a comprehensive obstetrics patient safety program improves safety climate and culture

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Research www.AJOG.org

OBSTETRICS

A comprehensive obstetrics patient safetyprogram improves safety climate and cultureChristian M. Pettker, MD; Stephen F. Thung, MD; Cheryl A. Raab, RNC; Katie P. Donohue, RN;Joshua A. Copel, MD; Charles J. Lockwood, MD; Edmund F. Funai, MD

OBJECTIVE: The purpose of this study was to determine the effect of anobstetrics patient safety program on staff safety culture.

STUDY DESIGN: We implemented (1) obstetrics patient safety nurse,(2) protocol-based standardization of practice, (3) crew resource man-agement training, (4) oversight by a patient safety committee, (5) 24-hour obstetrics hospitalist, and (6) an anonymous event reporting sys-tem. We administered the Safety Attitude Questionnaire on 4 occasionsover 5 years (2004-2009) to all staff members that assessed teamworkand safety cultures, job satisfaction, working conditions, stress recog-
nition, and perceptions of management.
Gynecol 2011;204:216.e1-6.

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216.e1 American Journal of Obstetrics & Gynecology MARCH 2011

RESULTS: We observed significant improvements in the proportion of staffmembers with favorable perceptions of teamwork culture (39% in 2004 to63% in 2009), safety culture (33% to 63%), job satisfaction (39% to 53%),and management (10% to 37%). Individual roles (obstetrics providers, res-idents, and nurses) also experienced improvements in safety and team-work, with significantly better congruence between doctors and nurses.

CONCLUSION: Safety programs can improve workforce perceptions ofsafety and an improved safety climate.

Key words: patient safety, quality improvement, safety attitude
questionnaire, safety culture
Cite this article as: Pettker CM, Thung SF, Raab CA, et al. A comprehensive obstetrics patient safety program improves safety climate and culture. Am J Obstet

Safety culture is defined as the integra-tion of safety thinking and practices

nto clinical activities. This includes de-elopment of systems for data collectionnd reporting, the reduction of tenden-ies to place blame on individuals, and aocus on real or potential system laten-ies.1,2 Improvement of patient safety, inerms of risk and outcomes, in a health-are system depends on the building of a

From the Department of Obstetrics,Gynecology, and Reproductive Sciences,Yale University School of Medicine (DrsPettker, Thung, Copel, Lockwood, andFunai), and Yale–New Haven Hospital (MsRaab and Ms Donohue), New Haven, CT.

Presented at the 30th Annual Meeting of theSociety for Maternal-Fetal Medicine, Chicago,IL, Feb. 1-6, 2010.

Received July 30, 2010; revised Sept. 11,2010; accepted Nov. 2, 2010.

Reprints not available from the authors.

Supported in part by MCIC Vermont, Inc (NewYork, NY) as a quality assurance activity.

0002-9378/free© 2011 Mosby, Inc. All rights reserved.doi: 10.1016/j.ajog.2010.11.004

For Editors’ Commentary,

patient safety culture; some investigatorshave argued that the key to quality im-provement may lie in this type of organi-zational change.3

Safety climate is the quantitative de-scription of the safety culture. Safety cli-mate can be assessed in several ways thatinclude examination of adverse events(outcomes measures),4,5 analysis of adher-nce to practices (process measures),6,7 or

calibration of healthcare teams’ attitudesabout issues relevant to safety.8 Many pa-ient safety programs have shown signifi-ant reductions in adverse outcomes; how-ver, less is known of the impact of suchfforts on staff safety perceptions andttitudes.9

With the hypothesis that a multifac-eted approach to enhance the overallsafety culture would reduce the rate ofadverse outcomes, we partnered withour hospital (Yale–New Haven Hospi-tal) and our malpractice carrier (MCICVermont, Inc, New York, NY) to assessand improve our safety climate. The goalof this program was to improve patientsafety and the safety culture, decrease pa-tient injury, and decrease liability losses

hat identified and

initiated cultural changes and specificrisk-reduction clinical practices. We re-ported the details of the incrementalreduction in adverse outcomes, as mea-sured by the obstetrics Adverse Out-comes Index, over a 3-year period in aprevious publication.10

Simultaneously, we aimed to deter-mine the effect of a comprehensive ob-stetrics patient safety program on staffperceptions of safety and teamwork thatwas measured by the Safety AttitudeQuestionnaire (SAQ), which is a stan-dardized and validated questionnairethat measures staff attitudes towardssafety and quality in the workplace.8

MATERIALS AND METHODSWe sequentially introduced multiple pa-tient safety interventions from Decem-ber 2002 to November 2006 at a univer-sity-based obstetrics service at Yale–NewHaven Hospital. The details of this pro-gram have been previously described.10

Briefly, the effort involved the initiationof the following interventions:

Outside expert reviewIn 2002, 2 independent consultants (amaternal–fetal medicine physician and a
nurse specialist/leader) initiated an out-

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side expert review. This site visit culmi-nated in a review and recommendationsthat focused on principles of patientsafety, evidence-based practice, and con-sistency with standards of professionaland governing bodies.

An obstetrics patient safety nurseAn obstetrics patient safety nurse was re-sponsible for data collection (which wasbegun prospectively in September 2004)on a “case occurrence” basis.11 Thisnurse also led educational efforts (teamtraining, electronic fetal monitoringcertification), directed the anonymousevent reporting system, and initiated andled adverse event reviews.

Protocol and guidelineProtocol and guideline development be-gan in 2004; the aim was to codify andstandardize existing practices.

Reporting systemAn anonymous, computerized event re-porting system (Peminic, Inc, Princeton,

FIGURE 1Changes in perception of teamwor

Difference between 2004 and 2009 statisticallyPettker. Obstetrics patient safety program improves safety cul

TABLESurvey response numbers and rate

Variable 2004

Target respondents, n 234...................................................................................................................

Surveys administered, n 215...................................................................................................................

Surveys returned, n 192...................................................................................................................

Response rate, % 89...................................................................................................................

Pettker. Obstetrics patient safety program improves safety

NJ) was initiated in 2004 and allowedany hospital worker to report events thatmay have caused or could cause harm toa patient/visitor.

An obstetrics hospitalist/Yale on-call attendingAn obstetrics hospitalist/Yale on-call at-tending physician position was imple-mented in 2004 to provide a consistentsystem of inpatient coverage and resi-dent supervision. This coverage was pro-vided by a Maternal-Fetal Medicine spe-cialist 24 hours a day, 7 days a week.

Obstetrical Patient Safety CommitteeThis multidisciplinary committee (phy-sicians, nurses, administrators) was ini-tiated in 2004 was responsible for qualityassurance and quality improvement re-views and, in particular, addressed theneed for protocols and policies to im-prove safety and efficiency.

ulture

ificant (P � .0001) by �2 testing.. Am J Obstet Gynecol 2011.

2006 2007 2009

230 231 310..................................................................................................................

209 201 254..................................................................................................................

198 189 183..................................................................................................................

95 94 72..................................................................................................................

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The SAQThe SAQ is a tool that was adapted fromthe aviation field and is used for the as-sessment of healthcare employee percep-tion of teamwork and safety.8

Team trainingStarted in 2005, team training was a con-tinuing series of crew resource manage-ment seminars that were based on semi-nars of airline and defense industries.Four-hour classes included videos, lec-tures, and role-playing and integratedobstetrics staffing domains (physicians,nurses, administrators, assistants). Sem-inars were organized as a 1-time trainingopportunity for existing staff members.New employees who were hired after theinitial set of seminars received trainingshortly after beginning work. Crew re-source management techniques havebeen reinforced since that time throughobstetrics simulations in an on-site sim-ulation facility. Completion of the crewresource management seminar was acondition for employment and/or clini-cal privileges.

Electronic fetal monitoringcertificationElectronic fetal monitoring certification,which began in 2005, involves dissemi-nation and review of National Instituteof Child Health and Human Develop-ment guidelines, a review of tracings, theallocation of study guides, and voluntaryreview sessions and culminates in astandardized, certified examination. Allmedical staff members and employeeswho are responsible for fetal monitoringinterpretation were obligated to take thisexamination. New employees who werehired after the initial effort were requiredto take this examination within 1 year ofemployment; a passing score was re-quired within 18 months. There was a100% pass rate among physicians andmidwives and a 98% pass rate on firstattempt among nurses over the time ofthis study.

Workforce safety climateWorkforce safety climate was assessedwith the obstetrics SAQ.12 This anony-

ous survey helps to detect perceivedystemic weaknesses and differences of

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groups (eg, staff, nursing, physicians)that result from a professional educationthat is marked by differing languages/vo-cabularies and contrasting perspectives.The survey consists of a series of state-ments to which the respondent is able toanswer with agreement or disagreement,with a 5-point Likert scale (disagree/never, disagree/rarely, neutral/some-times, agree/most of the time, agree/al-ways). Agreement with a statement, forinstance, is concluded when a respon-dent answers either “most of the time” or“always.” The survey involves 58 ques-tions and takes approximately 10 min-utes to complete. Sample questions in-clude: “I would feel safe being treatedhere as a patient,” “The physicians andnurses here work together as a well-co-ordinated team,” and “Morale in thisunit/clinical area is high.”

The SAQ has been validated in nonob-stetrics healthcare settings. Favorablescores are associated with shorter lengthsof stay, fewer medication errors, lowerventilator-associated pneumonia rates,lower bloodstream infection rates, andlower risk-adjusted mortality rates.13,14

Furthermore, having favorable scores in4 of 6 safety domains is associated withlower nurse turnover.13

The SAQ was administered on 4 occa-sions (2004-2009) to all Labor & BirthUnit staff members (includes attendingobstetricians, nurse midwives, pediatri-cians, neonatologists, anesthesiologists,residents, nurses, surgical technicians,aides, and social workers) to survey pa-tient safety culture. The SAQ measurescaregiver assessments of safety andquality within 6 climate domains: (1)teamwork culture (perceived quality ofcollaboration between personnel), (2)safety culture (perceptions of a strongand proactive organizational commit-ment to safety), (3) job satisfaction (pos-itivity about the workplace), (4) workingconditions (perceived quality of thework environment and logistical sup-port), (5) stress recognition (acknowl-edgement of how performance is influ-enced by stressors), and (6) perceptionsof management (approval of managerialaction).8 Demographic characteristics of
espondents were not assessed.
216.e3 American Journal of Obstetrics & Gynecolo

Sexton has published standards for theetermination of the clinical significancef SAQ results.14-16 Differences of �10%ver time or between groups are consid-red clinically significant. Overall scoreshat show 80% agreement that the team-ork climate is favorable are considered

he target for change; �60% indicates anrea of higher risk. We also analyzed re-ponses between 2004 and 2009 and be-ween caregiver groups (physicians/mid-ives, residents, nurses) with chi-square

esting.

FIGURE 2Changes in perception of safety cu


FIGURE 3Changes in perception of job satisf


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This project was reviewed by the Chairf the Yale University Human Investiga-ions Committee and was deemed a qual-ty assurance activity and thus not requiredo undergo review by the Committee.

RESULTSDetails of the numbers of surveys thatwere administered and returned arelisted in the Table. The median totalnumber of employees who responded toeach survey was 191 (range, 183–198).Overall response rates were 89%, 95%,

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94%, and 72% for each period of admin-istration respectively (median, 91.5%).The last survey (2009) added our post-partum staff, which accounted for alarger number of surveys that were ad-ministered. Although this administra-tion period showed the lowest responserate, the total number of surveys re-turned was largely unchanged. The lastsurvey was administered by computer,rather than on paper, which may haveaffected response rates.

FIGURE 4Changes in perception of working


FIGURE 5Changes in perception of stress re

Difference between 2004 and 2009 not statisticPettker. Obstetrics patient safety program improves safety cul

Responses demonstrated agreementwith satisfactory conditions within the 6domains (teamwork culture, safety cul-ture, job satisfaction, working condi-tions, stress recognition, and percep-tions of management; Figures 1-6).There were clinically significant in-creases (according to the SAQ criteria of�10%) in perceptions of teamwork cul-ture, safety culture, and job satisfactionfrom 2004-2009; however, no categoryhas yet attained the target goal of 80%.

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significant (P � .6) by �2 testing.. Am J Obstet Gynecol 2011.

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When we compared responses from2004 with those of 2009 with chi-squaretesting, statistically significant improve-ments were seen for teamwork culture(P � .0001), safety culture (P � .0001),job satisfaction (P � .009), and percep-tions of management (P � .0001). Per-ceptions of favorable working condi-tions actually declined between 2004 and2009 (P � .048); perceptions of stress rec-ognition showed no statistically significantchange (P � .6).

In 2004, at study inception, positiveperception of safety and teamwork cul-tures were low among obstetrics provid-ers (attending physicians and nurse mid-wives), residents, and nurses (Figure 7).Clinically significant differences wereseen in the perception of teamwork cul-ture between obstetrics providers andnurses. Perceptions of both safety andteamwork climate demonstrated clinicallyand statistically significant improvementsover time among all 3 caregiver domainsby chi-square testing (P � .01).

COMMENTBerenholtz and Pronovost17 have pro-posed a safety scorecard that consists of 4domains: outcome measures (How oftendo we harm patients?), process measures(How often do we use evidence-basedmedicine?), structural measures (Howdo we know we learned from our mis-takes?), and staff attitudes surveys (Howwell have we created a culture of safety?).

We describe the overall improvementof safety climate, as measured by work-force surveys, in the setting of a compre-hensive patient safety effort. In a previousreport, we demonstrated the improve-ment in adverse outcomes, as assessed bythe obstetrics Adverse Outcome Index,that were related to this project.10 Thecombination of both improved quality ofcare and safety climate is a powerful argu-ment for the usefulness of a comprehen-sive and programmatic approach to pa-tient safety.

We did not surpass the 80% targets forany of the 6 climate domains. This re-mains an important long-term goal forour continuing patient safety effort. Thisshortcoming should not undervalue

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overall improvement. Continued qualityimprovement is a critical element of anypatient safety effort.

Our safety program did not have pos-itive impact on all domains of the safetyculture. Notably, perception of workingconditions and workforce stress recogni-tion did not show improvements. At thistime, we have not conducted any directinvestigation into the reasons that per-ceptions of working conditions wors-ened. We speculate that other activitiesand pressures in our workplace may havelimited improvement in these areas orthat our specific quality improvementmeasures were not directed specificallyat these measures. Other events that oc-curred simultaneously during this pe-riod that may have affected working con-ditions and stress recognition were theconversion to an electronic medical re-cord and computerized order entry, anincreasing cesarean delivery rate, andstaffing challenges because of increasedpatient acuity and triage census. That jobsatisfaction scores improved in the faceof declining working conditions scores isa contradiction that we are unable to as-sess further. We speculate that pressuresthat are defined under working condi-tions were unable to overcome otherpositive enhancements that were notmeasured by the SAQ that influence jobsatisfaction.

The validity of surveys is highly depen-dent on response rate. Notably, our re-sponse rate was lowest during our lastsurvey period, likely because of an at-tempt to capture a larger number of re-spondents and a growth in the numberof surveys distributed (Table). More-over, our fourth (and last) survey wasdone on computer, which is a changethat may have affected response rates. Asa result, we do not believe that the dropin response rate meaningfully affects theresults of the survey for that period.

Many different patient safety climatesurveys are available. The Agency forHealthcare Research and Quality’s Hos-pital Survey on Patient Safety Culture is apublicly available tool with a centralizedcomparative database that allows orga-nizations to benchmark survey results.This survey was not available at the time
we started our initiative, so we chose to
216.e5 American Journal of Obstetrics & Gynecolo

continue using the SAQ so that we couldmake meaningful comparisons overtime within our own unit. The SAQ isalso supported by a systematic reviewthat demonstrates that only the SAQ hasbeen used to explore the relationship

FIGURE 6Changes in perception of managem


FIGURE 7Changes in perception of safety cu3 caregiver domains (physicians/m

Each asterisk designates changes (2004-2009significant (P � .01) by �2 testing.OB, attending and midwife; RN, registered nurse.

Pettker. Obstetrics patient safety program improves safety cul

gy MARCH 2011

between safety perceptions and patientoutcomes.18

Although the primary motivationsthat drive patient safety efforts are qual-ity care and the elimination of harm,many secondary benefits must be con-

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sidered. For instance, economic savingsthat are associated with the eliminationof the costs of adverse events are animportant factor that guides investmentin patient safety by governments andhealthcare institutions.19-21 Improved

orkforce culture and satisfaction arelso important secondary benefits thatid with staff recruitment and retention.any hospital organizations conduct

mployee opinion surveys to gauge theuality of the workplace for potentialtrengths and areas for improvement;taff safety surveys may be seen as an ex-ension of this.

There currently is debate as to whetherealthcare culture and climate are im-ortant predictors of quality of care.22

According to a review by Sexton et al,15

there is ample evidence that demon-strates that safety climate scores correlatewith unsafe staff behaviors, safety-spe-cific organizational citizenship behav-iors, patient injury, and accidents. Ourresults add to the growing body of evi-dence that a healthy safety culture devel-ops in tandem with safer patient care.Further work to investigate perceptionsof safety and quality from the patient’sperspective is also warranted. f

ACKNOWLEDGMENTSWe would like to acknowledge MCIC Vermont,Inc, its leadership, and the individual hospitals ofMCIC Vermont, Inc, that contributed with simi-lar patient safety initiatives at their own institu-
tions.
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a comprehensive obstetrics patient safety program improves safety climate and culture

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