Abstract

Patient safety has featured prominently on the health care agenda in recent years, but the majority of research has focused on the hospital setting rather than nursing homes. Using survey responses from a nationally representative sample of 2,840 nursing homes in the United States, this study examines patient safety culture in nursing homes, compares nursing home safety scores against hospital benchmark scores, and ascertains if and how the safety culture of nursing homes varies according to facility and market characteristics. Background: Patient safety has featured prominently on the health care agenda in recent years. A key component of patient safety is the patient safety culture of the health care organization itself. Patient safety culture has been defined as, "the product of individual and group values, attitudes, perceptions, competencies, and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organization's health and safety management" and is regarded by some as a proxy measure for quality of care. Most patient safety research has focused on the hospital setting and less is known about this critical area in nursing homes. This study examines patient safety culture in nursing homes and ascertains if and how the safety culture of nursing homes varies according to facility and market characteristics (described below).

Methods: Data for the study came from a representative national survey of 2,840 (out of a potential 4,000, yielding a 71% response rate) nursing homes across the United States. Nursing home administrators completed the Hospital Survey on Patient Safety Culture (HSOPSC) instrument, which was developed by the Agency for Health Care Research and Quality and has been previously validated for assessing safety culture in hospitals. The HSOPSC contains 12 patient safety subscales: overall perceptions of safety, frequency of event reporting, manager expectations and actions promoting safety, organizational learning, teamwork within units, communication openness, feedback and communication about errors, non-punitive response to errors, staffing, management support for patient safety, teamwork across units, and handoffs and transitions. Nursing home scores from this survey were compared against hospital benchmark scores. Twelve facility and market characteristics of the nursing home were identified to enable an examination of relationships between patient safety and these characteristics. Facility characteristics included staffing levels, number of beds (to proxy facility size), case mix (a proxy measure of activities of daily living was used), ownership (for-profit vs. not-for-profit), chain membership (chain vs. non-chain), private-pay occupancy rates, and overall resident census (number of residents divided by number of beds). Market characteristics included rural location and number of nursing homes in the county (a proxy measure for competition). Relationships between the 12 patient safety subscales and the 12 facility and market characteristics were analysed.

Findings: Fifty-two percent of nursing homes in the sample belonged to chains and 59% were for-profit. A comparison of nursing home and hospital patient safety scores revealed that nursing homes scored lower in all subscales except for teamwork across units. The authors interpret this as suggesting patient safety culture is lower in nursing homes than hospitals. Facility characteristics associated with high patient safety scores include high staffing levels of registered nurses (RNs) (in 10/12 patient safety subscales), high licensed practical nurse (LPN) staffing (2/12 subscales), and high nursing aid staffing (7/12 subscales). Facility characteristics associated with low patient safety include for-profit ownership (in 9/12 subscales), chain membership (10/12 subscales), and lower than average private-pay occupancy (11/12 subscales). Both market characteristics (rural location and number of nursing homes) were associated with low patient safety scores.

Conclusions: The results suggest that patient safety culture in nursing homes may lag behind hospitals. The authors suggest that improvement in patient safety culture in nursing homes is critical to improving the care provided by this industry. From a policy perspective, the most striking findings pertain to the importance of high RN staffing levels in ensuring patient safety and the strong relationships between for-profit ownership, chain membership, and low patient safety culture. It should be noted that because researchers examined only the views of nursing home administrators as opposed to multiple levels of management, a partial view of patient safety culture in nursing homes is provided.

Reference: Castle NG, Handler S, Engberg J, Sonon K. Nursing home administrators' opinions of the resident safety culture in nursing homes. Health Care Management Review. 2007; 32: 66-76.