Healthcare Quarterly

Healthcare Quarterly 11(Sp) March 2008 : 10-15.doi:10.12927/hcq.2013.19604
Creating a Patient Safety Culture

Patient Safety Culture Improvement Tool: Development and Guidelines for Use

Mark Fleming and Natasha Wentzell


The Patient Safety Culture Improvement Tool (PSCIT) was developed to assist healthcare organizations in identifying practical actions to improve their culture. This article describes the development process of the PSCIT and provides a guide to using the PSCIT.   The tool is based on a safety culture maturity model, which describes five stages of cultural evolution, from pathological to generative. The PSCIT consists of nine elements that cover five patient safety culture dimensions, namely, leadership, risk analysis, workload management, sharing and learning and resource management. Each element describes the systems in place at each level of maturity, enabling organizations to identify their current level of maturity and actions to move to the next level. The PSCIT should be used with caution as there is currently a lack of reliability and validity data.

The importance of considering safety culture in patient safety improvement is widely accepted within the healthcare industry. The Institute of Medicine report To Err Is Human highlighted the importance of safety culture by stating that "health care organizations must develop a culture of safety such that an organization's care processes and workforce are focused on improving the reliability and safety of care for patients" (2000: 14). Pronovost and Sexton (2005) suggest that having a culture that promotes safety within your organization is an important and necessary precursor to improving the insufficiencies in patient safety. In January 2005, the Canadian Council on Health Services Accreditation (CCHSA) formally recognized the importance of culture in healthcare standards by including a culture of safety as one of their patient safety goals and also specifying five required organizational practices to promote a positive culture. The emphasis on creating the rightculture to support patient safety is recognition that a poor culture is a significant risk factor that can threaten patient safety (Nieva and Sorra 2003) and that until the culture within healthcare changes, nothing else will (Vincent 2005). There are two fundamental assumptions underlying much of the safety culture research: (1) a positive safety culture is associated with improved safety performance (Clarke 1999) and (2) it is possible to improve the culture of an organization (Guldenmund 2000). Yet, there is a lack of empirical data on what a good culture looks like (Cox and Cox 1996) and how to develop a good safety culture (Parker et al. 2006).

Currently, patient safety culture is commonly assessed via self-completion questionnaires. This process typically involves mailing questionnaires to all staff and collating and calculating mean responses to items or factors (see Fleming and Hartnell 2007). Safety culture surveys provide much information about employee attitudes, but it is difficult to use the results to identify practical actions to improve the culture. In fact, safety culture surveys have been likened to "describing the water to a drowning man; they tell you how bad things are but do little to help in solving the problem" (Fleming 2003). Therefore, there is a need to provide healthcare organizations with more solution-focused safety culture instruments. This can be achieved by identifying the organizational practices required to promote a positive patient safety culture since an effective way to improve a culture is by changing the organization's systems and processes.  

Schein (1990) argues that organizational culture is shaped through leadership action and systems that promote desired behaviours, including the following:

  • Areas that leaders pay attention to, measure and control
  • Deliberate role-modelling and coaching by leaders
  • Operational criteria for the allocation of rewards and status
  • Operational criteria for recruitment, selection and promotion
  • The organization's design and structure
  • Organizational systems and procedures

Schein's (1990) view of culture suggests that the patient safety culture is a reflection of the extent to which the above mechanisms support patient safety. For example, if managers are rewarded for reducing cost or cutting budgets with no consideration for quality or patient safety, this is likely to limit the priority they place on safety, which is a key component of safety culture (Flin et al. 2000; Zohar 2000).  

Similarly, Parker et al. (2006) argue that safety culture is affected by organizational changes, such as a change in leadership or the introduction of new systems and processes. This suggests that safety culture is influenced by the systems, processes and practices of the organization. For example, an organization with a poor safety culture will have limited safety systems, while an organization with a positive culture will have many systems in place to promote patient safety. This argument suggests that it should be possible to assess the extent to which systems and processes promote a positive safety culture by evaluating organizational practices that influence the culture. This approach is supported by Zohar (2000) and Parker et al. (2006), who have demonstrated that safety culture consists of both concrete and abstract aspects. The concrete aspects of safety culture are tangible and observable and can therefore be used to develop a list of organizational practices that support a positive safety culture. More recently, Flin (2007) has argued that organizational indicators of a positive safety culture allow management to both monitor patient safety culture and influence patient safety outcomes. This argument is further supported by the recent development and initial validation of a safety culture improvement tool for the petrochemical industry by the current authors. This tool uses concrete organizational indicators to assess the maturity of the safety culture (Fleming et al. 2007). Based on the success of the petrochemical industry tool, we decided to develop a similar tool for healthcare. The Patient Safety Culture Improvement Tool (PSCIT) was developed to assess a number of important organizational practices that influence patient safety culture.

Developing the Tool

The development of patient safety culture indicators requires the specification of the cultural attributes that distinguish between "poor" and "good" safety cultures. Safety culture maturity models describe the stages of safety culture development (Fleming 2000). They are useful to organizations as they enable them to assess their current level of maturity (Paulk et al. 1993) and to identify areas of particular strength and weakness (National Patient Safety Agency and School of Psychological Sciences, University of Manchester 2006) and actions that need to be taken to reach the next level of maturity (Paulk et al. 1993). The safety culture maturity model of Ashcroft et al. (2005) describes the stages of safety culture development; thus, it is a useful framework to use for the basis of the patient safety culture indicators.  

The safety culture maturity model used by Ashcroft et al. (2005) to develop the Manchester Patient Safety Framework was based on the work of Westrum (2004) and Reason (1998). Ashcroft et al. (2005) described five levels of culture: pathological, reactive, calculative, proactive and generative. At the pathological level of maturity, organizations see safety as a problem; they suppress information and focus on blaming individuals to support the personal needs, power and glory of those in charge. Organizations at the reactive level view safety as important but respond only after significant harm has occurred. Calculative organizations tend to be fixated on rules, positions and departmental territory. After a safety incident has occurred, information may be ignored by this type of organization and failures explained away or resolved, with no deeper inquiry into them. Organizations at the proactive level focus their efforts on anticipating safety issues before they occur by involving a wide range of stakeholders in safety. Generative organizations actively seek out information to understand why they are safe and unsafe. Inquiries into safety-related events serve as a means to attack the underlying conditions, not just the immediate causes of the failures. The characteristics of a high-reliability organization can be likened to the characteristics of an organization that has reached the generative level of cultural maturity. This model can be used to describe how organizations at different levels of maturity approach safety culture improvement (Table 1).


Although this model provides a useful framework for safety culture improvement and general guidance on the nature of a positive culture, it does not specify the systems and processes associated with a positive patient safety culture. Therefore, patient safety culture indicators were developed by reviewing the literature on patient safety culture perception surveys and current guidelines on safety culture improvement (e.g., CCHSA Required Organizational Practices).

Patient safety culture is commonly assessed via a self-report perception survey (Fleming and Hartnell 2007). Reviews of patient safety culture instruments (e.g., Colla et al. 2005; Flin et al. 2006; Singla et al. 2006) have identified common cultural dimensions. Given that these instruments were developed independently using different populations, the common elements identified could be considered the fundamental building blocks of patient safety culture. Table 2 identifies the common dimensions from these patient safety survey reviews. From the literature review on patient safety culture surveys, five main patient safety indicators were identified and included in the PSCIT. To fully assess the systems and processes influencing patient safety, these five patient safety indicators were further broken down into more detailed elements of patient safety (see Table 2).

[Table 2]


Consultation with Patient Safety Experts

The content and face validity of the original version of the PSCIT was tested by interviewing patient safety experts across Canada. Experts were sent the PSCIT in advance of the interview and asked to evaluate the tool for clarity, the extent to which the indicators were objective and the completeness of the tool. They were also asked to consider the extent to which the indicators would differentiate between organizations at different levels of cultural maturity.  

Five interviews with patient safety experts were completed. Interviews were conducted over the telephone or face to face and were tape-recorded with the participant's permission. During the interviews, participants commented on their ability to assess their own organization's maturity and benefits of using the PSCIT. The participants identified a number of potential improvements to the PSCIT, such as the need to clarify some of the terms used as they differ across organizations. All the participants indicated that the PSCIT covered the important aspects of patient safety culture and that it was easy to assess the maturity of their systems using the instrument. Participants also indicated that reviewing the PSCIT was a useful exercise. In the words of one participant, "This was excellent. I have identified a list of improvement actions." The PSCIT was revised as a result of the feedback provided during these interviews.  

Using the PSCIT

The PSCIT was developed to enable healthcare organizations to assess the maturity of the systems currently in place to promote a positive patient safety culture. (See Appendix 1.) The PSCIT outlines increasing levels of cultural maturity and describes the systems associated with each level. The PSCIT provides organizations with a straightforward and structured process for reviewing the extent to which current systems promote a positive safety culture. Improvement actions are identified by comparing current systems with the practices associated with the next level of maturity.  

For the best results, the PSCIT should be completed by a multidisciplinary team, consisting of those with expertise in the operation of current patient safety systems, those with budgetary authority and healthcare providers. The PSCIT can be used at the organizational or departmental level. The appropriate level of analysis depends on the organizational structure; the important issues are budgetary authority and the ability to implement new systems. For example, a surgical department could use the tool to identify opportunities for improvement as long as it has the autonomy to implement new systems such as leadership training. If departments or units do not have control over all the elements (e.g., leader performance evaluation), they should skip those elements that they cannot change and focus on evaluating the elements that they can improve.  

Initially, team members should individually complete the tool, after which they should meet as a group to discuss their results and reach a consensus. For each element, the team should assess the level of maturity of each indicator (e.g., incident reporting) by reviewing each level of maturity (from 0 to 4) and choosing the maturity level that best describes the systems and processes within their organization. Once the level of maturity has been chosen, the team should assess the degree of implementation within their organization. Thus, for every indicator, the team assesses the degree to which the systems described have been implemented across the organization or department by classifying it as low (i.e., implemented in less than a third of the organization/target group), medium (i.e., implemented in less than two thirds of the organization/target group) or high (i.e., implemented in over two thirds of the organization/target group) and inserting L, M or H in the box that corresponds to this level. Figure 1 provides an example of what one indicator from the PSCIT looks like upon completion. The next step in the process is to discuss the current systems and processes in more detail (e.g., why it was developed, how effective it is) and to consider barriers to moving to the next level of maturity. The team should only use the practices associated with the next level of maturity as a starting point for discussion and should not automatically adapt these practices as an action plan. The focus of the discussion should be the development of a strategic plan for improving the culture, including specific action plans that describe the steps the organization is going to take to reach the next level of maturity.

[Figure 1]



Creating a positive culture that promotes patient safety is one of the key challenges facing healthcare organizations. Recently, many healthcare organizations have conducted safety culture surveys to assess their current culture and identify areas for improvement. It is likely that these organizations have experienced similar difficulties as those encountered by other industries when they try to use their survey results to identify concrete actions to improve their culture (Fleming and Hartnell 2007). The PSCIT was developed to assist organizations in their efforts to improve their culture. It assesses the organizational practices, systems and processes related to nine patient safety culture elements. The results of the PSCIT provide a description of the current state of an organization's patient safety culture and can be used to develop strategic plans to improve its level of patient safety culture maturity.  

The PSCIT has only recently been developed; thus, the psychometric properties (i.e., the reliability and validity) have not been determined. Therefore, this tool should be used with caution to facilitate discussion and support the identification of actions for cultural improvement. Given the early developmental stage, the PSCIT may not be a comprehensive assessment of patient safety culture and should be considered a guide; therefore, improvement teams should not limit the coverage of patient safety culture aspects they may wish to improve to those covered by this tool. The maturity model approach to safety culture improvement is only one way to improve patient safety culture and is offered as a tool that healthcare organizations can use on their journey to creating a positive safety culture. Additional research is currently being developed and conducted to address the lack of reliability and validity data.  

[To view the Appendix, please download the PDF.]

About the Author(s)

Mark Fleming, PhD, is with Saint Mary's University in Halifax, Nova Scotia. He can be contacted at 902-420-5273, by fax at 902-496-8287 and by e-mail at

Natasha Wentzell is with Saint Mary's University.


The authors would like to thank the five patient safety experts who volunteered time out of their busy schedules to complete the interviews regarding the original version of the PSCIT.


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