital performance (171). Although only suggestive, there are indications that external actors can influence hospital error reduction. For example, The Joint Commission on Accreditation of Healthcare Organizations has influenced hospital-level patient safety initiatives (27), as have advocacy organizations such as the Institute for Healthcare Improvement, the National Patient Safety Foundation, and the Lucian Leape Institute.

Collaboratives, such as the Pittsburgh Regional Health Initiative, also spur hospital-level efforts to reduce hospital errors (143). The Institute for Healthcare Improvement’s national and international initiatives, such as the 100,000 Lives Campaign, establish goals and provide a model for spreading improvement practices to reduce hospital errors (90). Other research suggests external forces, e.g., tort reform, may induce hospitals to focus on reducing errors (4); however, the evidence of their efficacy is mixed (24). Legislatures and other policy-setting bodies are external forces that affect health care delivery through rules regarding practices shown to compromise safety, e.g., extended-duration work shifts (greater than 12.5 h) (83). Regulations that eliminated PU34CH22-Singer ARI 13 February 2013 23:6 Table 1 Interventions designed to enable, enact, and elaborate safety culture and reduce hospital errors Intervention category or Range and types Examples of research gaps and further investigation References for needed sample articles subdomain of studies Summary of findings External motivators There is little systematic investigation, but there are some suggestive case studies. Accrediting bodies (the Joint Commission), advocacy organizations (e.g., the Institute for Healthcare Improvement), and collaboratives (e.g., Pittsburgh Regional Health Initiative) can spur the pursuit of safety and adoption of safer practices. Influence of external motivators on leader cognition and action from direct, empirical assessments Effects of external motivators on new practices and other innovations Accreditation (27) Collaboratives (143) Internal motivators: leader characteristics and behaviors Most studies use cross-sectional survey design with some case-control studies. Studies show leader practices (e.g., executive WalkRounds), behaviors (e.g., inclusiveness), and characteristics (transformational leadership) positively impact safety climate. Use different aspects of safety climate in multiple studies Simultaneous examination of leader characteristics and behaviors Identification of the conditions under which leader practices are successful Leadership WalkRounds (38) Transformational leadership (92) Leader inclusiveness (105) Internal motivators: HR practices Studies predominantly use cross-sectional survey design. Bundles of HR practices as well as individual practices (e.g., staffing levels) are associated with aspects of safety climate and fewer hospital errors. The use of consistent, dependent variables across studies Stronger research designs Staffing (102) HR practices (117) Internal motivator: information technology Most studies use a pre/postintervention design. Numerous case studies also exist. Studies of computerized physician order entry (a) showed mixed results for adverse drug events, (b) showed a small positive effect on patient safety, and (c) are promising for bar code verification and medication reconciliation, but such studies are limited. Control Mechanisms in Health Services

Studies that explicitly measure and model organizational context and organizational readiness for the use of information technology CPOE (93) Bar code verification (116) Internal motivator: safety climate Most studies have a cross-sectional survey design. There are some case-control intervention studies. Consistent positive effects of a safety climate have been found on a range of outcomes related to hospital errors, including infections, treatment errors, patient safety indicators, readmissions, error reporting, and safety grades. Safety climate varies across units, professions, and organizational levels, affecting outcomes. The use of similar specifications of safety climate, i.e., survey items and modeling strategies Longitudinal investigations to assess the effects of change on outcomes and to document how hospitals can use information about safety climate to reduce hospital errors Variation and relationship with outcomes (57, 63) Effective interpersonal Most studies are quasi Selected interpersonal behaviors (mindful organizing and Additional construct validation and differentiation of related Relational coordination (7) Annu. Rev. Public Health 2013.34:373-396. Downloaded from www.annualreviews.org Access provided by Walden University on 09/29/19. For personal use only. Enabling Enacting (Continued ) www.annualreviews.org • Reducing Hospital Errors 377 PU34CH22-Singer ARI 13 February 2013 23:6 Table 1 (Continued ) Intervention category or Range and types References for needed sample articles of studies Summary of findings processes: teamwork, mindful organizing, relational coordination, and patient involvement experimental with pre/post-test design. Many are controlled. Some use mixed methods, incorporating interviews alongside surveys or other quantitative measures. A few case studies and qualitative studies exist. relational coordination) are related to preventing hospital errors and quality performance. Ineffective interpersonal processes yield negative consequences, and organizational conditions (e.g., culture and human factors) and practices (e.g., hiring, training, rewards) can promote more effective interpersonal processes.

Interventions to promote more effective teamwork improve quality, quantity, and perception of desired behaviors. concepts Direct evidence linking interventions to reductions in medical errors Patient involvement (62) Mindful organization (163) Teamwork (166) Reporting and voicing concerns Studies have a predominantly cross-sectional survey design. Some are questionnaire and some scenario based. There are a handful of case studies and longitudinal, pre/postintervention studies. Substantial underreporting occurs among clinicians. Different reporting systems yield complementary insights. Conditions that promote reporting include psychological safety, responsiveness, and closure. Willingness to voice concerns correlates with reduced hospital errors. Additional research that specifically addresses effects of reporting and voicing concerns on learning and hospital errors over time Studies of the conditions under which learning is more likely to occur Complementary insights (80) Underreporting (108) Coordination at care transitions and across interdependent functions: checklists, standardized protocols, and others There is a large mix of pre/postintervention studies, sometimes controlled, and a handful of case studies and cross-sectional o … Control Mechanisms in Health Services