organisational culture: variation across hospitals and connection to patient safety climate

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Organisational culture: variation across hospitals and connection to patient safety climate T Speroff, 1,2,4,9,10 S Nwosu, 1,4 R Greevy, 1,4 M B Weinger, 1,5,6,9,10 T R Talbot, 7 R J Wall, 11 J K Deshpande, 5,8 D J France, 5,9 E W Ely, 1,2,3,10 H Burgess, 12 J Englebright, 12 M V Williams, 13 R S Dittus 1,2,10 ABSTRACT Context Bureaucratic organisational culture is less favourable to quality improvement, whereas organisations with group (teamwork) culture are better aligned for quality improvement. Objective To determine if an organisational group culture shows better alignment with patient safety climate. Design Cross-sectional administration of questionnaires. Setting 40 Hospital Corporation of America hospitals. Participants 1406 nurses, ancillary staff, allied staff and physicians. Main outcome measures Competing Values Measure of Organisational Culture, Safety Attitudes Questionnaire (SAQ), Safety Climate Survey (SCSc) and Information and Analysis (IA). Results The Cronbach alpha was 0.81 for the group culture scale and 0.72 for the hierarchical culture scale. Group culture was positively correlated with SAQ and its subscales (from correlation coefficient r¼0.44 to 0.55, except situational recognition), ScSc (r¼0.47) and IA (r¼0.33). Hierarchical culture was negatively correlated with the SAQ scales, SCSc and IA. Among the 40 hospitals, 37.5% had a hierarchical dominant culture, 37.5% a dominant group culture and 25% a balanced culture. Group culture hospitals had significantly higher safety climate scores than hierarchical culture hospitals. The magnitude of these relationships was not affected after adjusting for provider job type and hospital characteristics. Conclusions Hospitals vary in organisational culture, and the type of culture relates to the safety climate within the hospital. In combination with prior studies, these results suggest that a healthcare organisation’s culture is a critical factor in the development of its patient safety climate and in the successful implementation of quality improvement initiatives. The introduction of quality improvement into healthcare has brought attention to the relevance of organisational culture. Indeed, models for total quality management emphasise the fundamental importance of gaining leadership support for a psychology of change in order to bring about change. 1 A growing body of literature shows that the ability to make improvements depends on organisational context. 2e4 Organisational cultures that emphasise teamwork and innovation have been found in alignment with quality improve- ment, whereas bureaucratic, hierarchical cultures, which inherently promote stability and resist change, are less suited for quality improvement. 5e9 Systems engineering models for highly reliable organisations as well as crew resource management principles also emphasise collaborative communi- cation, leadership, organisational learning and teamwork. 10 11 Based on the prior ndings of a fundamental relationship between an organisa- tions culture and quality improvement, we hypothesised that organisational culture empha- sising teamwork and/or innovation will be aligned with favourable attitudes towards patient safety. This study surveyed personnel in intensive care units on organisational culture and safety climate to characterise whether organisations vary in culture and to assess the association between organisational culture and safety climate. A secondary aim was to produce a greater under- standing of the psychometrics of these scales and their use by level of analysis, and to provide a reference for their use. METHODS Setting The study was a cross-sectional analysis of surveys distributed across 61 hospitals managed by HCA (formerly, Hospital Corporation of America). HCA distributed the survey to providers and managers. Instructions stated that participation was volun- tary and anonymous. Surveys were sent to 110 adult and paediatric Intensive Care Units (ICUs) between 20 December 2005 and 28 February 2006. HCA provided data on process, outcome and covariate measures aggregated within the medical centre. The project was approved by the Vanderbilt University IRB. Measures The surveys included four existing survey instru- ments. The Competing Values Organisational Culture Assessment Instrument (see online appendix) assesses staff perception across ve characteristics: organisational character, management, cohesion, emphasis and distribution of rewards. 12e14 The particular mix of values shapes the attributes of the organisation and characterises its framework for structure, order, orientation to strategy and devel- opment, leadership style and mode of operation that form the organisations behaviour and common way of thinking. 13e17 Measures of organisational culture included the continuous scaled score for each of the four culture types and a category score for dominance. An organisation is classied as having a dominant culture if one of the four culture scales exceeds all others by ve or more < An additional appendix is published online only. To view this file please visit the journal online (http//qshc.bmj.com). For numbered affiliations see end of article. Correspondence to Dr Ted Speroff, Department of Medicine, Center for Health Services Research, 6000 Medical Center East, Vanderbilt University School of Medicine, Nashville, TN 37232, USA; [email protected] Accepted 19 July 2010 592 Qual Saf Health Care 2010;19:592e596. doi:10.1136/qshc.2009.039511 Error management group.bmj.com on July 15, 2014 - Published by qualitysafety.bmj.com Downloaded from

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Organisational culture: variation across hospitals andconnection to patient safety climate

T Speroff,1,2,4,9,10 S Nwosu,1,4 R Greevy,1,4 M B Weinger,1,5,6,9,10 T R Talbot,7

R J Wall,11 J K Deshpande,5,8 D J France,5,9 E W Ely,1,2,3,10 H Burgess,12

J Englebright,12 M V Williams,13 R S Dittus1,2,10

ABSTRACTContext Bureaucratic organisational culture is lessfavourable to quality improvement, whereasorganisations with group (teamwork) culture are betteraligned for quality improvement.Objective To determine if an organisational groupculture shows better alignment with patient safetyclimate.Design Cross-sectional administration of questionnaires.Setting 40 Hospital Corporation of America hospitals.Participants 1406 nurses, ancillary staff, allied staff andphysicians.Main outcome measures Competing Values Measureof Organisational Culture, Safety Attitudes Questionnaire(SAQ), Safety Climate Survey (SCSc) and Informationand Analysis (IA).Results The Cronbach alpha was 0.81 for the groupculture scale and 0.72 for the hierarchical culture scale.Group culture was positively correlated with SAQ and itssubscales (from correlation coefficient r¼0.44 to 0.55,except situational recognition), ScSc (r¼0.47) and IA(r¼0.33). Hierarchical culture was negatively correlatedwith the SAQ scales, SCSc and IA. Among the 40hospitals, 37.5% had a hierarchical dominant culture,37.5% a dominant group culture and 25% a balancedculture. Group culture hospitals had significantly highersafety climate scores than hierarchical culture hospitals.The magnitude of these relationships was not affectedafter adjusting for provider job type and hospitalcharacteristics.Conclusions Hospitals vary in organisational culture,and the type of culture relates to the safety climatewithin the hospital. In combination with prior studies,these results suggest that a healthcare organisation’sculture is a critical factor in the development of itspatient safety climate and in the successfulimplementation of quality improvement initiatives.

The introduction of quality improvement intohealthcare has brought attention to the relevance oforganisational culture. Indeed, models for totalquality management emphasise the fundamentalimportance of gaining leadership support fora psychology of change in order to bring aboutchange.1 A growing body of literature shows thatthe ability to make improvements depends onorganisational context.2e4 Organisational culturesthat emphasise teamwork and innovation havebeen found in alignment with quality improve-ment, whereas bureaucratic, hierarchical cultures,which inherently promote stability and resistchange, are less suited for quality improvement.5e9

Systems engineering models for highly reliableorganisations as well as crew resource managementprinciples also emphasise collaborative communi-cation, leadership, organisational learning andteamwork.10 11 Based on the prior findings ofa fundamental relationship between an organisa-tion’s culture and quality improvement, wehypothesised that organisational culture empha-sising teamwork and/or innovation will be alignedwith favourable attitudes towards patient safety.This study surveyed personnel in intensive careunits on organisational culture and safety climateto characterise whether organisations vary inculture and to assess the association betweenorganisational culture and safety climate. Asecondary aim was to produce a greater under-standing of the psychometrics of these scales andtheir use by level of analysis, and to providea reference for their use.

METHODSSettingThe study was a cross-sectional analysis of surveysdistributed across 61 hospitals managed by HCA(formerly, Hospital Corporation of America). HCAdistributed the survey to providers and managers.Instructions stated that participation was volun-tary and anonymous. Surveys were sent to 110adult and paediatric Intensive Care Units (ICUs)between 20 December 2005 and 28 February 2006.HCA provided data on process, outcome andcovariate measures aggregated within the medicalcentre. The project was approved by the VanderbiltUniversity IRB.

MeasuresThe surveys included four existing survey instru-ments. The Competing Values OrganisationalCulture Assessment Instrument (see online appendix)assesses staff perception across five characteristics:organisational character, management, cohesion,emphasis and distribution of rewards.12e14 Theparticular mix of values shapes the attributes of theorganisation and characterises its framework forstructure, order, orientation to strategy and devel-opment, leadership style and mode of operationthat form the organisation’s behaviour andcommon way of thinking.13e17 Measures oforganisational culture included the continuousscaled score for each of the four culture types anda category score for dominance. An organisation isclassified as having a dominant culture if one of thefour culture scales exceeds all others by five or more

< An additional appendix ispublished online only. To viewthis file please visit the journalonline (http//qshc.bmj.com).

For numbered affiliations seeend of article.

Correspondence toDr Ted Speroff, Department ofMedicine, Center for HealthServices Research, 6000Medical Center East, VanderbiltUniversity School of Medicine,Nashville, TN 37232, USA;[email protected]

Accepted 19 July 2010

592 Qual Saf Health Care 2010;19:592e596. doi:10.1136/qshc.2009.039511

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points; otherwise, the organisation has a balanced culture.8 9

The group culture scale measures values associated with affilia-tion, teamwork and participation. The developmental culturescale is characterised by risk-taking, entrepreneurial innovationand change. The hierarchical culture scale reflects bureaucracyand chain of command. The rational culture scale emphasisesefficiency, production and achievement.

The Safety Attitudes Questionnaire (SAQ), a validated 30-item survey, was used to measure ICU safety climate across sixscales: (1) Teamwork Climate, (2) Safety Climate, (3) JobSatisfaction, (4) Perceptions of Management, (5) Stress Recog-nition and (6) Working Conditions.18 The Safety Climate Scale(SCSc) is a 10-item survey adapted from aviation safety and usedto assess patient safety climate.10 19 20 Information and Analysis(IA) is a four-item scale used in the RAND ICICE study thatassesses how the organisation uses data and information relatedto quality improvement.8 9 21

Data and analysisAnalysis at the respondent level included Cronbach alpha asa measure of internal consistency, comparisons of means andmedians for respondent and hospital characteristics, and Pearsoncorrelation coefficients across survey scales and subscales.Scoring rules for subscale and scale scores imputed means formissing values, provided the majority of subscale items arepresent; otherwise, the scale was scored as a missing value. Arandom-effects mixed model with covariates was used to modelthe effect of organisational culture on safety climate afteradjusting for provider job type, ICU type and hospital charac-teristics (location, hospital admissions per year, percentage ofMedicare/Medicaid patients and percentage of emergencydepartment admissions). Because all multivariable models werenearly identical to and replicated our results, we choose topresent the simpler analysis for ease of presentation and read-ability. Data were also aggregated at the ICU and the hospitallevel for analyses on organisational culture and climate. One-way analysis of variance (ANOVA) was used to analyse fordifferences between job types and hospitals classified by domi-nant type of culture.

RESULTSRespondentsSixty-seven ICUs (61%) from 41 hospitals (67%) returned 1502(43.4%) completed surveys. Three of these ICUs had fewer thansix respondents accounting for deletion of 9 surveys; 86 surveyshad missing data for organisational culture, and one survey hadmissing data for the safety climate scales. Therefore, the dataused in analysis included 1406 respondents representing 64 totalICUs (58%) from 40 hospitals (66%). The hospitals wereprimarily suburban but included rural (18%) and inner city(28%) hospitals. ICUs were 17% surgical, 22% medical andremainder combined medicalesurgical. Survey respondents werenurses (66.2%), ancillary nursing staff (8.3%), allied clinicians(14.2%) and physicians (5.3%). The HCA hospitals participatingin the survey did not differ from the non-participating hospitalsin administrative variables (data not shown).

Psychometrics of organisational culture instrumentThe descriptive statistics for the four scales of organisationalculture are shown in table 1. The group and hierarchical scales hadCronbach alpha values of 0.81 and 0.72, respectively, whereas thedevelopmental and rational scales obtained unreliable values,excluding further analyses on these subscales.22 The correlation

matrix (table 2) shows a significant negative correlation of �0.73between the group and hierarchical culture scales.

Variation of organisational culture across hospitalsPooling across respondents and using conventional scoringrules,8 9 15 of the 40 hospitals (37.5%) were classified as hier-archical culture organisations, 15 (37.5%) as group cultureorganisations and 10 (25%) as balanced-culture organisations.

Psychometrics of the climate scalesThe descriptive statistics and Cronbach alpha for the SAQ, SCScand IA scales are shown in table 3. The correlations between theoverall SAQ climate score and the subscales are displayed intable 4. The Cronbach alpha of the SAQ and subscales is greaterthan 0.70, and each item displayed substantial item-to-scalecorrelations. Except for Stress Recognition, the SAQ subscalesshow positive correlations ranging between 0.67 and 0.81. StressRecognition is negatively correlated with all of the other SAQsubscales and is not correlated with the SAQ overall score. Thecorrelations at the respondent level of analysis were 0.86between the SAQ and SCSc, 0.68 between the SAQ and the IA,and 0.70 between the SCSc and IA.

Ratings by job typePhysicians had higher scores on group culture and lower scoreson hierarchical culture (table 5). Nurses and ancillary providersscored group culture lower and hierarchical culture higher.Nurses also had lower ratings on the SAQ and SCSc comparedwith physicians but did not differ on the IA scale.

Association between organisational culture and patient safetyThe univariate correlations between the group and hierarchicalculture scales and the SAQ, SCSc and IA scales are shown in

Table 1 Descriptive statistics and coefficient of internal consistencyfor the organisational culture scales, n¼1406 survey responders

Organisationculture scale Median (IQR)

Range(low to high)

Mean(SD)

Cronbachalpha*

Group 25.0 (13.3 to 38.3) 0 to 100 27.2 (17.8) 0.81

Developmental 15.8 (9.2 to 21.7) 0 to 66 15.9 (9.6) 0.54

Hierarchical 29.2 (17.5 to 43.3) 0 to 100 32.6 (19.3) 0.72

Rational 23.3 (16.7 to 30.0) 0 to 92 24.3 (11.9) 0.44

Each scale has five items (see online appendix).*Cronbach alpha is a psychometric statistic measuring the consistency of the correlationsbetween the survey items and the overall scale. An internal consistency greater than 0.70 isadequate when using a scale for group comparisons.22

Table 2 Correlation matrix of the organisational culture scales

Organisationculture scale

Analysis at the level of respondent (n[1406 surveyresponders)

Development Hierarchical Rational

Group 0.10 �0.73* �0.40*

Development �0.47* �0.20*

Hierarchical �0.15*

Analysis at the level of intensive care unit (n¼64 intensivecare units)

Group 0.10 �0.84* �0.44*

Development �0.47* �0.06

Hierarchical �0.01

Analysis at the level of hospital (n¼40 hospitals)

Group 0.09 �0.82* �0.48*

Development �0.51* 0.22

Hierarchical �0.01

*p<0.001.

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table 6. Except for the stress recognition subscale of the SAQ,there was consistently a high positive correlation between thepatient safety climate and group organisational culture scalesand a high negative correlation between safety climate andhierarchical organisational culture scales. The partial correlationsbetween organisational culture and safety climate adjusted foradministrative hospital characteristics, provider job type andhospital location resulted in correlations and statistical signifi-cance equivalent to the unadjusted respondent level resultsshown in table 6.

Using a hospital-level one-way ANOVA, mean SAQ, SCC andIA scores were compared across hospitals categorised into theirdominant category of hierarchical, balanced or group culture(table 7). The hierarchical culture hospitals had significantlylower average safety climate scores than did the group culturehospitals. The balanced-culture hospitals scored higher than thehierarchical-culture hospitals on all scales but lower than thegroup-culture hospitals on the overall SAQ and IA scales. Amultivariate mixed model accounting for nesting of respondentsand adjusting for covariates replicated the statistical significanceof the one-way analysis of variance results shown in table 7. Inaddition, differences between ICUs within the same hospitalwere minor, amounting to only 2.7% of total variation.

DISCUSSIONThe findings of this study support our premise that hospitalsvary in organisational culture and that the type of culturewithin the hospital would relate to perceived safety climate. Wefound a substantial variation in hospital organisational cultureresulting in almost equal percentages of dominance amonggroup, hierarchical and balanced types of culture. There wasa significant positive association between group-orientedorganisational culture and the attitudes and climate for patientsafety, and a significant negative association between hierar-chical culture and these same factors.

Our findings replicated the high internal consistency for thegroup and hierarchical scales, and the low consistency of therational scale,8 9 21 23 and did not show internal consistency forthe developmental scale.24 25 In addition, our negative correla-tion of �0.73 between the group and hierarchical scales repli-cates the inverse correlation of �0.65 previously reported.7 Ourfindings also replicate the psychometric findings for the SAQ,SCC, and IA.18 19 26 The pattern of our SAQ findings with regardto the stress recognition subscale is consistent with priorwork,18 indicating that the stress recognition items do notcontribute positively towards the construct of safety climate asintended and should be excluded from the SAQ. Physicians andadministrators provide higher safety climate ratings than donurses and ancillary staff. Furthermore, nursing staff viewedculture as more bureaucratic5 27 and rated their organisationlower in safety climate.11 19 20 28 Comparing organisations andinterpretation using these scales must consider the differencesbetween professions in perception of culture.Organisations characterised as having group culture are more

effective, and hospitals with hierarchical culture are less effectiveat implementing quality improvement,8 9 24 29 team functioningand staff morale,5 15 patient satisfaction2 23 24 and overall safetyclimate.25 30 Collaborative teams from balanced hospitalcultures have greater perceived team effectiveness.8 9 Our find-ings extend the results of these prior studies; we show thatgroup culture is associated positively with patient safety team-work climate, safety climate, job satisfaction, perceptions ofmanagement, working conditions, and information and analysis.These findings provide significant criterion validity to thetheoretical framework that group culture is supportive ofpatient safety climate and quality improvement.Restrictions to our sampling produced some study limitations.

Our participating hospitals may differ substantially from non-participants. Moreover, ICU respondents may not be represen-tative of the hospital in general.16 In addition, study physicianswere community practitioners comprising a relatively small

Table 3 Descriptive statistics and coefficient of internal consistency for the Safety Attitudes Questionnaire, Safety Climate Survey, and Informationand Analysis scales

Scale

No ofsurveyitems

Cronbachalpha

Respondent level N[1406 Intensive care unit level N[64 Hospital level N[40

Mean (SD) Median (IQR) Mean (SD) Median (IQR) Mean (SD) Median (IQR)

Safety Attitudes Questionnaire: overall18 30 0.93 3.65 (0.53) 3.69 (3.4 to 4.0) 3.66 (0.27) 3.73 (3.5 to 3.8) 3.69 (0.23) 3.74 (3.6 to 3.8)

Team Work 6 0.80 3.75 (0.66) 3.83 (3.3 to 4.2) 3.76 (0.34) 3.82 (3.6 to 4.0) 3.79 (0.27) 3.81 (3.7 to 4.0)

Safety Climate 7 0.82 3.79 (0.60) 3.86 (3.4 to 4.1) 3.80 (0.28) 3.87 (3.6 to 4.0) 3.82 (0.23) 3.87 (3.7 to 4.0)

Job Satisfaction 5 0.83 3.77 (0.73) 3.80 (3.4 to 4.2) 3.79 (0.36) 3.83 (3.6 to 4.0) 3.83 (0.31) 3.90 (3.7 to 4.0)

Stress Recognition 4 0.73 3.68 (0.74) 3.75 (3.3 to 4.0) 3.67 (0.28) 3.65 (3.5 to 3.8) 3.66 (0.22) 3.64 (3.5 to 3.8)

Perceptions of Management 4 0.78 3.30 (0.87) 3.50 (2.8 to 4.0) 3.30 (0.50) 3.41 (3.0 to 3.6) 3.37 (0.46) 3.44 (3.2 to 3.6)

Working Conditions 4 0.76 3.45 (0.76) 3.50 (3.0 to 4.0) 3.47 (0.36) 3.56 (3.3. to 3.7) 3.49 (0.32) 3.56 (3.3 to 3.7)

Safety Climate19 10 0.86 3.63 (0.63) 3.70 (3.2 to 4.0) 3.63 (0.33) 3.69 (3.5 to 3.8) 3.66 (0.29) 3.72 (3.6 to 3.8)

Information and Analysis9 4 0.95 3.72 (0.76) 4.00 (3.25 to 4.0) 3.72 (0.37) 3.73 (3.5 to 4.0) 3.74 (0.32) 3.75 (3.5 to 4.0)

Each item is answered using a five-point Likert scale: 1¼disagree strongly; 2¼disagree slightly; 3¼neutral; 4¼agree slightly; 5¼agree strongly.

Table 4 Correlations among Safety Attitudes Questionnaire and subscales, n¼1406 survey responders

Correlation (r) matrixTeamworkclimate

Safetyclimate

Jobsatisfaction

Stressrecognition

Perceptions ofmanagement

Workingconditions

Safety Attitudes Questionnaire: overall 0.89* 0.89* 0.88* 0.006 0.83* 0.83*

Teamwork 0.80* 0.76* �0.15* 0.67* 0.69*

Safety Climate 0.75* �0.15* 0.66* 0.70*

Job Satisfaction �0.17* 0.73* 0.68*

Stress Recognition �0.16* �0.16*

Perceptions of Management 0.70*

*p<0.001.

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portion of the sample. Our response rate was 43%, and ourmeasures were restricted to a single point in time. Finally, HCAfacilities represent only a private, for-profit hospital sector of thehealthcare industry. Only further research can clarify the effectsof these limitations, but reproducing study results similar tothose reported in the literature enhances our confidenceregarding the generalisability of our findings about organisa-tional culture.

CONCLUSIONThe influence of context on quality improvement and patientsafety is widely appreciated.29 31 Quality improvement andpatient safety studies cite contextual factors involving the microand macro systems of healthcare organisations.29 31e37 However,

measures of organisational structure are generally crude, focus-sing on such things as teaching status, hospital size, orpercentage capitated care. The Competing Values Modelprovides a conceptual framework and instrument for measuringorganisational culture that has been employed in the study offirms but rarely in the industry of healthcare.13 The currentstudy ’s findings in combination with prior research suggest thata healthcare organisation’s culture is a pivotal force to contendwith in the implementation of quality improvement and thedevelopment of a patient safety climate. Culture’s role in facil-itating innovation may be the enabling factor for the success ofquality initiatives and key to effective implementation ofevidence-based findings derived from translational research.Future healthcare system intervention studies should includeevaluation of the culture underlying the structure of thehealthcare sector to understand better how we can bring aboutthe positive impacts of healthcare reform the nation hopes toachieve.

Author affiliations1Geriatric Research, Education, and Clinical Center (GRECC) and Center for HealthServices Research, Veterans Affairs Tennessee Valley Healthcare System, Tennessee,USA2Division of General Internal Medicine and Center for Health Services Research,Vanderbilt University School of Medicine, Tennessee, USA3Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Schoolof Medicine, Tennessee, USA4Department of Biostatistics, Vanderbilt University School of Medicine, Tennessee,USA5Department of Anesthesiology, Vanderbilt University School of Medicine, Tennessee,USA6Departments of Biomedical Informatics and Medical Education, Vanderbilt UniversitySchool of Medicine, Tennessee, USA7Division of Infectious Diseases, Departments of Medicine and Preventive Medicine,Vanderbilt University School of Medicine, Tennessee, USA8Division of Paediatric Critical Care, Department of Pediatrics, Monroe Carell JrChildren’s Hospital, Vanderbilt University School of Medicine, Tennessee, USA

Table 5 One-way (ANOVA) on respondent job type

ScaleNursesn[930

Ancillaryn[199

Alliedn[116

Physiciansn[75 F3,1319 p Value

Group Culture 26.4 (17.4)z 25.9 (18.0)z 31.2 (16.2) 34.9 (22.0) 7.65 0.0001

Hierarchical Culture 33.3 (19.7)y 33.3 (18.7)y 29.3 (16.8) 26.5 (17.3) 413.0 0.006

Safety AttitudesQuestionnaire

3.62 (0.53)z 3.61 (0.54)z 3.86 (0.45) 3.86 (0.37) 11.58 0.0001

Safety Climate Survey 3.57 (0.62)z 3.60 (0.66)z 3.90 (0.55) 3.81 (0.56) 11.92 0.0001

Information and Analysis 3.73 (0.77) 3.55 (0.74)* 3.95 (0.65)* 3.72 (0.72) 6.77 0.0002

Eighty-six (6.1%) had missing data on job type; these respondents were excluded from analysis. Degrees of freedom were 3 in the numerator and 1319 in the denominator. All data presented asmean (SD). Ancillary staff includes nurse practitioners and assistants. Allied staff includes pharmacists and respiratory therapists.*Information and Analysis: nurses scored the same as physicians but higher than ancillary personnel and lower than allied professionals.yHierarchical Culture: nurses and ancillary staff scored higher than physicians.zGroup Culture, Safety Attitudes Questionnaire, and Safety Climate Survey: nurses and ancillary staff scored lower than allied professionals or physicians.

Table 6 Correlation between organisational culture and Safety Attitudes Questionnaire, Safety Climate Survey, and Information and Analysis scales

Correlation (r) matrix

Respondent level Intensive care unit level Hospital level

Group Hierarchical Group Hierarchical Group Hierarchical

SAQ overall 0.49z �0.48z 0.66z �0.57z 0.69z �0.63zTeamwork Climate 0.41z �0.39z 0.54z �0.43z 0.57z �0.49ySafety Climate 0.40z �0.39z 0.56z �0.47z 0.51z �0.43yJob Satisfaction 0.55z �0.49z 0.71z �0.63z 0.74z �0.66zStress Recognition �0.12z 0.10z �0.30* 0.35y �0.42y 0.47yPerceptions of Management 0.48z �0.47z 0.68z �0.59z 0.75z �0.68zWorking Conditions 0.40z �0.42z 0.60z �0.63z 0.62z �0.73z

Safety Climate 0.47z �0.48z 0.64z �0.58z 0.65z �0.63zInformation and Analysis 0.33z �0.37z 0.56z �0.56z 0.55z �0.54*

*p<0.05; yp<0.01; zp<0.001.

Table 7 One-way ANOVA comparing hospitals’ dominantorganisational culture

Safety climate scales

Dominant culture

HierarchicalN[15

BalancedN[10

GroupN[15

Safety Attitudes Questionnaire:overall

3.54 (0.19)* 3.67 (0.23)* 3.85 (0.14)

Teamwork Climate 3.64 (0.22)* 3.80 (0.36) 3.94 (0.19)

Safety Climate 3.70 (0.21)* 3.80 (0.23) 3.96 (0.17)

Job Satisfaction 3.63 (0.27)* 3.77 (0.31)* 4.07 (0.15)

Stress Recognition 3.75 (0.21)* 3.69 (0.23) 3.54 (0.19)

Perceptions of Management 3.04 (0.41)* 3.34 (0.38)* 3.71 (0.29)

Working Conditions 3.28 (0.27)* 3.47 (0.31) 3.70 (0.23)

Safety Climate 3.45 (0.26)* 3.67 (0.26) 3.86 (0.19)

Information and Analysis 3.57 (0.29)* 3.66 (0.31)* 3.95 (0.25)

All analysis of variance p values <0.001.*Indicates post-hoc p<0.05 between Group Culture Hospitals and Hierarchical or BalancedCulture Hospitals, respectively.

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9Center for Perioperative Research in Quality, Vanderbilt University School of Medicine,Tennessee, USA10Institute for Medicine and Public Health, Vanderbilt University School of Medicine,Tennessee, USA11Pulmonary, Critical Care and Sleep Disorders Medicine, Southlake Clinic, ValleyMedical Center, Washington, USA12Department of Quality, Safety, and Performance Improvement, Hospital Corporationof America (HCA), Tennessee, USA13Division of Hospital Medicine, Northwestern University Feinberg School of Medicine,Illinois, USA

Acknowledgements We would like to thank the AHRQ collaborative investigatorsfor their work in this study: XL Liu, L Brewer, J Hickok, S Horner, S Littleton,P McFadden, S Mok, J Perlin, J Reischel, SG Chernestky Tejedor and all the HCAmedical centres that participated in this project.

Funding This project was supported by Partnerships in Implementing Patient Safety(PIPS) from the Agency for Healthcare Research and Quality (AHRQ), Grant AwardNumber: U18 HS015934.

Competing interests None.

Ethics approval Ethics approval was provided by the Vanderbilt University School ofMedicine.

Contributors TS had full access to all of the data in the study and takes responsibilityfor the integrity of the data and the accuracy of the data analysis. Study concept anddesign: TS, EWE, RG, MBW, TRT, JKD, DJF, RSD. Acquisition of data: TS, RG, DJF,HB, JE, MVW. Analysis and interpretation of data: TS, EWE, RG, MBW, TRT, RJW,JKD, DJF, SN, MVW. Drafting of the manuscript: TS. Critical revision of the manuscriptfor important intellectual content: EWE, RG, MBW, TRT, RJW, JKD, DJF, SN, HB, JE,MVW, RSD. Statistical analysis: TS, RG, SN. Obtained funding: TS, EWE, MBW, TRT,RJW, JKD, DJF, RSD. Administrative, technical or material support: EWE, MBW, TRT,RJW, JKD, DJF, HB, JE, MVW, RSD. Study supervision: TS, JE.

Provenance and peer review Not commissioned; externally peer reviewed.

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596 Qual Saf Health Care 2010;19:592e596. doi:10.1136/qshc.2009.039511

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