Quality - Module 3

RESEARCH ARTICLE Open Access

Improving patient safety culture in Saudi Arabia (2012–2015): trending, improvement and benchmarking Khalid Alswat1, Rawia Ahmad Mustafa Abdalla2, Maher Abdelraheim Titi1, Maram Bakash1, Faiza Mehmood1, Beena Zubairi1, Diana Jamal2 and Fadi El-Jardali2,3*

Abstract

Background: Measuring patient safety culture can provide insight into areas for improvement and help monitor changes over time. This study details the findings of a re-assessment of patient safety culture in a multi-site Medical City in Riyadh, Kingdom of Saudi Arabia (KSA). Results were compared to an earlier assessment conducted in 2012 and benchmarked with regional and international studies. Such assessments can provide hospital leadership with insight on how their hospital is performing on patient safety culture composites as a result of quality improvement plans. This paper also explored the association between patient safety culture predictors and patient safety grade, perception of patient safety, frequency of events reported and number of events reported.

Methods: We utilized a customized version of the patient safety culture survey developed by the Agency for Healthcare Research and Quality. The Medical City is a tertiary care teaching facility composed of two sites (total capacity of 904 beds). Data was analyzed using SPSS 24 at a significance level of 0.05. A t-Test was used to compare results from the 2012 survey to that conducted in 2015. Two adopted Generalized Estimating Equations in addition to two linear models were used to assess the association between composites and patient safety culture outcomes. Results were also benchmarked against similar initiatives in Lebanon, Palestine and USA.

Results: Areas of strength in 2015 included Teamwork within units, and Organizational Learning—Continuous Improvement; areas requiring improvement included Non-Punitive Response to Error, and Staffing. Comparing results to the 2012 survey revealed improvement on some areas but non-punitive response to error and Staffing remained the lowest scoring composites in 2015. Regression highlighted significant association between managerial support, organizational learning and feedback and improved survey outcomes. Comparison to international benchmarks revealed that the hospital is performing at or better than benchmark on several composites.

Conclusion: The Medical City has made significant progress on several of the patient safety culture composites despite still having areas requiring additional improvement. Patient safety culture outcomes are evidently linked to better performance on specific composites. While results are comparable with regional and international benchmarks, findings confirm that regular assessment can allow hospitals to better understand and visualize changes in their performance and identify additional areas for improvement.

Keywords: Patient safety culture, Riyadh, Trending, Benchmarking

* Correspondence: [email protected] 2Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon 3Department of Health Research Methods, Evidence, and Impact, McMaster University, CRL-209, 1280 Main St. West, Hamilton, ON L8S 4K1, Canada Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Alswat et al. BMC Health Services Research (2017) 17:516 DOI 10.1186/s12913-017-2461-3

Background Patient safety (PS) and the prevention of harm has been linked to developing a strong patient safety culture (PSC) [1]. Creating and maintaining a strong PSC in healthcare organizations is linked to better performing health organizations [2]. Evidence on patient safety culture in hospitals can

provide healthcare leaders and policymakers with the information they need to improve quality and prevent errors. Administrators, managers and policymakers alike will reap the benefits of improving patient safety culture in improved quality, improved patient out- comes, reduced errors and a more cost effect health- care system [1, 3–6]. Patient safety culture is determined by multiple factors

within a health organization and can support the pre- vention and reduction of harms to patients. It is the out- come of different factors within a healthcare institution including attitudes, values, skills and even behaviors to commit to patient safety management [7]. International accreditation organizations are now re-

quiring PSC assessments as an integral component of their surveys and provide important information that would help better understand overall organizational per- ception on areas related to PS [8, 9]. So in response to these requirements, many hospitals around the world are using different tools for redesigning and restructur- ing their work environments to support safe job per- formance and promote PSC [9]. The Hospital Survey on Patient Safety Culture (HSOPSC) has become the most frequently used tool to assess patient safety culture [10]. This tool measures different aspects of patient safety culture and can help hospitals better understand the fac- tors that determine how they relate to their actions, managerial support, organizational activities, feedback about errors, communication, teamwork within and across units, staffing, handoffs and response to error [10]. In spite of the abundance of literature and evidence that attests to the importance of patient safety culture assessments, this topic has not been sufficiently ad- dressed in in the Arab world and particularly in the Kingdom of Saudi Arabia (KSA). The existing evidence about KSA found that organizational learning [11, 12], teamwork within units, in addition to feedback and communication about errors are among the strongest aspects of patient safety culture [12]. On the other hand, and in accordance with international trends, punitive re- sponse to error [11, 12] staffing, and teamwork across units are some of the areas requiring improvement [12]. Evidence from a multi-site facility in Riyadh also con- firmed that the composites on organizational learning, and teamwork within units were areas of strength while punitive response to error, staffing and communication were areas of weakness [13].

In Lebanon, a national study that targeted hospital em- ployees used an adapted Arabic version of the HSOPSC. The study found that teamwork within units, hospital management support for patient safety, and organizational learning and continuous improvement were areas of strength. Areas requiring improvement at the national level were teamwork across hospital units, hospital hand- offs and transitions, staffing, and non-punitive response to error [14]. The study also found significant associations between patient safety culture outcomes and composite scores [15]. A study in Oman focusing on patient safety culture

from the nursing perspective found perception of patient safety was associated with better scores on supervisor or manager expectations, feedback and communications about errors, teamwork across hospital units, and hos- pital handoffs and transitions [4]. Another study focus- ing on public hospitals in Palestine found that the composites with the lowest scores were non-punitive re- sponse to error, frequency of events reported, communi- cation openness, hospital management support for patient safety and staffing [16]. Assessments of patient safety culture using the Agency

for Healthcare Research and Quality (AHRQ) tool should ideally be repeated every two or 3 years [17, 18]. This recommendation was also highlighted in the Saudi Central Board for Accreditation of Healthcare Institu- tions (CBAHI) accreditation standards which recom- mends conducting a patient safety culture assessment on an annual basis [19]. We have yet to document a study that has conducted and reported such repeated assess- ments in the Eastern Mediterranean Region, and specif- ically in the Kingdom of Saudi Arabia. Such assessments can provide hospital management and higher leadership with some insight on how their performance has chan- ged as a result of quality improvement plans that were developed in response to the findings of the patient safety culture survey. This particular study is a second round assessment of

a previous patient safety culture survey conducted in 2012. This study focused on the same multi-site facility in an effort to determine whether performance on pa- tient safety culture composites has changed. The current study also compares results to the previous assessment in 2012 in addition to benchmarking to other initiatives conducted regionally and internationally. To our know- ledge, this is the first study to perform this type of as- sessment in the context of Kingdom of Saudi Arabia (KSA) and Arab countries.

Objectives We aim to re-assess PSC in a large multi-site healthcare facility in Riyadh, Kingdom of Saudi Arabia and to com- pare it with an earlier assessment conducted in 2012 and

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benchmarked against regional and international studies. Furthermore, we explored the association between PSC predictors and outcomes while considering demographic characteristics and hospital size.

Methods Design, setting and sampling The tool used was adapted from the Hospital Survey on Patient Safety Culture (HSOPSC) developed by the Agency for Healthcare Research and Quality. The sur- vey is available in English and was translated to Arabic in a previous study conducted in Lebanon [14]. The research team piloted the translated version in 2012 survey and made minor changes to the word- ing of some statements to better fit the context of the hospital. The changes were cross checked with the English version to make sure not to alter the ori- ginal meaning [13]. Minimal changes were made to the current version and they only related to categories of employment. The Medical City is a tertiary care teaching hospital

with a capacity of 800 beds. It has a wide range of spe- cialties and services and serves patients from all over KSA. The facility is divided into two settings: the larger setting (Site A) has 700 beds and the smaller setting (Site B) has 100 beds. Site A is located towards the North of Riyadh and offers free medical services with a wide range of specialties. Site B is located towards the center of Riyadh and was the first educational hospital in Saudi Arabia but offers fewer services compared to Site A given its smaller size. The Dental Site is within Site A and offers inpatient and outpatient dental services. The survey randomly sampled staff including physi-

cians, registered nurses, other clinical or non-clinical staff, pharmacists, laboratory technicians, dietary de- partment staff, radiologists, and administrative staff including managers and supervisors. The two sites had a total of 9000 hospital employees of which 4500 were targeted and 2592 responded to the survey (re- sponse rate of 57.6%). Data collection spanned July 2015 to December 2015. The survey was available in electronic format for all respondents. Some respon- dents preferred paper based surveys and as such were provided with the surveys in sealed envelopes. A total of 397 respondents returned the completed surveys in designated boxes in sealed envelopes to maintain the confidentiality of their responses. The consent form was included on the first page of the survey and de- tailed the information for participants and some defi- nitions. Respondents were asked not to write their names or sign any section of survey. Surveys were provided in both English and Arabic

with respondents favoring the English version. Data was

not collected on language for either the online version of the survey. It should be noted, however, that the ratio of English to Arabic surveys in the paper based version was 3 to 1 which confirms preference of the English version.

Data management and analysis Data was analyzed using IBM SPSS Statistics 24.0 at a significance level of 0.05. The tool included a total of 44 items, 42 of them measure 12 patient safety culture composites (two of which are patient safety culture outcomes). The tool includes four outcomes, two of which are included within the composites, they are: frequency of events reported and overall perception of patient safety. The two other outcome variables are patient safety grade and number of events both of which are multiple choice questions. The HSOPSC includes both positively and negatively worded items scored using a five-point scale reflect- ing agreement or frequency of occurrence on a five- point Likert scale. The total percent positives, nega- tives and neutrals were calculated for each compos- ite making sure to reverse negatively worded items [18]. Composites that had at least 70% positive response was considered an area of strength whereas those scoring less were considered areas for improvement. Composite level scores were also calculated. This was

done through adding up the score for each item within a composite then dividing by the number of non-missing items within the scale. Computed scores ranged from 1 to 5. Internal consistency was measured using Cron- bach’s alpha. Confirmatory Factor Analysis was conducted results

confirmed that 9 of the 12 composites loaded on one factor with acceptable eigen values and percent variance explained. The three composites supervisor/manager ex- pectations, overall perception of patient safety, and staff- ing each loaded on two factors. Detailed results are not reported in this paper. Demographic characteristics of respondents were sum-

marized using univariate analysis. In fulfillment of the comparative component within

this study, the two datasets were merged to combine survey items from the 2012 survey with those of the 2015 survey. Only scale related items were merged, demographics were not included. A Student T-Test was used to examine whether a statistically significant differ- ent exists between the survey items for each of 2012 and 2015 datasets. Results from this hospital were also benchmarked

against similar initiatives in the United States (US) [17] and Lebanon [15]. Comparison to the benchmark value was done using the below formula [20]:

Alswat et al. BMC Health Services Research (2017) 17:516 Page 3 of 14

%Distance from benchmark ¼ ððbenchmark value –hospital resultÞ=benchmark valueÞ� 100:

Categories of achievement were determined by the value of % distance from benchmark as follows: ➢ Values <10% were categorized as Meets or better

than benchmark (☑). Values below zero (0) indicate that the benchmark value is lower than the hospital re- sult thus giving a result of “meet or better than benchmark”. ➢ Values between [10–50%] were categorized as

Deviates slightly from benchmark (▣). ➢ Values exceeding 50% were categorized as Major

deviation from benchmark (☒). The four outcome variables were regressed against

the 10 composite scores, respondent’s gender, age, ex- perience, degree, respondent position, patient inter- action and size of the hospital. Four regression models were used to analyze the association between the com- posites and the outcome variables. The first two models were Generalized Estimating Equations which included recoded versions of the variables on number of events reported and patient safety grade. These two outcomes were reduced to include three items each. Patient safety grade was reduced to include the cat- egories: “Poor or Failing,” “Acceptable,” and “Excel- lent/Good.” Number of events was reduced to include: “>5 events reported,” “1 to 5 events reported,” and “No events reported.” Linear regression was used for the two composites on frequency of events and overall per- ception of patient safety. For the purpose of linear re- gression, the independent variables were entered as dummy variables.

Results General results A total of 4500 surveys were sent to respondents of which 2592 completed (2128 from Site A and 441 from Site B, in addition to a total of 23 respondents from den- tal and combined sites) yielding an overall response rate of 56.7%. Analysis revealed that the majority of respondents

were females (84.1%) and around half were aged be- tween 30 and 45 (46.4%) and married (64.4%). Around half the respondents indicated working in Medical de- partments (51.9%) while 30.6% worked in Surgical de- partments. The majority of respondents indicated working as Registered Nurses (78.3%) (Table 1). Most respondents reported holding a Bachelor’s degree (56.2%) and having 3 to 5 years of experience (25.2%) at the hospital, 6 to 10 years of experience in their work area (31.5%) and 6 to 10 years of experience in their profession (32.3%). Most respondents indicated

working 40 to 60 h a week (92.9%) and having direct contact with patients (90.9%). Less than half the respondents gave their hospital a

Very Good patient safety grade (49.4%) while 55.8% re- ported no events (55.8%), 27.8% reported 1 to 2 events, and 10.6% reported 3 to 5 events. It is worth noting that only 1.3% of respondents reported 21 or more events (Table 1).

Areas of strengths and areas requiring improvement Areas of strength (those where percent positive rating exceeds 70%) and those requiring improvement (scoring below 70%) were then examined [10]. The dimensions considered areas of strength were Teamwork within units (84.8%), Organizational Learning – Continuous Improvement (86.3%), Management support for patient safety (75.3%) and Feedback and Communication about error (71.8%) (Table 2). Areas of strength and those requiring improvement

were derived. A major area of strength highlighted in the survey findings included the degree to which the hos- pital is engaging in actions to improve patient safety (94.8% positive). Additional areas of strength were re- vealed within the composite on Teamwork within units. Respondents indicated that staff support each other within the unit (90.1% positive responses), and work to- gether as a team (89.3% percent positive). Moreover, as highlighted within the composite on Hospital Manage- ment Support for Patient Safety, 86.9% of respondents indicated that the actions of hospital management reflect that patient safety is a priority for the administration (Table 2). Areas requiring improvement related to staffing. In

fact, respondents indicated that hospital employees work longer than what should be considered best for patient safety (11.2% positive response). As for the dimension on Non-Punitive Response to Error, 13.7% of staff were worried that their mistakes were being kept in their personnel file and 29.3% felt that they were being written up when reporting an event (Table 2). Other items that reflect areas of strength and items requiring improve- ment are listed in Table 2.

Comparing results from 2015 to 2012 The difference in mean scores on the survey compos- ites was statistically significant between 2012 and 2015. Results improved on all survey composites indi- cating better performance in 2015 compared to the initial survey. Non-punitive response to error and Staffing remained the lowest scoring composites in 2015. The highest ranking composite for both surveys were Organizational Learning-Continuous Improve- ment. While Teamwork within Units had the second highest score in 2012, it ranked third in 2015 while

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Feedback and Communication about Errors ranked second (Table 3).

Comparative against regional and international findings Composite scores were compared to similar studies done in Lebanon, Palestine and United States. As compared to the US, the Medical City in Riyadh was found to meet or exceed benchmarks for dimension pertaining to Teamwork within Units, Organizational Learning—Con- tinuous Improvement, Management Support for Patient Safety, Feedback and Communication About Error, Fre- quency of Events Reported Staffing, and Non-Punitive Response to Error (Table 4).

Table 1 Socio-demographic and professional characteristics of respondents in addition to frequency of events and patient safety grade

N (%)

Gender

Male 398 (15.9%)

Female 2103 (84.1%)

Age group

Below 30 year old 925 (37.3%)

Between 30 to 45 years old 1152 (46.4%)

Between 46 to 55 years old 253 (10.2%)

Above 55 years old 151 (6.1%)

Marital Status

Single 851 (34.2%)

Married 1602 (64.4%)

Divorced/ Separated 16 (0.6%)

Widowed 13 (0.5%)

Others 6 (0.2%)

Highest Education

Under High School Level 2 (0.1%)

High School Level 7 (0.3%)

Diploma Level 836 (33.5%)

Bachelor’s Degree 1403 (56.2%)

Master’s Degree 127 (5.1%)

Doctorate Degree 102 (4.1%)

Others 19 (0.8%)

Work Area

Many different hospital unit/No Specific Unit

21 (0.8%)

Administrative 138 (5.4%)

Medical 1332 (51.9%)

Surgical 786 (30.6%)

Diagnostics 99 (3.9%)

Other 191 (7.4%)

Staff Position

Administrator/Manager/Director 47 (1.9%)

Physician 141 (5.6%)

Specialist 61 (2.4%)

Coordinator 10 (0.4%)

Assistant/Aide 39 (1.6%)

Pharmacist 36 (1.4%)

Therapist 1 (0%)

Registered Nurse 1969 (78.3%)

Resident/PG/Intern 64 (2.5%)

Assistant/Clerk/Secretary/Facilitator 28 (1.1%)

Technician 52 (2.1%)

Other, please specify: 67 (2.7%)

Table 1 Socio-demographic and professional characteristics of respondents in addition to frequency of events and patient safety grade (Continued)

Tenure in Profession

Less than 1 year 133 (5.3%)

1 to 5 years 741 (29.6%)

6 to 10 years 809 (32.3%)

11 to 15 years 348 (13.9%)

16 to 20 years 222 (8.9%)

21 years or more 252 (10.1%)

Hours worked per week

Less than 20 h per week 25 (1%)

20 to 39 h per week 148 (6%)

40 to 60 h per week 2280 (92.9%)

Contact with Patients

YES, I typically have direct interaction or contact with patients.

2229 (90.9%)

NO, I typically do NOT have direct interaction or contact with patients.

224 (9.1%)

Patient Safety Grade

A – Excellent 495 (19.3%)

B - Very Good 1235 (48.1%)

C – Acceptable 650 (25.3%)

D – Poor 51 (2.0%)

E – Failing 5 (0.2%)

Missing 133 (5.2%)

Frequency of Events

No event reports 1352 (55.8%)

1 to 2 event reports 678 (28.0%)

3 to 5 event reports 257 (10.6%)

6 to 10 event reports 76 (3.1%)

11 to 20 event reports 30 (1.2%)

21 event reports or more 32 (1.3%)

Missing 144 (5.9%)

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Table 2 Cronbach’s alpha and distribution of positive responses and scores for survey composites and items

Composites and survey items Average% positive responsea Mean (Standard deviation)

Overall Perception of Safety (Cronbach’s α = 0.234) 59.5 3.41 (0.54)

It is just by chance that more serious mistakes do not happen around here (R)b 29.4 2.72 (1.06)

Patient safety is never sacrificed to get more work done 76.6 3.80 (0.97)

We have patient safety problems in this unit (R) 49.7 3.19 (1.09)

Our policies and procedures and systems are effective in preventing errors 82.1 3.91 (0.75)

Supervisor/Manager Expectations & Actions Promoting Patient Safety (Cronbach’s α = 0.395)

60.8 3.44 (0.60)

My supervisor/manager says a good word when he/she sees a job done according to established patient safety procedures

74.2 3.74 (0.94)

My supervisor/manager seriously considers staff suggestions for improving patient safety

76.4 3.80 (0.87)

Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking shortcuts (R)

52.1 3.27 (1.06)

My supervisor/manager overlooks patient safety problems that happen over and over (R)

40.4 2.94 (1.16)

Organizational learning and Continuous Improvement (Cronbach’s α = 0.614) 86.3 4.03 (0.53)

We are actively doing things to improve patient safety 94.8 4.31 (0.64)

Mistake have led to positive changes here 76.8 3.78 (0.78)

After we make changes to improve patient safety, we evaluate their effectiveness 87.4 4.01 (0.69)

Teamwork within units (Cronbach’s α = 0.757) 84.8 3.40 (0.60)

Staff support one another in this unit 90.1 4.11 (0.71)

When a lot of work needs to be done quickly, we work together as a team to get the work done

89.3 4.11 (0.71)

In this unit, people treat each other with respect 85.4 4.03 (0.75)

When members of this unit get really busy, other members of the same unit help out

74.2 3.75 (0.95)

Non-punitive Response to Error (Cronbach’s α = 0.694) 24.8 2.62 (0.79)

Staff feel like their mistakes are held against them (R) 31.4 2.82 (1.04)

When an event is reported, it feels like the person is being written up, not the problem (R)

29.3 2.76 (1.02)

Staff worry that mistakes they make are kept in their personnel file (R) 13.7 2.29 (0.93)

Staffing (Cronbach’s α = 0.210) 33.8 2.79 (0.57)

We have enough staff to handle the workload 56.1 3.29 (1.18)

Staff in this unit work longer hours than is best for patient care (R) 11.2 2.17 (0.89)

We use agency/temporary staff than is best for patient care (R) 45.2 3.14 (1.08)

When the work is in “crisis mode” we try to do too much, too quickly (R) 22.8 2.56 (1.01)

Hospital Management Support for Patient Safety (Cronbach’s α = 0.519) 75.3 3.76 (0.62)

Hospital management provides a work climate that promotes patient safety 85.3 3.95 (0.68)

The actions of hospital management show that patient safety is a top priority 86.9 4.07 (0.77)

Hospital management seems interested in patient safety only after an adverse event happens (R)

53.6 3.26 (1.10)

Teamwork Across Hospital Units (Cronbach’s α = 0.627) 67.0 3.59 (0.62)

There is good cooperation among hospital units that need to work together 73.0 3.69 (0.82)

Hospital units work well together to provide the best care for patients 85.5 4.03 (0.77)

Hospital units do not coordinate well with each other and this might affect patient care (R)

55.8 3.30 (1.04)

It is often not easy to work with staff from other hospital units (R) 53.7 3.35 (0.97)

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Compared to Lebanon, the Medical City in Riyadh fared better on dimensions relating to Teamwork Within Units, Teamwork across units, Supervisor/Manager Expectations & Actions Promoting Patient Safety, Organizational Lear- ning—Continuous Improvement, Management Support for Patient Safety, Feedback and Communication about Error, Frequency of Events Reported, Staffing, Handoffs & Transitions and Non-punitive Response to Error (Table 4).

Results from the Medical City were found to be better than the Palestine benchmark with the exception of the composite relating to Staffing (Table 4).

Generalized estimating equations findings patient safety grade Table 5 shows how increases in patient safety com- posite scores affect outcomes. A one unit increase on

Table 2 Cronbach’s alpha and distribution of positive responses and scores for survey composites and items (Continued)

Hospital Handoffs & Transitions (Cronbach’s α = 0.783) 55.8 3.39 (0.75)

Things “fall between the cracks”, i.e., things might go uncontrolled and get lost (ex: medical records, medical treatment, patient information and education, discharge criteria) when transferring patients from one unit to another (R)

45.5 3.18 (1.01)

Important patient care information is often lost during shift changes (R) 66.8 3.59 (0.96)

Problems often occur in the exchange of information across hospital units (R) 46.2 3.22 (0.95)

Shift changes are problematic for patients in this hospital (R) 64.5 3.56 (0.93)

Communication Openness (Cronbach’s α = 0.533) 45.0 3.36 (0.83)

Staff will freely speak up if they see something that may negatively affect patient care 64.5 3.84 (1.07)

Staff feel free to question the decisions or actions of those with more authority 34.3 3.08 (1.21)

Staff are afraid to ask questions when something does not feel right (R) 36.2 3.15 (1.15)

Feedback and Communications About Error (Cronbach’s α = 0.732) 71.8 4.04 (0.79)

We are given feedback about changes put into place based on event reports 56.5 3.69 (1.06)

We are informed about errors that happen in this unit 79.0 4.21 (0.95)

In this unit, we discuss ways to prevent errors from happening again 79.9 4.22 (0.93)

Frequency of events reported (Cronbach’s α = 0.902) 68.8 3.92 (1.10)

When a mistake is made, but is caught and corrected affecting the patient, how often is this reported?

65.6 3.83 (1.21)

When a mistake is made, but has no potential to harm the patient, how often is this reported? 65.9 3.86 (1.22)

When a mistake is made that could harm the patient, but does not, how often is this reported? 74.9 4.07 (1.17) athe composite-level percentage of positive responses was calculated using the following formula: (number of positive responses to the items in the composite/ total number of responses to the items (positive, neutral, and negative) in the composite (excluding missing responses))*100 bNegatively worded items that were reverse coded

Table 3 T-test to compare composite scores in 2012 to scores in 2015

2012 2015 P-value

Mean SD Mean SD

Frequency of Event Reporting 3.64 1.16 4.04 1.54 <0.001

Overall Perceptions of Safety 3.43 0.59 3.60 1.56 <0.001

Supervisor/manager expectations and actions promoting safety 3.46 0.65 3.57 1.34 <0.001

Organizational Learning-Continuous Improvement 3.89 0.69 4.16 1.14 <0.001

Teamwork Within Hospital Units 3.85 0.75 4.04 0.71 <0.001

Communication Openness 3.25 0.85 3.45 1.08 <0.001

Feedback and Communication About Errors 3.73 0.95 4.11 1.10 <0.001

Non-punitive Response to Error 2.68 0.81 2.76 1.26 0.013

Staffing 2.84 0.62 3.02 1.19 <0.001

Hospital Management Support for Patient Safety 3.69 0.76 3.85 1.05 <0.001

Hospital Handoffs and Transitions 3.36 0.79 3.82 2.29 <0.001

Teamwork Across Hospital Units 3.52 0.71 3.76 1.36 <0.001

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all patient safety composites with the exception of non-punitive response to error significantly increased odds of reporting better patient safety grades. A one- unit increase in staffing had 1.04 higher odds of reporting better patient safety grade (95% CI = 1.01– 1.08). A one unit increase on remaining composites increased odds of reporting better patient safety grade ranging from an OR of 1.12 to 1.66. Noteworthy is the finding that a one unit increase on Hospital Man- agement Support for Patient Safety had 2.43 higher odds of reporting better patient safety grade (95% CI = 2.09–2.83) (See Table 5). Female respondents had 0.62 lower odds (95%

CI = 0.62–0.63) of reporting better patient safety grades while those aged above 55 had 1.28 higher odds of reporting better patient safety grades (95% CI = 1.14– 1.42). Work experience was associated with higher pa- tient safety grades whereby 3 to 5 years of experience was associated with 0.96 lower odds of reporting better patient safety grades whereas respondents with 11 to 15 years or 16 to 20 years of experience had significantly greater odds of reporting better patient safety grades (See Table 5). Respondent positions such Physicians, Co- ordinators, Pharmacist, Nurses, and Resident/PG/Intern were all associated with lower odds of reporting better patient safety grades. However, Assistant/Aide and Technicians had higher odds of reporting better patient safety grades. Respondents who did not have patient interaction and those working in the smaller setting also had lower odds of reporting better patient safety grades (See Table 5).

Number of events reported A one unit increase in Hospital Management Support for Patient Safety had 1.15 higher odds of reporting higher number of events (95% CI = 1.08–1.23). More- over, a one unit increase in Hospital Handoffs and Tran- sitions had 1.10 higher odds of reporting higher number of events (95% CI = 1.06–1.14). Teamwork within units, Communication Openness, Non-punitive Response to Error, Staffing, and Teamwork across Hospital Units were all associated with lower odds of reporting higher number of events (See Table 5). Female respondents had 1.56 higher odds (95%CI = 1.45–

1.67) of reporting higher number of events. Respondents aged 46 and above were found to have significantly lower odds of reporting higher number of events. This observa- tion is reversed when it comes to years of experience where more experienced respondents had consistently higher odds of reporting higher number of events. More- over, respondents holding Masters or Doctoral degrees had significantly lower odds of reporting higher number of events. As for respondent positions, Physicians, Spe- cialists, Assistant/Aide, Registered Nurse, Resident/PG/ Intern, Technicians and Other all had significantly lower odds of reporting higher number of events. How- ever, Pharmacists had 2.97 higher odds of reporting higher number of events (95% CI = 2.30–3.84). As ex- pected, respondents who had no patient interaction had 0.64 lower odds of reporting higher number of events. The smaller hospital also had significantly lower odds of reporting higher number of events (OR = 0.87, 95% CI = 0.87–0.87) (See Table 5).

Table 4 Benchmarking 2015 results to similar initiatives in the US and Lebanon

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Table 5 Generalized estimating equations

Patient safety grade Number of events reported

OR (95% CI) P-value OR (95% CI) P-value

Patient Safety Culture Composites

Supervisor/Manager Expectations & Actions Promoting Patient Safety 1.20 (1.19–1.22) <0.001 1.27 (0.91–1.78) 0.162

Organizational learning and Continuous Improvement 1.66 (1.55–1.77) <0.001 1.10 (0.99–1.22) 0.073

Teamwork within units 1.61 (1.59–1.62) <0.001 0.82 (0.76–0.89) <0.001

Communication Openness 1.22 (1.10–1.35) <0.001 0.93 (0.90–0.97) 0.002

Feedback and Communications About Error 1.50 (1.29–1.74) <0.001 0.99 (0.97–1.01) 0.282

Non-punitive Response to Error 1.09 (0.93–1.27) 0.308 0.83 (0.71–0.98) 0.029

Staffing 1.04 (1.01–1.08) 0.007 0.74 (0.67–0.83) <0.001

Hospital Management Support for Patient Safety 2.43 (2.09–2.83) <0.001 1.15 (1.08–1.23) <0.001

Hospital Handoffs & Transitions 1.12 (1.11–1.13) <0.001 1.10 (1.06–1.14) <0.001

Teamwork Across Hospital Units 1.48 (1.45–1.50) <0.001 0.94 (0.90–0.98) 0.004

Gender

Male 1 1

Female 0.62 (0.62–0.63) <0.001 1.56 (1.45–1.67) <0.001

Age

Less than 30 years of age 1 1

Between 30 and 45 1.06 (0.92–1.23) 0.423 0.96 (0.81–1.14) 0.641

Between 46 and 55 1.00 (0.72–1.40) 0.995 0.56 (0.46–0.69) <0.001

Aged above 55 1.28 (1.14–1.42) <0.001 0.40 (0.38–0.43) <0.001

Experience at the hospital

1 to 2 years 1 1

3 to 5 years 0.96 (0.85–1.08) <0.001 1.54 (1.21–1.94) <0.001

6 to 10 years 0.67 (0.57–0.78) 0.291 1.44 (1.35–1.53) <0.001

11 to 15 years 1.07 (1.01–1.14) 0.025 1.55 (1.51–1.59) <0.001

16 to 20 years 0.78 (0.49–1.24) <0.001 2.38 (1.54–3.68) <0.001

More or equal to 21 years 1.58 (1.55–1.60) 0.463 3.34 (2.53–4.41) <0.001

Highest Degree

Under High School Level - - 1

High school level - - 0.50 (0.19–1.28) 0.148

Diploma level - - 0.36 (0.12–1.09) 0.070

Bachelors Degree - - 0.65 (0.26–1.62) 0.354

Masters Degree - - 0.49 (0.30–0.81) 0.005

Doctorate Degree - - 0.33 (0.17–0.65) 0.001

Position at the hospital

Administrator/Manager/Director 1 1

Physician 0.50 (0.40–0.64) <0.001 0.43 (0.35–0.51) <0.001

Specialist 1.65 (0.74–3.67) 0.223 0.32 (0.24–0.43) <0.001

Coordinator 0.65 (0.65–0.65) <0.001 1.01 (0.58–1.76) 0.964

Assistant/Aide 1.89 (1.34–2.67) <0.001 0.27 (0.23–0.31) <0.001

Pharmacist 0.53 (0.52–0.55) <0.001 2.97 (2.30–3.84) <0.001

Registered Nurse 0.60 (0.57–0.64) <0.001 0.29 (0.17–0.50) <0.001

Resident/PG/Intern 0.18 (0.14–0.22) <0.001 0.14 (0.11–0.18) <0.001

Assistant/Clerk/Secretary/Facilitator 0.65 (0.65–0.65) 0.611 1.02 (0.91–1.14) 0.734

Alswat et al. BMC Health Services Research (2017) 17:516 Page 9 of 14

Linear regression findings Overall perception of safety Perception of patient safety improved by 0.131 (P-Value <0.001) for a one unit increase in the score on Super- visor/Manager Expectations and Actions Promoting Safety, by 0.10 (P-Value =0.003) for every unit increase in the score on organizational learning and continuous improvement, and by 0.052 (P-Value =0.007) for a one unit increase in the score on Non-Punitive Response to Error. A one unit increase in the composites on Staffing, Hospital Management Support for Patient Safety, Hos- pital Handoffs & Transitions were also found to increase overall perception of patient safety by 0.079 (p-value =0.002, 0.114 (p-value <0.001) and 0.12 (p-value <0.001) (See Table 6). As age of respondents increased, overall overall per-

ception of patient safety progressively decreased. How- ever, respondents with higher educational degrees had significantly better perception of patient safety. Special- ists and respondents working in the larger site also had significantly lower overall perception of patient safety (Table 6).

Frequency of events reported Linear regression analysis showed that a one unit in- crease in the score on Feedback and Communications about Error increased the frequency of events reported by 0.431 (P-Value <0.001) (See Table 6). Respondents aged between 30 and 45 years reported

−0.172 fewer events (p-value =0.021) compared to re- spondents aged below 30. Moreover, respondents with 6 to 10 years reported 0.202 more events (p-value = 0.031) compared to respondents with 1 to 2 years of experi- ence. As for respondent positions, Administrator/Man- ager/Director, Physician, Specialist, Registered Nurses and Assistant/Clerk/Secretary/Facilitator were all signifi- cantly less likely to report higher number of events (See Table 6).

Discussion This is the first study to conduct a repeated assessment of patient safety culture in a country where a dearth of

such studies exist. Findings confirm that tangible im- provement has been achieved on some composites while other areas still require further work. These findings are of utmost importance in the context of KSA where such assessments are limited but can provide valuable infor- mation to hospital leaders on how performance has changed as a result of quality improvement plans. Study findings also provide recent data on patient safety cul- ture in the context of a leading health provider in a major city in KSA. When comparing study findings to previous studies,

evidence indicated that Organizational Learning [11, 12], Teamwork within Units, and Feedback and Communica- tion about Errors are among the strongest aspects of pa- tient safety culture [12] whereas the highly Punitive Response to Error [11, 12] Staffing, and Teamwork across Hospital Units as areas requiring improvement [12]. Another study conducted at a multi-site facility in Riyadh confirmed Organizational Learning, and Team- work within Units as areas of strength and Punitive Re- sponse to Error, Staffing and Communication as areas of weakness [13]. In Lebanon, Teamwork within Units, Hospital Management Support for Patient Safety, and Organizational Learning and Continuous Improvement were areas of strength. Areas requiring improvement at the national level were Teamwork across Hospital Units, Hospital Handoffs and Transitions, Staffing, and Non- punitive Response to Error [14]. The study also found significant associations between patient safety culture outcomes and composite scores [15]. A similar study in Oman found that higher Overall Perception of Patient safety was associated with better composite scores on Supervisor or Manager Expectations, Feedback and Communications about Errors, Teamwork across Hos- pital units, and Hospital Handoffs and Transitions [4]. In Jordan, the main area of strength was Teamwork within Units [21]. Another study focusing on public hospitals in Palestine found that the composites with the lowest scores were Non-punitive Response to Error, Frequency of Events Reported, Communication Openness, Hospital Management Support for Patient Safety and Staffing [16].

Table 5 Generalized estimating equations (Continued)

Technician 2.84 (2.49–3.24) <0.001 0.55 (0.53–0.58) <0.001

Other 1.04 (0.98–1.12) 0.189 0.19 (0.06–0.63) 0.006

Interaction with patients

No 0.81 (0.74–0.88) <0.001 0.64 (0.54–0.76) <0.001

Yes 1 1

Hospital Size

Small 0.56 (0.56–0.57) <0.001 0.87 (0.87–0.87) <0.001

Large 1 1

Alswat et al. BMC Health Services Research (2017) 17:516 Page 10 of 14

Table 6 Linear regression model

Perception of patient safety Frequency of events reported

Beta (Standard error) P-value Beta (Standard error) P-value

Patient Safety Culture Composites

Supervisor/ Manager Expectations & Actions Promoting Patient Safety

0.131 (0.027) <0.001 −0.009 (0.057) 0.880

Organizational learning and Continuous Improvement 0.100 (0.034) 0.003 0.133 (0.071) 0.060

Teamwork within units 0.055 (0.029) 0.059 −0.107 (0.061) 0.080

Communication Openness −0.026 (0.020) 0.181 −0.004 (0.041) 0.922

Feedback and Communications About Error 0.008 (0.022) 0.728 0.431 (0.046) <0.001

Non-punitive Response to Error 0.052 (0.019) 0.007 −0.061 (0.04) 0.125

Staffing 0.079 (0.026) 0.002 −0.017 (0.054) 0.748

Hospital Management Support for Patient Safety 0.114 (0.030) <0.001 0.119 (0.063) 0.056

Hospital Handoffs & Transitions 0.120 (0.023) <0.001 −0.031 (0.047) 0.515

Teamwork Across Hospital Units 0.003 (0.032) 0.926 −0.014 (0.066) 0.834

Gender

Male 0.142 (0.054) 0.008 0.048 (0.11) 0.667

Female 0 0

Age

Less than 30 years of age 0 0

Between 30 and 45 −0.055 (0.035) 0.122 −0.172 (0.074) 0.021

Between 46 and 55 −0.137 (0.068) 0.042 0.022 (0.143) 0.880

Aged above 55 −0.203 (0.094) 0.031 0.16 (0.195) 0.412

Experience at the hospital

1 to 2 years 0 0

3 to 5 years 0.038 (0.036) 0.287 0.136 (0.075) 0.071

6 to 10 years 0.010 (0.045) 0.825 0.202 (0.094) 0.031

11 to 15 years 0.061 (0.056) 0.278 0.173 (0.117) 0.140

16 to 20 years 0.046 (0.089) 0.607 0.03 (0.185) 0.871

More or equal to 21 years 0.086 (0.091) 0.345 0.048 (0.19) 0.801

Highest Degree

Under High School Level 0 0

High school level 0.483 (0.237) 0.042 −0.288 (0.493) 0.559

Diploma level 0.528 (0.237) 0.026 −0.326 (0.492) 0.508

Bachelors Degree 0.583 (0.247) 0.019 0.076 (0.513) 0.882

Masters Degree 0.569 (0.258) 0.027 −0.231 (0.533) 0.665

Doctorate Degree 0.271 (0.283) 0.339 −0.105 (0.597) 0.861

Position at the hospital

Administrator/Manager/Director 0.229 (0.123) 0.064 −0.656 (0.269) 0.015

Physician −0.167 (0.099) 0.093 −0.597 (0.203) 0.003

Specialist −0.292 (0.128) 0.023 −0.858 (0.265) 0.001

Coordinator 0.152 (0.216) 0.482 0.356 (0.449) 0.429

Assistant/Aide 0.001 (0.101) 0.995 0.037 (0.21) 0.860

Pharmacist 0.083 (0.152) 0.585 −0.37 (0.332) 0.266

Registered Nurse −0.161 (0.109) 0.143 −0.499 (0.218) 0.023

Resident/PG/Intern 0.084 (0.181) 0.641 −0.279 (0.404) 0.490

Alswat et al. BMC Health Services Research (2017) 17:516 Page 11 of 14

Results of this survey showcased areas of strength and those requiring improvement and also showed whether any changes can be observed compared to the previous assessment. Areas of strength in this assessment were Teamwork within units, Organizational Learning – Con- tinuous Improvement, Management support for patient safety and Feedback and Communication about error; the last composite being a new addition compared to the previous assessment [13]. The findings on these composites in particular reflect commitment from hos- pital management to focus on feedback as a means of improving reporting. Moreover, the effect of size con- tinues to impact survey outcomes with smaller hospitals showing better overall scores reflecting that the impact of fewer hierarchical and bureaucratic requirements serve to the benefit of the smaller setting [13]. It is worth noting that Non-punitive Response to Error

remains the composite with the lowest score in 2015. This reflects a culture which places more emphasis on punishment in addressing errors; this reflects ineffective policies that cannot prevent errors, improve reporting and ultimately impact patient safety [22]. Studies show that fear of punishment would reduce frequency of error reporting among nurses [2] and this is confirmed in the regression results from this study. Evidence links hospital cultures that foster sharing and

reporting of errors to better patient safety and quality of care [23]. This should go hand in hand with addressing issues such as poor communication, lack of visible lead- ership, poor teamwork, lack of reporting systems, inad- equate analysis of adverse events and inadequate staff knowledge about safety [4]. The study also benchmarked hospital performance to

similar assessments in the US and Lebanon. While there are no major deviations from benchmarks, some areas of slight deviation indicate that additional attention is re- quired to consistently improve future performance. Comparing to other countries in the region showed that the Medical City fares much better on integral compos- ites. For instance, Management Support for Patient Safety had a percent positive score of 75.3% while it

scored 37% in Palestine [16] and 25.2% in Oman [4]. Moreover, Feedback and Communication about Error received 71.8% percent positive response in Riyadh but scored 46% in Palestine [16]. Some other composites were found to be common areas requiring improvement across the three countries such as Staffing, Communica- tion Openness and Non-Punitive Response to Error. Of note is the significant association between most

safety culture composites and lower number of events report. In fact, only Hospital Management Support for Patient Safety and Hospital Handoffs and Transitions were found to be associated with higher number of events. The significant association between Feedback and Communication about Error and Frequency of events reported is also of note in this context. This indi- cates that the underlying system that governs these pro- cesses may actually improve reporting compared to other patient safety culture composites. Incident and event reporting are critical to maintain patient safety. Hospital staff are often too busy to report, unsure about the mechanisms of reporting or simply insufficiently en- gaged in the importance of reporting [24]. Another interesting observation is the impact of

higher scores hospital management on improved patient safety grade and higher number of events reported. This highlights the importance of managerial commitment particularly as evidence shows a link between adminis- trative support and performance in process of care, lower mortality rates (Jiang et al. 2009), and better over- all hospital performance [25–27]. Furthermore, results indicated that pharmacists were

almost three times as likely to report events. This is in line with findings in the literature that indicate that pharmacists’ role in in error reporting [28]. Still, this in- dicates the need to work on improving the reporting process through addressing communication and feed- back channels to ensure that pharmacists continue to re- port [28] and that other staff members are equally inclined to report errors. To our knowledge, this is the first study to conduct a

re-assessment of patient safety culture in Riyadh. Results

Table 6 Linear regression model (Continued)

Assistant/Clerk/Secretary/Facilitator 0.006 (0.121) 0.961 −0.478 (0.24) 0.046

Technician −0.052 (0.100) 0.607 −0.096 (0.213) 0.652

Other 0 0

Interaction with patients

No 0 0

Yes 0.068 (0.062) 0.273 0.108 (0.13) 0.406

Hospital Size

Small 0 0

Large −0.098 (0.034) 0.004 −0.087 (0.071) 0.223

Alswat et al. BMC Health Services Research (2017) 17:516 Page 12 of 14

can provide valuable insight to hospital leaders on how their quality improvement plans over a span of 3 years have affected patient safety culture. Despite using a pre- validated survey which was also provided in Arabic, the values of Cronbach’s Alpha are still considered low and did not improve much compared to the previous assess- ment [13]. However, it should be noted that they are comparable to a similar assessment in the region where the values were attributed to the use of two languages and the wide range of respondents [14]. Evidence also shows that lower Cronbach’s Alpha values are typically expected with psychological constructs where diverse items are being measured [29].

Conclusion Study findings indicate that while tangible improvements were observed, there are still areas that the hospital can enhance in effort to improve overall patient safety cul- ture. Study findings will guide and inform overall strat- egies to further improve patient safety practices. There is a need to invest further in determinants of patient safety culture, particularly areas that impact event reporting. Results confirm that regular assessment can allow hospitals to better understand how overall per- formance improved and if any other areas need further enhancement.

Abbreviations CI: Confidence interval; HSOPSC: Hospital Survey on Patient Safety Culture; OR: Odds ratio; PS: Patient safety; PSC: Patient safety culture; SD: Standard deviation; US: United States

Acknowledgements Authors would like to thank all study respondents for their participation for their support.

Funding No funding was provided for conducting this study.

Availability of data and materials Kindly contact the corresponding author for a copy of the dataset. Requests will be reviewed by the study team before they are sent.

Authors’ contributions KA contributed to the study design, manuscript development and review, RA, MT, MB, FM and BZ contributed to data collection and review. DJ contributed to data analysis and review, and FE contributed to study design, data analysis, manuscript development and review. All authors read and approved the final version of the manuscript.

Ethics approval and consent to participate No local ethical review was required as advised by hospital administration of King Saud University Medical City. The study adhered to all ethical considerations pertaining to confidentiality of the responses provided by employees, informed consent form was provided and anonymity of responses was ensured. The survey was available in an online format and adhered to all ethical standards.

Competing interests The authors declare that they have no competing interests.

Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Author details 1King Khalid University Hospital, King Saud University Medical City, Riyadh, Saudi Arabia. 2Department of Health Management and Policy, American University of Beirut, Beirut, Lebanon. 3Department of Health Research Methods, Evidence, and Impact, McMaster University, CRL-209, 1280 Main St. West, Hamilton, ON L8S 4K1, Canada.

Received: 3 November 2016 Accepted: 19 July 2017

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