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National Academy of Engineering (US) and Institute of Medicine (US) Committee on Engineering and the Health Care System; Reid PP, Compton WD, Grossman JH, et al., editors. Building a Better Delivery System: A New Engineering/Health Care Partnership. Washington (DC): National Academies Press (US); 2005.

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Building a Better Delivery System: A New Engineering/Health Care Partnership.

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The Context of Care and the Patient Care Team: The Safety Attitudes Questionnaire

J. Bryan Sexton and Eric J. Thomas

University of Texas Center of Excellence for Patient Safety Research and Practice


Peter Pronovost

The Johns Hopkins University School of Medicine

In the words of psychologist John Lauber, a former member of the National Transportation Safety Board, “Human performance doesn't take place in a vacuum, it takes place in an environment engendered and maintained by management, government, and frontline personnel” (Lauber, 1995). Taking the context into consideration is critical for understanding the complexities of human performance. As climate researchers in quality of care, our task is to identify (with methodological rigor) the systems and cultural influences that affect the safe delivery of care.

In the wake of recent reports from the Institute of Medicine and National Health Service, interest in patient safety research has grown substantially (IOM, 1999; Department of Health, 2000). Experience in other safety-critical industries suggests that measuring attitudes toward teamwork and the overall context of work is an important step in improving safety (Maurino et al., 1995; Reason, 1997). In health care, quality of care must also be investigated within the framework of the systems and contextual factors that provide the environments in which errors and adverse events occur (Cook and Woods, 1994; Leape, 1994; Reason, 1995; Vincent et al., 1998). For example, Charles Vincent and his colleagues identify several factors that influence clinical practice: organizational factors (e.g., safety climate and morale), work environment factors (e.g., staffing levels and managerial support), team factors (e.g., teamwork and supervision), and staff factors (e.g., overconfidence and being overly self-assured) (Vincent et al., 1998). These factors are believed to influence the safe delivery of care, but to date, the attitudes of caregivers about these key factors remain largely unexplored (Pronovost et al., 2001; Vella et al., 2000).

Influential organizations in health care agree that caregivers' attitudes about these issues should be examined. Research agencies (Agency for Healthcare Research and Quality, National Patient Safety Foundation, and National Patient Safety Agency), regulators (Joint Commission on Accreditation of Healthcare Organizations [JCAHO]), health maintenance organizations (e.g., Kaiser Permanente), professional organizations (e.g., American Hospital Association), and quality improvement experts (e.g., Institute for Healthcare Improvement) are encouraging the measurement of caregiver attitudes about the context of work. Despite this interest, there is no commonly used metric to measure these attitudes. The lack of a common metric led our research team at the University of Texas Center of Excellence for Patient Safety Research and Practice to develop and validate a tool that can be used across different types of clinical areas, different types of health care providers, and in different national cultures.


The Safety Attitudes Questionnaire (SAQ) is a refinement of the Intensive Care Unit Management Attitudes Questionnaire (Sexton et al., 2000; Thomas et al., 2003), which was derived from a questionnaire widely used in commercial aviation, the Flight Management Attitudes Questionnaire (FMAQ) (Helmreich et al., 1993; Merritt, 1996). The SAQ differs from other medical attitudinal surveys (Shortell et al., 1991) in that it maintains continuity with its predecessor (FMAQ), a traditional human factors survey with a 20-year history (Gregorich et al., 1990; Helmreich, 1984). Preserving this continuity allows for comparisons between professions and assists with the search for universal human factors issues. There is a 25 percent overlap in item content between the SAQ and the FMAQ. The new (non-overlapping) SAQ items were generated by focus groups of health care providers, literature review, and roundtable discussions with subject matter experts. More than 100 items were initially generated, but the number was reduced through pilot testing. The SAQ has been adapted for use in intensive care units (ICUs), operating rooms (ORs), general inpatient settings (medical wards, surgical wards), ambulatory clinics, pharmacies, and labor and delivery units. All versions of the SAQ have the same item content, with minor modifications to reflect the clinical area. For example, “In this ICU, it is difficult to discuss mistakes” would be changed to “In the ORs here, it is difficult to discuss mistakes.”

The SAQ elicits caregiver attitudes through six-factor analytically derived scales: teamwork climate; job satisfaction; perceptions of management; safety climate; working conditions; and stress recognition. These six scales are based on prior research in the aviation industry and in medicine (Helmreich and Merritt, 1998; Sexton, 2002; Sexton and Klinect, 2001; Sexton et al., 2000; Thomas et al., 2003). The SAQ is a single-page (double-sided) questionnaire with 60 items and demographics information (age, sex, experience, and nationality). The questionnaire takes approximately 10 to 15 minutes to complete. Each of the 60 items is answered using a five-point Likert scale (Disagree Strongly, Disagree Slightly, Neutral, Agree Slightly, Agree Strongly).

To date, we have administered the survey in more than 300 organizations in the United States, the United Kingdom, and New Zealand. Our rule of thumb is that all personnel in a clinical area who influence, or are influenced by, the working environment in that area are invited to participate (e.g., attending/staff physicians, resident physicians, registered nurses, charge nurses, pharmacists, respiratory therapists, technicians, ward clerks, and others). Participation is voluntary, and administration techniques included hand delivery, meetings, and in-house mailings.

The SAQ is a psychometrically valid instrument for assessing the safety-related attitudes and perceptions of frontline health care providers. The SAQ factor structure was replicated in ICUs, ORs, ambulatory clinics, and inpatient settings, as well as three national cultures.

The SAQ results reported here demonstrate the substantial variability in teamwork climate and safety climate across 50 organizations (Figures 1 and 2). Each bar represents the percentage of respondents who reported positive attitudes in each of 50 organizations.

FIGURE 1. Teamwork climate in 50 organizations.


Teamwork climate in 50 organizations.

FIGURE 2. Safety climate in 50 organizations.


Safety climate in 50 organizations.

In Figure 1, the right side of the distribution corresponds to organizations with a positive teamwork climate. These organizations are information rich, have good collaboration, effective conflict resolution, and decision making based on input from the team. The left side represents organizations with a negative teamwork climate. These organizations are information poor; the quality of collaboration is abysmal; nurses do not feel comfortable speaking up if they perceive a problem with patient care; conflicts often go unresolved; and decision making does not integrate input from the team. Organizations on the left have problems with turnover and absenteeism, whereas organizations on the right enjoy high levels of retention, good participation, and better working conditions.

In Figure 2, the right side of the distribution shows organizations with a positive safety climate. These organizations have a proactive, rather than reactive, patient-safety posture. Individuals are encouraged to report safety concerns; medical errors are handled appropriately; rules and guidelines are followed; and it is easy to learn from the mistakes of others.

It is noteworthy that the answers of senior leadership were substantially more positive than the answers of health care providers working at the front line. In fact, senior leadership was four times as positive about teamwork climate as front line personnel and two-and-a-half times as positive about safety climate.

We have established a large archive of SAQ administrations to use as bench marks for comparisons in future research. We hope the SAQ can be used to meet some of the demand for survey assessments of climate and culture in medicine.

The SAQ was designed for organizational diagnoses and interventions relevant to patient safety. Hospitals, federal regulators, quality improvement organizations, and JCAHO could use the SAQ as an economical and efficient means of collecting safety-relevant data proactively, rather than waiting for problems to manifest themselves through adverse and sentinel events. The SAQ can be used to assess strengths and weaknesses in a given organization and to provide a basis for suggesting interventions. Examples of interventions include: briefings, checklists, executive walk-rounds, human factors training, multidisciplinary rounds, and the Comprehensive Unit-Based Safety Program (CUSP).

For example, a poor teamwork climate in the OR may indicate a need for preoperative, multidisciplinary surgical briefings, with participation by anesthetists, surgeons, and nurses. More than 90 percent of OR personnel report that briefings are important for patient safety, but only 23 percent report that briefings are routinely held. On average, surgical briefings require less than two minutes; they cover the plan for contingencies for “this patient, this procedure, this equipment, and this team today,” including who is responsible for tasks and what the expectations are. Surgical briefings have been shown to improve nurse retention rates and to have a positive impact on teamwork climate as shown in the higher percentage of respondents reporting that nurse input is well received, that they know the names of the personnel they work with, and that they feel comfortable speaking up if they perceive a problem with patient care.

Poor teamwork climate in the ICU might suggest a need for multidisciplinary rounds (Uhlig et al., 2001), whereas a poor safety climate might suggest a need for executive walk-rounds (Frankel et al., 2003) or CUSP (Pronovost et al., unpublished). CUSP is an eight-step program developed by the Johns Hopkins Hospital Patient Safety Committee and implemented in hospital work units, beginning in ICUs. Improvement teams were identified at each unit; outcome variables included: changes in safety climate from pre-implementation to six months post implementation; and a decrease in medication errors, length of stay, and nursing turnover rates. CUSP was carried out in the Weinberg Intensive Care Unit; a second ICU (the Surgical Intensive Care Unit) was used as a control (see Figure 3). The evidence from Johns Hopkins Hospital demonstrates that safety climate can be improved and that these improvements are associated with decreases in medication errors, lower nurse turnover rates, and shorter ICU lengths of stay (Pronovost et al., unpublished).

FIGURE 3. CUSP results.


CUSP results.

To date, more than 150,000 copies of the SAQ are in circulation, many being used in longitudinal quality-of-care investigations. As our understanding of health care climates and contextual factors evolves, we are becoming better equipped to improve quality of care. Current research at the University of Texas Center of Excellence for Patient Safety Research and Practice is focused on the relationships between provider attitudes and patient, provider, and organizational outcomes. Some preliminary evidence shows that SAQ factors are related to annual rates of nurse turnover (Roberts, 2002; Sexton, 2002), medication errors, and ICU length of stay (Pronovost et al., unpublished). Additional links to outcomes have been found outside of medicine, where predecessors of the SAQ have been linked to pilot performance (Helmreich, 1984), pilot error management (Sexton and Klinect, 2001), and incident rates among night train conductors in Japan (Itoh et al., 2000). Taken together, these relationships suggest that the SAQ can shed light on important clinical, economical, and administrative issues in medicine and beyond.


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Copyright © 2005, National Academy of Sciences.
Bookshelf ID: NBK22830


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