Measuring “Culture of Safety” Tawam’s Experience Discovery: Tawam Hospital’s Executive leadership realized the need to establish a “Culture of Safety” within the organization and implemented the Johns Hopkins Medicine “Comprehensive Unit based Safety Program” (CUSP). CUSP was introduced as a pilot project in the Intensive Care Unit (ICU), Neonatal Intensive Care Unit (NNU) and Paediatric Oncology Unit (Peds Onc). Prior to implementation the leadership decided to measure staff perception of safety using evidence based tool. Solution: Tawam partnered with Pascal Metrics to implement the Safety Attitude Questionnaire survey. The SAQ was administered to all Tawam Hospital staff in three phases (2008, 2010 and 2011). In 2010 the pilot CUSP units were also resurveyed to determine the status of safety culture since its introduction in 2008.  An email from the CEO was sent to the participants encouraging them to participate in the SAQ survey.  Physicians, nurses, ward-clerks; respiratory therapist, physiotherapist, dieticians etc were included in the survey.  Those who spent at least 50% of their time in the identified units were only included to participate in the survey.  Survey was administered during departmental meetings to increase response rate.  Conducted separate sessions of physicians.  Staff dropped the completed surveys in an envelope.  82% of staff in the patient care areas of the whole hospital participated in the overall 3 phases of SAQ Survey.  The three CUSP pilot units were re-surveyed in 2010.  Anonymity, privacy and confidentiality were maintained from the beginning till the end. Outcome: The survey results were graded against percentage positive responses. Responses that were less than 60% mark were graded in the danger zone and anything above the 80% mark were graded in the goal zone. Teamwork climate and Safety climate scale scores are considered to be primary dependent variables, because they are important in preventing patient harm. The overall hospital score on all the domain scores were in the danger zone, less than 60%. 20 clinical locations in 2010 and 7 clinical locations in 2011 had less than 60% scores in the primary dependent variables. The SAQ results were disseminated department wise in the presence of a hospital Senior Executive. Every department did an action plan using the SAQ de-briefer tool. The hospital administrators to bring about the change played a facilitators role and helped the departments to come up with their actionable plans. The hospital leadership in their pursuit to continuing the culture of safety journey, identified six more units for CUSP implementation based on the Phase 2 SAQ scores of 2010. Accordingly the Medical 1, Medical 2, Surgical 1, Surgical 2, Day Case and OBGYN Units were identified for the CUSP roll out. Senior Executive leaders were assigned to each of these new CUSP units to ensure leadership commi

1. Safety Attitudes Questionnaire
A way to measure “Culture of Safety”
Presented via Skype (2:00pm-2:15pm)
URMPM World Congress 9th September 2012 –London
Krish Sankaranarayanan MS, MBA, CPHQ
Senior Safety Officer
Tawam Hospital
Abu Dhabi
United Arab Emirates

2. “Culture is local” and “so is change.”

3. Safety Attitudes Questionnaire
provides a baseline to understand staff
perception of safety

4. Early adopters- Aviation
6 main components (called characteristics) of safety culture are
described:
• Commitment
• Justness
• Information
• Awareness
• Adaptability
• Behavior

5. Most rigorously tested and well known
tools
• Safety Attitudes Questionnaire
• Patient Safety Culture in Healthcare
Organizations
• Hospital Survey on Patient Safety Culture
• Safety Climate Survey
• Manchester Patient Safety Assessment
Framework

6. Safety Attitudes Questionnaire-
Adopted in Healthcare
J. Bryan Sexton, Ph.D.,
• Was the Assistant Professor in Anesthesiology and Critical
Care Medicine at The Johns Hopkins University School of
Medicine.
• Currently Director of Patient Safety Operations at Duke
University Hospital.

8. Culture of Safety Survey- Domains
1.Teamwork Climate: The perceived quality of teamwork and
collaboration within a given unit.
2.Safety Climate: The perceived level of commitment to and focus on
patient safety within a given unit.
3.Job Satisfaction: Employees' general feelings of positivity
regarding their work experience.
4.Stress Recognition: Employees' recognition of how stressors
impact their performance.
5.Working Conditions: Employees' perceptions of the quality of
their work environment.
6.Perceptions of Hospital Management: Employees'
perceptions of the support and competence of hospital-level management.
7.Perceptions of Unit Management: Employees' perceptions
of the support and competence of unit-level management

9. Culture linkages to Clinical,
Operational & other Outcomes
•Wrong Site •Burnout
Surgeries •Unit size
•Decubitus Ulcers •Communication
•Delays breakdowns
•Bloodstream •Familiarity
Infections •Spirituality
•Post-Op Sepsis •Most validated:
•Post-Op Infections Qual. Saf. Health
•Post-Op Bleeding Care
•PE/DVT 2005;14;364-366
•RN Turnover
•Absenteeism
•VAP

10. SAQ- Administration methodology
• The hospital partnered with Pascal Metrics.
• Identified the units and collected the list of staff.
• Staff that spent 50% of their time in the
identified units were only included in the survey.
• All disciplines were included in the survey.
• Given a brief introduction of the purpose of the
survey
• Was anonymous and a voluntary exercise.
• Hand delivered survey
• Done during a staff/department meeting.

11. SAQ- Administration methodology.
Contd…
• Distributed sharpened pencil with eraser.
• Didn’t leave the surveys in pigeon holes for staff
to complete.
• Didn’t leave the surveys with departments
heads.
• Conducted separate sessions of physicians.
• Staff dropped the completed surveys in an
envelope.

13. Survey participation and response rate
• 82% of staff in patient care areas of the whole
hospital participated in the overall 3 phases of SAQ
Survey.
Targeted Surveys Survey Survey
Location Year staff Administered Returned response rate
Phase 1 CUSP Pilot Units 2008 199 199 199 100%
Phase 2 In-patient areas 2010 1600 1476 1450 98%
Out-Patient & satellite Qtr 4
Phase 3 locations 2011 805 497 483 60%
Total 2604 2172 2132

14. Dissemination of the SAQ ?
Challenges we faced
• The questions in the SAQ did not translate well.
• Staff took the results personally if low scores.
• Dept managers defended low scores.
▫ Especially on perception of unit management.
• Staff expected positive actions from
management based on SAQ results.

15. Dissemination of the SAQ ?
• Results were sensitive, so did it with individual
departments.
• Did not share results of one dept with the other.
• Had a senior executive leader (C-Suites)while
disseminating.
• Emphasized that the SAQ was a survey on
perception and NOT AN EXAM RESULT.
• Emphasized that “Culture is local” and “so is
change.” (Micro System)

16. Perceptions of Hospital Management
Is always low
• Staff may not see the C-suites frequently.
• Staff relate themselves more with the unit
mangers than executive leaders.

17. 2008 SAQ Phase-1 (CUSP Pilot Units)
SAQ Results 2008
100%
80%
Average % Positive
60%
ICU
40%
Pediatric Oncology
NNU
20%
0%
Teamwork Safety Job Stress Perceptions Perceptions Working
Satisfaction Recognition of Hospital of Unit Conditions
Management Management
Domain

18. 2010 SAQ Phase-2 (All In-patient Units-
& CUSP Pilot Units Re-survey)

19. 2011 SAQ Phase-3 (Out-patient Units)

20. Team Work Climate

21. ICU Physicians and ICU RN
100
Collaboration
90
80
70 88%
60
50
40
30
51%
20
10
0 KP L &D
RN rates ICU Physician ICU Physician rates RN

22. Teamwork Disconnect
• RN: Good teamwork means I am asked
for my input
• MD: Good teamwork means the nurse
does what I say

24. Safety Climate

25. Job Satisfaction

26. Stress Recognition

27. Perceptions Of Hospital Management

28. Perceptions Of Unit Management

29. Working Conditions

30. Dependent Variables of SAQ
• The primary dependent variables -teamwork
climate and safety climate scale scores.
• These primary dependent variables were chosen
because they are important in preventing patient
harm.
• The rest of them are secondary dependent
variables.
Sexton J.B., et al.: The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC
Health Serv Res 6(44):Apr. 3, 2006.
Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact of the Comprehensive Unit-Based Safety Program
(CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf 2010;36(6):252-260.

31. Safety Climate
Perception of Unit Management
Safety Climate
Stress Recognition
Perception of Unit Management
Safety Climate
Working Conditions
Job Satisfaction
Team Work Climate
Job Satisfaction
Safety Climate
Stress Recognition

33. Home work
De-briefer (Group activity without dept
managers)
• Identify a specific area of concern.
• Select one or two items.
• Provide insights and recommendations.
• Foster actionable ideas for improvement.

34. Culture of Safety is a journey
• Takes as long as 5 years to develop a culture of
safety that is felt throughout an organization.
(Ginsburg et.al 2005)
• Need Patience, Perseverance, Commitment &
Engagement.
Ginsburg, L., P. G. Norton, A. Casebeer, and S. Lewis. 2005. ‘‘An Educational Intervention to Enhance Nurse Leaders’ Perceptions of Patient Safety Culture.’’
Health Services Research 40 (4): 997–1020.

35. Thank You
Contacts:
ksankara@tawamhospital.ae
050-9211649