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Measuring Safety Culture in the Ambulatory Setting: The Safety Attitudes Questionnaire—Ambulatory Version

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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.

Potential Financial Conflicts of Interest

The author has no financial conflicts of interests.

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Corresponding author

Correspondence to Eric J. Thomas MD, MPH.

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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