The relationships between quality management systems, safety culture and leadership and patient outcomes in Australian Emergency Departments

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Abstract

Objective

We aimed to examine whether Emergency Department (ED) quality strategies, safety culture and leadership were associated with patient-level outcomes, after controlling for other organization-level factors, in 32 large Australian hospitals.

Design

Quantitative observational study, using linear and multi-level modelling to identify relationships between quality management systems at organization level; quality strategies at ED level for acute myocardial infarction (AMI), hip fracture and stroke; clinician safety culture and leadership and patient-level outcomes of waiting time and length of stay.

Setting

Thirty-two large Australian public hospitals.

Participants

Audit of quality management processes at organization and ED levels, senior quality manager at each of the 32 participating hospitals, 394 ED clinicians (doctors, nurses and allied health professionals).

Main Outcome Measure(s)

Within the multi-level model, associations were assessed between organization-level quality measures and ED quality strategies; organization-level quality measures and ED quality strategies and ward-level clinician measures of teamwork climate (TC), safety climate (SC) and leadership for AMI, hip fracture and stroke treatment conditions; and organization-level quality measures and ED quality strategies and ward-level clinician measures of TC, SC and leadership, and ED waiting time and length of stay (performance).

Results

We found seven statistically significant associations between organization-level quality systems and ED-level quality strategies; four statistically significant associations between quality systems and strategies and ED safety culture and leadership; and nine statistically significant associations between quality systems and strategies and ED safety culture and leadership, and ED waiting time and length of stay.

Conclusions

Organization-level quality structures influence ED-level quality strategies, clinician safety culture and leadership and, ultimately, waiting time and length of stay for patients. By focusing only on time-based measures of ED performance we risk punishing EDs that perform well on patient safety measures. We need to better understand the trade-offs between implementing safety culture and quality strategies and improving patient flow in the ED, and to place more emphasis on other ED performance measures in addition to time.

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Most cited references 24

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A systematic review of evidence on the links between patient experience and clinical safety and effectiveness

Cathal Doyle, Laura Lennox, Derek Bell (2013)

Objective To explore evidence on the links between patient experience and clinical safety and effectiveness outcomes. Design Systematic review. Setting A wide range of settings within primary and secondary care including hospitals and primary care centres. Participants A wide range of demographic groups and age groups. Primary and secondary outcome measures A broad range of patient safety and clinical effectiveness outcomes including mortality, physical symptoms, length of stay and adherence to treatment. Results This study, summarising evidence from 55 studies, indicates consistent positive associations between patient experience, patient safety and clinical effectiveness for a wide range of disease areas, settings, outcome measures and study designs. It demonstrates positive associations between patient experience and self-rated and objectively measured health outcomes; adherence to recommended clinical practice and medication; preventive care (such as health-promoting behaviour, use of screening services and immunisation); and resource use (such as hospitalisation, length of stay and primary-care visits). There is some evidence of positive associations between patient experience and measures of the technical quality of care and adverse events. Overall, it was more common to find positive associations between patient experience and patient safety and clinical effectiveness than no associations. Conclusions The data presented display that patient experience is positively associated with clinical effectiveness and patient safety, and support the case for the inclusion of patient experience as one of the central pillars of quality in healthcare. It supports the argument that the three dimensions of quality should be looked at as a group and not in isolation. Clinicians should resist sidelining patient experience as too subjective or mood-oriented, divorced from the ‘real’ clinical work of measuring safety and effectiveness.

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The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research

John B Sexton, Robert Helmreich, Torsten Neilands … (2006)

Background There is widespread interest in measuring healthcare provider attitudes about issues relevant to patient safety (often called safety climate or safety culture). Here we report the psychometric properties, establish benchmarking data, and discuss emerging areas of research with the University of Texas Safety Attitudes Questionnaire. Methods Six cross-sectional surveys of health care providers (n = 10,843) in 203 clinical areas (including critical care units, operating rooms, inpatient settings, and ambulatory clinics) in three countries (USA, UK, New Zealand). Multilevel factor analyses yielded results at the clinical area level and the respondent nested within clinical area level. We report scale reliability, floor/ceiling effects, item factor loadings, inter-factor correlations, and percentage of respondents who agree with each item and scale. Results A six factor model of provider attitudes fit to the data at both the clinical area and respondent nested within clinical area levels. The factors were: Teamwork Climate, Safety Climate, Perceptions of Management, Job Satisfaction, Working Conditions, and Stress Recognition. Scale reliability was 0.9. Provider attitudes varied greatly both within and among organizations. Results are presented to allow benchmarking among organizations and emerging research is discussed. Conclusion The Safety Attitudes Questionnaire demonstrated good psychometric properties. Healthcare organizations can use the survey to measure caregiver attitudes about six patient safety-related domains, to compare themselves with other organizations, to prompt interventions to improve safety attitudes and to measure the effectiveness of these interventions.

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Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project.

John C Morey, Robert A. Simon, Gregory Jay … (2002)

To evaluate the effectiveness of training and institutionalizing teamwork behaviors, drawn from aviation crew resource management (CRM) programs, on emergency department (ED) staff organized into caregiver teams. Nine teaching and community hospital EDs. A prospective multicenter evaluation using a quasi-experimental, untreated control group design with one pretest and two posttests of the Emergency Team Coordination Course (ETCC). The experimental group, comprised of 684 physicians, nurses, and technicians, received the ETCC and implemented formal teamwork structures and processes. Assessments occurred prior to training, and at intervals of four and eight months after training. Three outcome constructs were evaluated: team behavior, ED performance, and attitudes and opinions. Trained observers rated ED staff team behaviors and made observations of clinical errors, a measure of ED performance. Staff and patients in the EDs completed surveys measuring attitudes and opinions. Hospital EDs were the units of analysis for the seven outcome measures. Prior to aggregating data at the hospital level, scale properties of surveys and event-related observations were evaluated at the respondent or case level. A statistically significant improvement in quality of team behaviors was shown between the experimental and control groups following training (p = .012). Subjective workload was not affected by the intervention (p = .668). The clinical error rate significantly decreased from 30.9 percent to 4.4 percent in the experimental group (p = .039). In the experimental group, the ED staffs' attitudes toward teamwork increased (p = .047) and staff assessments of institutional support showed a significant increase (p = .040). Our findings point to the effectiveness of formal teamwork training for improving team behaviors, reducing errors, and improving staff attitudes among the ETCC-trained hospitals.

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Author and article information

Contributors

Robyn Clay-Williams: (View ORCID Profile)

Natalie Taylor: (View ORCID Profile)

Teresa Winata: (View ORCID Profile)

Gaston Arnolda: (View ORCID Profile)

Elizabeth Austin: (View ORCID Profile)

Jeffrey Braithwaite: (View ORCID Profile)

Journal

Title: International Journal for Quality in Health Care

Publisher: Oxford University Press (OUP)

ISSN (Print): 1353-4505

ISSN (Electronic): 1464-3677

Publication date Created: January 2020

Publication date Created: February 06 2020

Publication date Created: February 05 2020

Publication date Other: January 2020

Publication date (Print): February 06 2020

Publication date (Electronic): February 05 2020

Volume: 32

Issue: Supplement_1

Pages: 43-51

Affiliations

[1 ]Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Road Macquarie University, NSW 2109, Australia

[2 ]Cancer Research Division, Cancer Council NSW, 153 Dowling St, Woolloomooloo, NSW 2011, Australia

[3 ]Faculty of Health Sciences, University of Sydney, Camperdown, Sydney, NSW 2006, Australia

Article

DOI: 10.1093/intqhc/mzz105

SO-VID: b3fd5dd0-89bf-43cf-bbb6-56789b347131

License:

https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model

The relationships between quality management systems, safety culture and leadership and patient outcomes in Australian Emergency Departments

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Abstract

Objective

Design

Setting

Participants

Main Outcome Measure(s)

Results

Conclusions

Related collections

Preventive and Emergency Medicine Insights

Most cited references 24

A systematic review of evidence on the links between patient experience and clinical safety and effectiveness

The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research

Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project.

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