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Safety Issues: Similarities, Differences Exist Among Small and Large Hospital

Heather Comak, April 20, 2009

Although the general principles of what goes into creating a culture of safety are the same at small and large hospitals, both types of facilities face different hurdles when addressing the topic.

"I think that there is not a substantive distinction," says Jennifer Lundblad, PhD, MBA, CEO of Stratis Health in Bloomington, MN, about the culture of safety in the two settings. "You can focus all you want on clinical change, but if you are not also simultaneously focusing on issues of the culture in a hospital, those changes are probably not sustainable, because culture drives so much of what occurs in terms of adverse events."

The Agency for Healthcare Research and Quality (AHRQ) recently published its annual Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report. The report compiles data from hospitals utilizing its Hospital Survey on Patient Safety Culture, originally released in 2004. Stratis Health, a nonprofit organization that works with hospitals on national and local levels to improve quality, helped implement this survey tool in Minnesota's hospitals as that state's Medicare Quality Improvement Organization. Karla Weng, MPH, CPHQ, program manager at Stratis Health, says that generally, small rural hospital score higher on the AHRQ survey.

"In particular, the biggest gap was on handoffs and transitions, they were 22% higher than their urban counterparts," says Weng.

Communication and Openness
Handoffs, in particular, highlight one of the areas in which small and large facilities have unique sets of problems. Coordination and communication between different departments are often the lowest scored domains when measuring the culture of safety.

"I think those are especially problematic in large organizations, just because of the complexity in dealing with different departments," says Marilyn Szekendi, RN, PhD, Patient Safety Leader at Northwestern Memorial Hospital (NMH) in Chicago. Szekendi cites a greater number of departments and less familiarity among staff members as one of the barriers that her large urban facility faces on a daily basis.

"At some large hospitals, transferring someone from one unit to another can take going to another building." Not only do transitions occur less smoothly than they do in rural facilities, staff members at large urban hospitals are often more stressed as a result of having to connect with staff members with whom they are not familiar and worry about keeping patients safe, says Szekendi.

From a small rural hospitals' perspective, communication and coordination present a whole different set of challenges. The close, personal atmosphere that many small hospitals foster plays well for handoff communication.

"Where rural health can really be a leader is because [the setting] is close and personal, those handoffs and transitions are managed so much better in that smaller environment," says Lundblad. "I think that's some of the reason we see those generally higher scores when looking at an urban and rural comparison around safety culture." She gives the example of a part time nurse in the emergency room who may also work in the medical unit, "They transition to themselves in some cases. There's not that lost information about the patient, that missed opportunity about medication reconciliation."

It's this same closeness that can also inhibit open communication among hospital employees. "There's a particular unique rural challenge in communication because you know these people personally as well as professionally," says Lundblad.

The role of leadership
Leadership plays an important and vital role in effecting culture change in small and large hospitals. In both settings, any culture change initiatives must come from the top-down to be successful.

The difference may be that in large settings, hospital leaders are more in tune with what quality and patient safety issues exist. At NMH, many of their culture of safety initiatives have come from the leadership team, says Szekendi. In a rural setting, this might not be true, especially with boards of directors, says Lundblad. At the board or trustee level, in small communities these people are often local business leaders.

"I think they have fewer opportunities than their urban counterparts to be exposed to or have the kinds of orientation and training that is specific to quality and patient safety," says Lundblad."

Additionally, if rural hospital leaders embrace a culture of safety, the effects can be seen quickly. Because of the closer environment, one leader can have much more influence than one leader in a large hospital, simply because he or she has more visibility and more influence over the entire facility.

"If leadership at a small facility really gets it, and really embraces the culture of safety, they can make things happen so quickly with such amazing results because it has the ability to so quickly infuse itself across the whole facility," says Lundblad.

Hospital leaders at large urban facilities have to make more of an effort to connect with staff and show that they are supportive of culture change, says Szekendi. Having hospital leaders take part in patient safety Walkrounds, or showing a presence in patient care areas in some other way can help staff members at a large hospital understand that their leaders stand behind a culture of safety.


Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailing hcomak@hcpro.com.

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