Background
Provider attitudes about issues pertinent to patient safety may be related to errors and adverse events. We know of no instruments that measure safety-related attitudes in the outpatient setting.
Objective
To adapt the safety attitudes questionnaire (SAQ) to the outpatient setting and compare attitudes among different types of providers in the outpatient setting.
Methods
We modified the SAQ to create a 62-item SAQ—ambulatory version (SAQ-A). Patient care staff in a multispecialty, academic practice rated their agreement with the items using a 5-point Likert scale. Cronbach’s alpha was calculated to determine reliability of scale scores. Differences in SAQ-A scores between providers were assessed using ANOVA.
Results
Of the 409 staff, 282 (69%) returned surveys. One hundred ninety (46%) surveys were included in the analyses. Cronbach’s alpha ranged from 0.68 to 0.86 for the scales: teamwork climate, safety climate, perceptions of management, job satisfaction, working conditions, and stress recognition. Physicians had the least favorable attitudes about perceptions of management while managers had the most favorable attitudes (mean scores: 50.4 ± 22.5 vs 72.5 ± 19.6, P < 0.05; percent with positive attitudes 18% vs 70%, respectively). Nurses had the most positive stress recognition scores (mean score 66.0 ± 24.0). All providers had similar attitudes toward teamwork climate, safety climate, job satisfaction, and working conditions.
Conclusion
The SAQ-A is a reliable tool for eliciting provider attitudes about the ambulatory work setting. Attitudes relevant to medical error may differ among provider types and reflect behavior and clinic operations that could be improved.
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Acknowledgments
Funding was provided by the Robert Wood Johnson Foundation, the Agency for Healthcare Research and Quality (1PO1HS1154401), and The Health Resources and Services Administration (8 D55 HP00045). Dr. Thomas was a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar. Dr. Isitri Modak was a General Internal Medicine fellow in the Joint Primary Care Fellowship, a faculty development training program. Funding for the program is provided in part by the United States Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions. This paper was presented at the 26th Annual National Meeting for the Society of General Internal Medicine, May 2003, in Vancouver, Canada.
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Appendix
Appendix
Items in the Ambulatory SAQ
Teamwork climate scale (6 items, alpha = 0.82) |
In this office, it is difficult to speak up if I perceive a problem with patient care* |
The physicians and nurses here work together as a well-coordinated team |
Disagreements in this office are appropriately resolved (i.e., not who is right but what is best for patient) |
Nurse input is well received in this office |
I have the support I need from other personnel to care for patients |
It is easy for personnel in this office to ask questions when there is something that they do not understand |
Safety climate scale (7 items, alpha = 0.76) |
I am encouraged by my colleagues to report any patient safety concerns I may have |
The culture in this office makes it easy to learn from errors of others |
Medical errors are handled appropriately in this office |
I know the proper channels to direct questions regarding patient safety in this office |
I receive appropriate feedback about my performance |
I would feel safe being treated here as a patient |
In this office, it is difficult to discuss errors* |
Perception of management scale (4 items, alpha = 0.72) |
Senior management of this office is doing a good job |
The management of this office supports my daily efforts |
I am provided with adequate, timely information about events in the hospital that might affect my work |
The levels of staffing in this office are sufficient to handle the number of patients |
Job satisfaction scale (5 items, alpha = 0.86) |
This office is a good place to work |
I am proud to work in this office |
Working in this office is like being part of a large family |
Morale in this office is high |
I like my job |
Working conditions scale (4 items, alpha = 0.68) |
This office does a good job of training new personnel |
This office constructively deals with problem physicians and employees |
All the necessary information for diagnostic and therapeutic decisions is routinely available to me |
Trainees in my discipline are adequately supervised |
Stress recognition scale (4 items, alpha = 0.72) |
When my workload becomes excessive, my performance is impaired |
I am more likely to make errors in tense or hostile situations |
Fatigue impairs my performance during emergency situations (e.g., code or cardiac arrest) |
I am less effective at work when I am fatigued |
Items not included in the scales (32 items) |
Ambulatory Process of Care Items (5 items) |
I am satisfied with the current referral process in this office |
There is adequate and timely transfer of patient information between primary care physician and specialist |
Medications are refilled in a timely manner |
Medications are filled correctly |
Abnormal test results are frequently lost or overlooked* |
Others (27 items) |
High levels of workload are common in this office* |
Briefing other personnel before a procedure (e.g., biopsy) is important for patient safety |
Briefings are common in this office |
When I am interrupted, my patients’ safety is not affected* |
The management of this office knowingly compromises the safety of patients* |
Decision-making in this office should include more input from other personnel than it does now |
This office encourages teamwork and cooperation amongst its personnel |
The medical equipment in this office is adequate |
I have seen others make errors that had the potential to harm patients |
Stress from personal problems adversely affects my performance |
Disruptions in the continuity of care (e.g., shift changes, patient transfers, etc.) can be detrimental to patient safety |
During emergencies, I can predict what other office personnel are going to do next |
I am frequently unable to express disagreement with attending physicians/primary care providers in this office* |
Very high levels of workload stimulate and improve my performance* |
Truly professional personnel can leave personal problems behind when working* |
I know the first and last names of all the personnel I worked with during my last shift |
I have made errors that had the potential to harm patients |
Attending physicians/primary care providers in this office are doing a good job |
All the personnel in this office take responsibility for patient safety |
If necessary, I know how to report errors that happen in this office |
Patient safety is constantly reinforced as the priority in this office |
Interactions in this office are collegial, rather than hierarchical |
Important issues are well communicated at shift changes |
There is widespread adherence to clinical guidelines and evidence-based criteria regarding patient safety here |
Personnel are not punished for errors reported through incident reports |
During emergency situations (e.g., emergency resuscitations), my performance is not affected by working with inexperienced or less capable personnel* |
Personnel frequently disregard rules or guidelines (e.g., handwashing, treatment protocols/clinical pathways, sterile field, etc.) that are established for this office* |
*Reverse-scored items
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Modak, I., Sexton, J.B., Lux, T.R. et al. Measuring Safety Culture in the Ambulatory Setting: The Safety Attitudes Questionnaire—Ambulatory Version. J GEN INTERN MED 22, 1–5 (2007). https://doi.org/10.1007/s11606-007-0114-7
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DOI: https://doi.org/10.1007/s11606-007-0114-7