Patient Safety and Quality

Perception of patient safety climate in hospitals varies by management level and clinical discipline

Senior managers at a hospital are more likely to perceive the patient safety climate more positively than hospital personnel closer to the front lines of care, according to a new study. However, physicians in senior management were more likely to have a view of their institution's patient safety climate similar to frontline and supervising physicians than did nurse senior managers relative to frontline and supervising nurses, the study found. The researchers conclude that interventions are needed to promote speaking up to senior management and encourage senior management to communicate downwards through activities that enhance their understanding of frontline workers' perspectives.

Overall, 17 percent of the responses to a 38-question survey were inconsistent with an optimal culture of patient safety—a value termed the percent of "problematic" responses (PPR). Senior management gave 12.4 PPR, while frontline employees yielded 17.6 PPR. Fear of being blamed or punished for making a mistake was cited by 31.5 percent of respondents (18.8 percent among senior management and 33.8 percent among frontline employees), while 30.0 percent of all respondents mentioned encountering at least one instance of unsafe care (a percentage that varied little between senior managers, supervisors, and frontline personnel). Relatively few managers or frontline personnel reported problems with safety norms on the clinical units, a PPR of 5.5 for senior managers and 10.3 for frontline employees.

The study indicated that differences in PPR between senior managers and frontline personnel varied with the respondent's clinical profession. Nurse senior managers had overall PPRs that were observably lower (11.5) than among frontline nurses (19.1), whereas physicians in senior management and on the front line of care differed little in their PPRs (16.1 versus 17.0 PPR, respectively). The researchers suggest that the result for physicians may be due to the fact that most physician-managers, even at the senior level, continue to practice medicine—unlike most non-physician senior managers who typically discontinue their work at the bedside upon promotion.

At the level of hospitals, those institutions with the greatest difference in percent of problematic responses between senior managers and frontline workers tended to have the worst safety climates. The data were collected from a generally representative sample of 92 United States hospitals that administered a safety climate survey over a 14-month period. The 18,361 respondents were a random sample of the hospital personnel.

The study was supported, in part, by the Agency for Healthcare Research and Quality (HS13920). More details are in "Patient safety climate in U.S. hospitals: Variation by management level," by Sara J. Singer, M.B.A., Ph.D., Alyson Falwell, M.P.H., David M. Gaba, M.D., and Laurence C. Baker, Ph.D. in the November 2008 issue of Medical Care 46(11), pp.1149-1156.

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