Patient safety culture in primary care

Abstract

Background A constructive patient safety culture is a main prerequisite for patient safety and improvement initiatives. Until now, patient safety culture (PSC) research was mainly focused on hospital care, however, it is of equal importance in primary care. Measuring PSC informs practices on their state of affairs and can guide further improvements. Measuring tools were only available for general practice and not much was known on effective interventions.

Aim The aim of the first part of the thesis was to develop and validate a generic PSC questionnaire for the Dutch primary care setting (SCOPE-PC) and to explore the prevailing culture. The second part was aimed at developing and testing two patient safety interventions in general practice.

Methods For developing the questionnaire we conducted an exploratory factor analysis and both calculated Cronbach’s alpha’s and inter-correlations. Mean dimension scores per each professions were determined and compared to the dimension mean to see whether professions differed.

To test two interventions, completing a PSC questionnaire (SCOPE) solely or combined with a complementary workshop, a three-armed trial was conducted. The workshop consisted of education and facilitated discussions using the Manchester Patient Safety Framework and their own SCOPE results. The primary outcome was the number of known incidents the year before the intervention and one year later. Secondary outcomes were quality- and safety indicators and PSC. A generalized linear model was used to analyse the number of incidents and multilevel analysis was used to analyse the culture questionnaires. In addition to the quantitative measures, we conducted interviews at follow up and used the theory of ‘Community of Practice’ for interpretation.

Results Validation of the SCOPE-PC questionnaire resulted in seven dimensions. Perceptions of caregivers were generally positive with little differences between professions. The dimension ‘Intention to report events’ scored lowest and showed the largest variation within professional groups.

Trial results showed that practices that participated in the workshop reported 42 times more incidents than the control group indicating improved PSC. Practices that only completed the questionnaire reported five times more incidents compared to the control group. The interviews showed that risk-awareness was improved after the workshop. Also interaction around the patient safety as an issue increased. Notable was that quantitative analysis of the SCOPE questionnaire showed no significant differences over time nor between the three groups at follow-up whilst the interviews as well as the changed reporting behavior did suggest improvement of culture in the workshop practices.

Conclusion Caregivers in primary care seem to be positive about their PSC. The workshops indicate that education plays an important role in risk-awareness. Also, discussing PSC was perceived to contribute to unity and clarity. Culture change is important for providing safe healthcare and this study showed that it is fruitful spending time on the subject in a team approach.