Dimensions of Patient Safety Culture in Family Practice
Safety culture has been shown to affect patient safety in healthcare. While the United States and United Kingdom have studied the dimensions that reflect patient safety culture in family practice settings, to date, this has not been done in Canada. Differences in the healthcare systems between these countries and Canada may affect the dimensions found to be relevant here. Thus, it is important to identify and compare the dimensions from the United States and the United Kingdom in a Canadian context.
The objectives of this study were to explore the dimensions of patient safety culture that relate to family practice in Canada and to determine if differences and similarities exist between dimensions found in Canada and those found in previous studies undertaken in the United States and the United Kingdom. A qualitative study was undertaken applying thematic analysis using focus groups with family practice offices and supplementary key stakeholders.
Analysis of the data indicated that most of the dimensions from the United States and United Kingdom are appropriate in our Canadian context. Exceptions included owner/managing partner/leadership support for patient safety, job satisfaction and overall perceptions of patient safety and quality. Two unique dimensions were identified in the Canadian context: disclosure and accepting responsibility for errors.
Based on this early work, it is important to consider differences in care settings when understanding dimensions of patient safety culture. We suggest that additional research in family practice settings is critical to further understand the influence of context on patient safety culture.
Since the release of the Institute of Medicine report To Err Is Human: Building a Safer Healthcare System (Kohn et al. 1999), more attention has been paid internationally to the issues surrounding patient safety. The safety of healthcare has been shown to be influenced by its organizational culture (Nieva and Sorra 2003; Schutz et al. 2007; Wachter 2004), which is the pattern of assumptions, values and norms within an organization (Schein 1990) and is the primary driver of safety (Ruchlin et al. 2004). If the organizational culture does not support patient safety, unsafe care will continue to occur (Baker and Norton 2001; Gaba et al. 2007; Pace 2007; Pronovost and Sexton 2005; Singer et al. 2007; Wachter 2004; Westrum 2004).
Organizational culture is a broad construct composed of many subsets of culture, one of which is safety (Clarke 1999; Hofstede 1980; Reiman and Oedewald 2004). The focus on safety culture began in the nuclear power and aviation industries (Health and Safety Commission 1993) and is now recognized as an important component in the delivery of healthcare (Blegen et al. 2009; Clarke 1999; Fleming and Wentzell 2008; Gaba et al. 1994; Ginsburg and Tregunno 2007; Hofstede 1980; National Patient Safety Agency [NPSA] 2006; Reiman and Oedewald 2004; Stock and Mahoney 2008). NPSA defines safety culture as one in which "both the individuals and the organisation are able to acknowledge mistakes, learn from them, and take action to put things right…[It] is open and fair, and one that encourages people to speak up about mistakes" (2006: 17, 21). It also has been suggested that "safety culture is a critical element necessary to achieve reductions in medical errors and adverse events" (Stock et al. 2007: 375). To improve patient safety, a shift in culture from "blame and shame" to "just and trusting" is required (Reason 1997).
In order to improve patient safety culture, it is necessary to be able to interpret and measure it. To date, the majority of research on patient safety culture interpretation and measurement has focused on acute care settings. Singla et al. (2006) performed a systematic review of existing instruments or tools developed in the United States to measure patient safety culture in acute care. They found 13 instruments identifying 23 dimensions of patient safety culture. These dimensions were grouped into six broad categories: management/supervision, risk, work pressure, competence, rules and miscellaneous. One of these instruments, the Stanford Instrument (Singer et al. 2003), was modified to fit the Canadian acute care context (York University n.d.).
Family practice settings differ from acute care in organizational structure, administrative and clinical processes and the reason for and type of visits. In family practice, a formalized organizational structure with set policies and procedures is rare; services such as specialist care, laboratories and diagnostic imaging are off site; there is less control over the patients' environments (Hammons et al. 2002; O'Beirne and Sterling 2009; Schutz et al. 2007); the turnaround of results is much slower; and patients are more likely to be seen for chronic issues rather than conditions of high acuity (Dovey et al. 2002a, 2002b).
Family practice also differs in relation to the types of incidents reported and in the strategies and interventions used to improve patient safety. In family practice, most incidents are related to failure or delay in diagnosis, failure or delay in referral, medication contraindication, medication prescription errors (Dovey et al. 2003; National Patient Safety Agency 2006) and test results management (Elder et al. 2009). In acute care, interventions and strategies focus on standardizing operating procedures in order to mitigate incidents. In family practice, interventions and strategies focus on "diagnosis, medication prescribing, dispensing and administration, and communication within practices, between different professions and between primary and secondary care" (National Patient Safety Agency 2006: 20).
Given the substantial differences in care settings, it is important to understand if and how differences influence or alter dimensions of patient safety culture. Unfortunately, very little work has been published on measuring patient safety culture in family practice. In the United States, three groups have developed sets of dimensions for family practice (Agency for Healthcare Research and Quality n.d.; Modak et al. 2007; Schutz et al. 2007), tied to respective questionnaires. Also, a framework of dimensions has been developed in the United Kingdom (Kirk et al. 2007). The dimensions from the three US sources and the UK source were similar but not identical. In the Canadian context, patient safety culture dimensions for family practice have not been developed. However, major distinctions among Canada, the United States and the United Kingdom exist within their incentives and management structures for family practice. In the United States, most of the family practice delivery is privately funded and delivered through managed care. In the United Kingdom, the delivery is primarily publicly funded and organized into "primary care trusts" (National Health Service 2009). In Canada, family practice care delivery is publicly funded and privately delivered. This variance in governance of family practice among the US, UK and Canadian contexts suggests that further exploration is required to better understand what dimensions are and are not appropriate for measuring patient safety culture in Canadian family practice.
As outlined, there are considerable gaps in knowledge concerning the dimensions of patient safety culture that need to be addressed specific to the family practice setting in the Canadian context. The remainder of this article discusses how investigation into these gaps has begun.
Purpose and Objectives
This study is part of a much larger program of research that focuses on patient safety in family practice – Medical Safety in Community Practice (MSCP; O'Beirne and Sterling 2009). The purpose of the MSCP research is to collect incident information from family practices located within Alberta Health Services, Calgary Zone, and to collaborate with these practices to develop, implement and evaluate risk management strategies to increase patient safety. The overarching purpose of the study presented in this article was to explore patient safety culture within family practice settings in order to enhance the understanding of this relatively under-studied setting. Primary objectives were (1) to begin to determine the dimensions of patient safety culture for family practice in Canada and (2) to subsequently determine if differences and similarities exist between dimensions found in Canada and those found in previous studies undertaken in the United States and the United Kingdom.
This qualitative case study involved identifying the dimensions of patient safety culture of relevance to family practice in Canada. A convenience sample of five clinics was chosen from the MSCP program. These clinics were invited via telephone to participate in the focus groups for this study. Two clinics accepted the invitation. One of these clinics was well entrenched in the patient safety study; the other was new to the study. A third focus group was held that involved informed stakeholders, including patient safety experts and family physicians, staff and patient advocates (members of a panel in the MSCP program). These focus groups were what Stewart and Shamdasani (1990) described as "compatible and heterogeneous" because they had a diversity of practitioners and professionals with a common interest in patient safety. A semi-structured script was used to guide discussion on the dimensions that participants felt were important to patient safety culture.
The focus groups were facilitated by one of the research team members and ran for one hour or less. Each group had between four and six participants. In total, five physicians, one nurse, six office staff members, one healthcare administrator and one layperson participated. All focus groups were tape-recorded. After the first focus group, participants suggested adding a definition of patient safety culture, and this was provided for the remaining groups. By the third focus group, no new information was emerging.
Tape recordings were transcribed, data coded and field notes used to supplement and clarify the data (Morse and Field 1995). Three researchers individually performed thematic analyses (Morse and Field 1995) on the focus group transcripts. The existing dimensions from the United States and United Kingdom were used as one lens for analysis; however, analysis remained open to identify new and emergent perspectives from the study participants. When comparing results, themes and dimensions of patient safety culture were convergent among the reviewers. The discussion and revision of themes focused primarily on how these similar concepts were named. A final review of emergent themes and dimensions of patient safety culture was undertaken by five researchers, serving to further triangulate results and allow for additional reflective interpretation of the study participant data. If the wording was different but the concept the same, the language used in the US study (Agency for Healthcare Research and Quality n.d.) was adopted.
The analyses of our review of existing literature and our own data highlight several important results. Thirteen dimensions of patient safety culture relevant to family practice in our Canadian cases were identified. Table 1 illustrates the dimensions and compares them with those in the US and UK studies. Each of these dimensions is further described in Table 2, which provides some examples of the Canadian perspectives found in the data.
|Table 1. Patient safety culture dimensions in family practice: comparison of US and UK cases with Canadian cases|
|Dimension*||US and UK Cases||Canadian Cases|
|Communication about error||X||X|
|Patient care tracking/follow-up||X||X|
|Patient safety and quality issues||X||X|
|Office processes and standardization||X||X|
|Information exchange with other settings||X||X|
|Work pressure and pace||X||X|
|Overall ratings on quality and patient safety||X||X|
|Owner/managing partner/leadership support for patient safety||X|
|Overall perceptions of patient safety and quality||X|
|Accepting responsibility for error||X|
*Dimensions from the three US sources (Agency for Healthcare Research and Quality [AHRQ] n.d.; Modak et al. 2007; Schutz et al. 2007) and one UK source (Kirk et al. 2007) were similar but not identical, and we chose the wording of AHRQ.
|Table 2. Dimensions, descriptions and examples for the Canadian cases|
|Dimension||Description of Dimension||Narrative Example|
|Organizational learning||Illustrates the level of learning that occurs from incidents within the practice, and work to improve those problems||"Well, in my opinion, it's hard to anticipate every aspect of the type of mistakes that can be made, but when a mistake is brought forward, something is done to address it so it hopefully does not happen again. And it's not disregarded."|
|Communication about error||Shows the openness of the practice members to admitting errors and discussing them with others||"Creating an atmosphere where people feel comfortable bringing forward mistakes."|
|Staff training||Reflects how well the office ensures staff members are trained in what they are required to do||"In-service training in various aspects of what the staff are doing would definitely help."|
|Teamwork||Identifies respect, working relationships and helping others in the work load as part of teamwork||"The idea of teamwork is hugely important. The people that contribute are present at the decision; co-operate in that collegial world of encounter."|
|Patient care tracking/follow-up||Measures the extent offices perform proper follow-up and tracking of patients||"Well, having test results going astray is big, especially when something has been missed. If there was something important in the results…"|
|Communication openness||Reflects how open all members of the office are in voicing their opinion and accepting others||"I think it's important that everyone feels free to contribute their ideas because everyone has a different role and, maybe, just a different way they to about things."|
|Patient safety and quality issues||Reflects things that can happen in medical offices that affect patient safety and quality of care (e.g., access to care, medication and medical records)||"In a perfect healthcare setting would be timely access to a physician, appropriate evaluation, proper medication and compliance by the patient and also appropriate laboratory investigation and follow-up on that."|
|Office processes and standardization||Identifies procedures, processes, workflow and standardization||"It is creating processes within our medical environments that allow patients or clients to move through these processes in a positive manner."|
|Information exchange with other settings||Captures how often the office has had problems exchanging accurate, complete and timely information with external settings (laboratory, diagnostic imaging, specialists)||"Because the clinic does not notify us when they've received our referral … we are now attaching a cover that says please respond that you have received this referral. They haven't returned our faxes, but we just started that last week."|
|Work pressure and pace||Explores distractions and volume of work||"If the environment you are working in is too distracting, it's unsafe."|
|Overall ratings on quality and patient safety||Measures overall ratings on patient-centred, effective, timely, efficient and equitable healthcare||"Part of patient safety is getting the most up-to-date evidence-based care."|
|Disclosure||Reflects disclosure of error to the patient||"Patients are confident in knowing that if something gets missed, it will be brought to their attention … it's not hidden from them; it's disclosed."|
|Accepting responsibility for error||Illustrates that individuals can accept that they made an error||"I think it's important if you have made a mistake to say, 'I'm sorry, I made a mistake,' because mistakes happen and it's not that you purposely try to make mistakes during your day at work."|
As Table 1 shows, three patient safety culture dimensions in family practice found in the US and UK cases were not found in the Canadian context: owner/managing partner/leadership support for patient safety, job satisfaction and overall perceptions of patient safety and quality. Two new dimensions were identified: disclosure and accepting responsibility for errors.
The data reported here explore the dimensions of patient safety culture in Canadian family practice settings in comparison with data found in the US and UK studies. Several interesting findings warrant discussion and further examination.
The dimensions found in family practice in Canada identified in Table 1 suggest that there is considerable consistency of patient safety culture dimensions in our Canadian cases when compared with the US and UK cases; but, there also appear to be some differences. Eleven of the existing dimensions were relevant in the Canadian context, three were not identified and two new dimensions were discovered.
There are many possible reasons for these differences. The absence of the dimension owner/managing partner/leadership support for patient safety could be due to the difference in governance found in these countries. In Canada, clinics are run more as a partnership, without an overlying organizational structure. It is difficult to explain the absence of the dimension job satisfaction in the Canadian study, but it is interesting to note that this dimension was also not found in studies of acute care in Canada (York University n.d.). It is possible that, in this study, job satisfaction was captured as an attribute (subcategory) under other dimensions such as office processes and standardization. Overall perceptions of patient safety and quality may simply have been too broad a dimension to emerge separately in our cases. This is an area that needs further exploration.
Two new dimensions were found to be relevant in Canadian family practice settings: While disclosure is closely aligned with the existing dimension communication about error, it concerns communicating outside the clinical team to patients and families. Accepting responsibility for error appears to be unique and distinct, going beyond communicating about an error to admitting fallibility. These new dimensions may have arisen as a consequence of recent media coverage and emphasis in Canada on disclosure and accepting responsibility (Health Quality Council of Alberta 2006; Windwick et al. 2007). Perhaps these dimensions were missing in the US and UK cases due to the earlier timing of the studies.
It is important to stress both the strengths and limitations of the study findings. Potential limitations to the study include the following: (1) participants may not have felt comfortable enough to openly express themselves in front of their colleagues, although this risk was minimized through careful facilitation of the focus groups; and (2) the small sample size from one city did not include all types of family practices (ranging from a single family physician practice with few employees and little organizational structure to multi-physician, multi-employee practices with some organizational structure). The major strength of the study is that it adds early and additional knowledge to understanding dimensions of patient safety culture in family practice, and it is the first of its kind in a Canadian setting.
Given that this is one early study with only a few Canadian cases, clearly more research is required to confirm and extend this initial exploratory case analysis. However, considering the significant consistency of dimensions found in common with those in the earlier US and UK studies, there is some promise for transferable lessons more generally for family practice in Canadian settings.
This study identified 13 dimensions relevant to patient safety culture in Canada. Based on this early work, it is important to consider context (country and setting) when adapting existing tools created in other jurisdictions. The dimensions found in this study will be used to develop a tool to measure patient safety culture in family practice in Canada. With this tool, we will be able to estimate patient safety culture and measure changes in culture after the implementation of safety or quality interventions.
While our work makes important contributions to understanding the dimensions of patient safety in family practice settings, additional exploration and evaluative research are needed. We encourage others to add to our empirical and theoretical knowledge of the role that culture plays in the capacity to develop and sustain patient safety in Canadian family practice settings. We also suggest that additional comparative research would provide valuable insight into how best to understand and measure the influence of patient safety culture in different countries with varying organizational arrangements for care and, especially, among distinct care settings.
About the Author
Luz Palacios-Derflingher, PhD, is a research associate, in the Department of Family Medicine, at the University of Calgary, Calgary.
Maeve O'Beirne, PhD, MD, FCFP, is an associate professor, in the Departments of Family Medicine and Community Health Sciences, at the University of Calgary, Calgary,
Pam Sterling, BSc, PMP, is a program manager, in the Department of Family Medicine, at the University of Calgary, Calgary.
Karen Zwicker, BScH, is a research associate, in the Department of Family Medicine, at the University of Calgary, Calgary.
Brianne K. Harding, BA, BHSc, is a student, in the Department of Community Health Sciences, at the University of Calgary, Calgary.
Ann Casebeer, MPA, PhD, is an associate professor, in the Department of Community Health Sciences, at the University of Calgary, Calgary.
We wish to acknowledge the full research team, especially Stacey Hohman for administrative and research support. Special thanks to all those study participants who provided their time and insights. The authors also want to acknowledge Canadian Health Services Research Foundation, Canadian Patient Safety Institute and Alberta Heritage Foundation for Medical Research for funding our work.
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