Table 2.

Studies on the relationship between safety culture and healthcare-associated infections

Authors, year	Design and number of sites or units; study period	Intervention(s)	Safety culture measurement and domains	Healthcare-associated infection(s) measured	Study-reported findings and relation to safety culture	Comments
Abusalem 2019	Cross-sectional research; 5 Medicaid-certified long-term care facilities; 2014	None	Nursing Home Survey on Patient/Resident Safety Culture (NHSPSC): teamwork, staffing, compliance with procedures, training and skills, nonpunitive response to mistakes, handoffs, feedback and communication about incidents, supervisor expectations and actions promoting resident safety, overall perceptions of resident safety, management support for resident safety, organizational learning	UTIs	The risk of UTI rates increased with greater number of residents (risk ratio 1.01, 95% confidence interval 1.01–1.01), with greater licensed practical nurse/licensed vocational nurse hours per resident day (risk ratio 61.5, 95% confidence interval 36.3–102.4), and decreased 79% with higher total number of licensed nursing staff hours per resident day (risk ratio 0.21, 95% confidence interval 0.15–0.31) Culture of safety was significantly associated with reduced rates for UTIs (risk ratio 0.80, 95% confidence interval 0.75–0.86) Handoffs between nursing shifts was inversely related to UTIs (r = − 0.143, p < 0.05) “There is a need to build strong culture of safety and foster patient-centered culture of safety attributes among nursing staff providing care in long-term care facilities”	Single time measurement of safety culture
Braddock 2015 (ePub 2014)	QI initiative; 4 medical and surgical units in an academic medical center; 2009–2011	Four improvement strategies: (1) early detection and treatment of hospital complications with in situ simulation training; (2) identification of safety risks by debriefing of medical urgencies and emergencies; (3) quality improvement of interdisciplinary care issues; (4) individual recognition of exemplary teamwork performance	Hospital Survey on Patient Safety Culture (HSOPSC): teamwork within units, manager expectations, organizational learning, management support, error feedback and communication, communication openness, non-punitive response, staffing, teamwork across units, handoffs and transitions, overall perceptions of safety outcomes, frequency of events	Hospital-acquired severe sepsis/septic shock	Rates of hospital-acquired severe sepsis/septic shock decreased from 1.78 to 0.64 per 1000 unit discharges Scores of safety culture significantly improved after the 1-year intervention for nurses (64.9% to 84.7%; p < 0.001), but not for residents (61.2 to 65.8%; p = 0.06) Scores significantly improved in 9 out of 12 survey dimensions for nurses, compared to 4 dimensions for residents “Interventions led to the discovery of safety issues on clinical microsystems that involved complex, interdisciplinary care practices that directly influenced patient safety”	Safety culture measured at baseline and after 1 year Single-site study Did not statistically analyze the association between safety culture and outcomes Resident rotation to different medical centers and their intermittent presence on study units may have prohibited their exposure to program interventions and affected their perceptions of safety culture
Chang 2020 (ePub 2019)	QI initiative; cardiac surgery units in 11 hospitals (11 cardiovascular operating rooms, 8 ICUs, 9 floor units, 3 universal-bed units); 2011–2014	Comprehensive Unit-based Safety Program* to improve safety culture and evidence-based bundles to prevent HAIs	Hospital Survey on Patient Safety (HSOPSC): teamwork within units, manager expectations and actions promoting safety, organizational learning, hospital management support, feedback and communication about error, communication openness, non-punitive response to error, staffing, teamwork across units, hospital handoffs and transitions, overall perceptions of safety, frequency of event reporting	CLABSI, SSI, and VAP	CLABSI and SSI rates showed a downward trend over 2 years, then the rates returned to levels similar to baseline in the third year (after June 2013) VAP rates mostly remained at a median of zero throughout the project Significant improvement of the patient safety culture domain “hospital management support” on measurements at time points 2 and 3 compared to baseline. Significant decline in patient safety domains “feedback and communication errors, and staffing at time points 2/3 and time 3 compared to baseline, respectively “These findings highlight the importance of sustainment efforts and suggest future work should anticipate both positive and negative changes in safety culture dimensions”	Safety culture was measured at 3 time points: baseline (July 2011–October 2011), time 2 (October 2012–March 2013), time 3 (April 2014–October 2014) VAP rate variations difficult to interpret because of changes in the VAP definition during the study period Did not statistically analyze the association between SC and outcomes
Fan 2016	Cross-sectional research; surgical units in 7 community hospitals; 2012–2013	No intervention	Hospital Survey on Patient Safety Culture (HSOPSC): overall perceptions of safety, supervisor expectation/actions, teamwork within units, communication openness, feedback, non-punitive response to error, staffing, management support, teamwork across units, handoffs and transitions, organizational learning, frequency of events reported	Colon SSI	Safety culture scores ranged from 16 to 92 (on a scale from 0 to 100). Nine out of 12 dimensions were significantly associated with lower colon SSI rates Only three out of 12 dimensions (communication openness, staffing, and non-punitive response to error) were not associated with colon SSIs “These data suggest an important role for positive safety and teamwork culture and engaged hospital management in producing high-quality surgical outcomes”	Single time measurement of safety culture
Harnage 2012	QI initiative; 1 community hospital; 2005–2011	Implementation of CLABSI bundle with 7 components along with education about the bundle	None	CLABSI	CLABSI reduced to zero after implementation of a CLABSI bundle No findings related to culture beyond conclusions which state “The bundle might be insufficient if it was not executed by a skilled vascular access team and if that team was not supported by administrations who emphasized patient safety over all considerations”	Safety culture not measured No baseline data of CLABSI rates provided
Hsu 2016	QI initiative; 103 ICUs in Michigan Keystone project; 2004–2006	Adoption of CUSP	Safety attitudes questionnaire, (scales of teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management, and working conditions)	CLABSI	The use of CUSP was associated with improved safety climate, job satisfaction, and working conditions after a 2-year period. The use of CUSP was not associated with reduced CLABSI rates but insufficient data was considered to be inconclusive.	Safety culture was measured at two time points
Kelly 2013	Retrospective cross-sectional research; 320 hospitals; 2005–2008	None	The Practice Environment Scale of the Nursing Work Index was used to measure critical care work environments: staffing and resource adequacy, nurse participation in hospital affairs, nursing foundations for quality of care, collegial nurse-physician relations, nurse manager ability, leadership and support of nurses	Nurse-reported frequency of CLABSIs, UTIs, VAPs	Nurses working in better work environments were 36 to 41% less likely to report that healthcare-associated infections occurred frequently “Health care–associated infections are less likely in favorable critical care work environments. These findings, based on the largest sample of critical care nurses to date, substantiate efforts to focus on the quality of the work environment as a way to minimize the frequency of health care–associated infections”	Single time measurement of safety culture Study based on critical care nurse work environment Respondents were nurses.
Meddings 2017	Quasi-experimental research, two prospective cohort studies; 1079 hospitals for CLABSI and 949 hospitals for CAUTI; 2008–2011 for CLABSI and 2011–2013 for CAUTI	Interventions used principles from Comprehensive Unit-based Safety Program*	Hospital Survey on Patient Safety Culture (HSOPSC): expectations, teamwork within, communication, feedback, non-punitive, staffing, management support, teamwork across, handoffs, overall perceptions, continuous improvement, organizational learning, frequency of event reporting, patient safety grade	CLABSI, CAUTI	Infection rates declined over the project periods (by 47% for CLABSI and 23% for CAUTI) No significant association between individual dimensions of safety culture with CLABSI or CAUTI outcomes measured at baseline or post-intervention. “It might be possible to improve CLABSI and CAUTI rates without making significant changes in safety culture, particularly as measured by instruments like Hospital Survey on Patient Safety Culture”	Safety culture measured at baseline and again 1 year later (post-intervention) Study assessing two large national collaboratives focused on prevention of CLABSI and CAUTI Involved a large number and wide variety of hospitals and unit types (ICU and non-ICU) Did not find significant association
Miller K 2016	QI initiative; 1 ICU each at 2 hospitals; 2010–2012	Adoption of CUSP	Not measured	CLABSI, CAUTI, and VAP	Implementation of CUSP was associated with significant decreases in CLABSI, CAUTI, and VAP. CUSP principles created a process improvement culture... and allowed for a grassroots, frontline team-based approach…which not only improved accountability but also increased teamwork within the units.	Safety culture not measured
Phipps 2018	QI initiative; 2014–2016; one 145-bed pediatric hospital	The No Harm Patient Safety Program included the following interventions: safety moments; leadership rounding; revising the cause analysis methodology; safety event reporting system enhancements; error prevention training; leadership methods training; identification of priority HACs; the Eye on Safety Campaign; and a safety coach program.	Not measured	CLABSI, CAUTI, SSI, ventilator-associated pneumonia (VAP), venous thrombo-embolism (VTE)	CLABSI rate significantly declined from 2.8 per 1000 line-days in 2015 to 1.6 in 2016, for a difference of − 0.00118 (95% CI − 0.002270, − 0.00008; p = 0.036). SSI rates declined from a 2015 rate of 3.8 infections per 100 procedures to a 2016 rate of 2.6 (p = 0.2962) CAUTI rates declined from a 2015 rate of 2.7 per 1000 catheter-days to a 2016 rate of 1.4 (p = 0.2770). “Outcomes of the patient safety program demonstrated sustained mindfulness of safety as an organizational imperative.”	Rates initially increased but were then followed by declines when interventions were fully in place
Profit 2017	Cross-sectional research; 44 NICUs (10 regional, 28 community, and 6 intermediate); 2010–2012	No intervention	Safety Attitudes Questionnaire (SAQ): teamwork items: “Nurse input is well received in this NICU”; “in this NICU, it is difficult to speak up if I perceive a problem with patient care”; “disagreements in this NICU are appropriately resolved”; “I have the support I need from others in this NICU to care for patients”; “It is easy for personnel here to ask questions when there is something they do not understand”; and “The physicians and nurses here work together as a well-coordinated team”	Hospital-associated infections in very low birth weight infants (without further detail)	Teamwork climate was independently associated with hospital-associated infection rates (odds ratio 0.82, 95% confidence interval 0.73–0.92) “Improving teamwork may be an important element in infection control efforts”	Single time measurement of safety culture Study focused on teamwork dimensions
Profit 2020 (ePub 2018)	Cross-sectional research; 44 NICUs in California; 2010 to 2012	California Perinatal Quality Care Collaborative (details of which are not described in this paper)	Safety Attitude Questionnaire six domains: teamwork climate, safety climate, job satisfaction, perceptions of management, stress recognition, and working conditions	9 perinatal-related metrics of quality in the composite outcome measure, one of which was healthcare-associated infection	Of the 9 metrics, only HAI exhibited a statistically significant relationship with teamwork and safety climate. “Overall, our findings reflect a weaker than expected correlation of metrics of quality with teamwork and safety climate. Caution is needed in equating efforts to improve safety culture with expectations for broad-based quality improvement”	Safety culture measured at single point in time
Richter 2018	Quasi-experimental research; 435 hospitals; 75% of units were ICUs; 2009–2012	Comprehensive Unit-based Safety Program. A conceptual model was used: Standard Comprehensive Unit-based Safety Program model to fit High Reliability Organizations theory	Hospital Survey on Patient Safety Culture (HSOPSC): supervisor support for safety, teamwork within units, communication openness, error feedback, non-punitive response to errors, staffing levels, management support, teamwork across units, successful handoffs, organizational learning, error reporting	CLABSI	Units with stronger safety culture prior to Comprehensive Unit-based Safety Program implementation were significantly associated with zero or reduced CLABSI rates after implementation. Dimensions significantly associated with zero or reduced CLABSI rates were baseline organizational learning, communication openness, staffing, and teamwork across units	Safety culture measured pre-intervention
Sakowski 2012	QI initiative; 6 community hospitals; 5 years (likely beginning in the end 2006 or 2007)	Nurses led quality improvement councils and clinical transformation directors. Clinical champions. Each hospital chose 6 areas for improvement, but varied across sites. Education and training for all council members	Hospital Survey on Patient Safety Culture (HSOPSC) Domains: not listed	CLABSI, CAUTI, VAP	Hospital-associated infection rates decreased during and after the intervention Favorable safety culture showed “modest increase” (57% pre-intervention and 61% post-intervention) Council participation improved job satisfaction. External support facilitated time dedicated to improvement “Staff-led councils have the potential to improve patient safety and quality of care”	Safety culture measured pre- and post-intervention: at baseline, at year 2 and year 4 Statistical association between safety culture and hospital-associated infections was not analyzed Low survey response rate pre-intervention (27%), and this might limit the conclusions regarding the change in safety culture during the study period
Smith S A 2017	Cross-sectional research; 164 hospitals; study period could not be determined	None	AHRQ Hospital Survey on Patient Safety Culture (HSOPSC): 12 composites of patient safety culture 1. Communication openness 2. Frequency of events reports 3. Feedback and communication about error 4. Handoffs and transitions 5. Management support for patient safety 6. Nonpunitive response to error 7. Organizational learning 8. Overall perceptions of patient safety 9. Staffing 10. Supervisor/manager expectations and actions promoting patient safety 11. Teamwork across units 12. Teamwork within units	Hospital-acquired infections (not specified)	Higher patient safety culture scores for four composites were associated with lower hospital-acquired infections, ranging from β = 0.19 to β = 0.24.	Single time measure of safety culture
Smith S N 2018	Quasi-experimental research; prospective cohort study; 196 nursing homes; June 2014 and June 2016. Cohort entry was on rolling basis. Cohorts 1–3 had a 12-month intervention phase. Cohort 4 had a compressed timetable of 10 months.	Agency for Healthcare Research and Quality (AHRQ) Safety Program for Long-term Care: Preventing CAUTI and Other HAIs	Nursing Home Survey on Patient Safety Culture (NHSPSC) Socio adaptive components—leadership engagement; empowering staff to implement change; and promoting effective team communication for supporting and implementing infection prevention activities	Catheter-associated urinary tract infection rates (CAUTI)	Nursing homes saw a 52% reduction in CAUTI rates over the intervention period. Multivariate models did not show a significant association between CAUTI rates and initial or over-time NHSOPS domains.	Safety culture measured twice over time Did not find significant association
Sreeramoju 2018	Quasi-experimental research; observational study; 6 medical wards at one 800-bed public academic hospital; retrospective 6-month baseline period, positive deviance (PD) intervention implemented over 9 months, with 9 months of follow-up	3 units randomly assigned to intervention of positive deviance (PD) intervention on healthcare personnel (HCP). The PD approach explores the social aspects of infection prevention practices among HCP. In addition to identifying barriers and potential solutions, the approach focuses on identifying and deploying peer role models to generate positive peer pressure and mobilize change.	Hospital survey of patient safety climate/culture (HSOPSC) adapted to infection prevention: Teamwork within teams, teamwork across teams, respect, safety climate, leadership, communication, frequency of events reported	Monthly HAI rate—a composite of central line–associated bloodstream infection (CLABSI), Clostridium difficile infection (CDI), catheter-associated urinary tract infection (CAUTI), and hospital-acquired pneumonia (HAP) per 1000 patient-days	Fitted time series of monthly HAI rates showed a decrease from 4.8 to 2.8 per 1000 patient-days (95% confidence interval [CI] 2.1 to 3.5) in wards without PD, and 5.0 to 2.1 per 1000 patient-days (95% CI − 0.4 to 4.5) in wards with PD. The measured patient safety culture was steady over time at 69% aggregate percent positive responses in wards with PD vs decline from 79 to 75% in wards without PD (F statistic 10.55; p = 0.005). “A positive deviance approach appeared to have a significant impact on patient safety culture among HCP who received the intervention.”	Patient safety culture surveyed at 6, 15, and 24 months
Vigorito 2011	Quasi-experimental research; 23 units from 11 hospitals; fall 2007 and 2008	Rhode Island ICU Collaborative—a unit-based patient safety program and evidenced-based practices (see also DePalo 2010). This study tested the impact of a unit-level Safety Attitudes Questionnaire Action Plan (SAQAP). The action plan focused on interventions intended to improve safety culture (rather than clinical outcomes)	Safety Attitudes Questionnaire—safety climate, teamwork climate, job satisfaction, stress recognition, working condition, perception of management	ICU central line-associated bloodstream infections (CLABSIs) per 1000 line days and ventilator-associated pneumonia (VAP) infections per 1000 ventilator days	The 9 units that completed an SAQAP demonstrated a higher rate of improvement from 2007 to 2008 in five of six domains of safety culture, with teamwork climate and job satisfaction (p < .07). Nine units with an SAQAP decreased CLABSI rates by 10.2% in 2008 compared with 2007, while those without an SAQAP had only a 2.2% decrease in rates (p = 0.59). Similarly, VAP rates decreased by 15.2% in SAQAP units, while VAP rates increased by 4.8% in those without an SAQAP. “Teams that developed an SAQAP not only had close to significant improvements in unit culture but also improved in CLABSI and VAP clinical outcomes, which suggests that an active targeted intervention in culture may carry over onto improved outcomes for patients.”	Safety culture measured annually. Unique in that tailored unit-level intervention designed to improve safety culture (rather than clinical outcomes) Did not find significant association
Weaver and Weeks 2014	Quasi-experimental research; retrospective analysis of a study; 237 ICUs; 2005–2011	Comprehensive Unit-based Safety Program, including education, checklist and audit tools, audit and feedback*	Hospital Survey on Patient Safety Culture (HSOPSC): supervisor expectations, teamwork within ICUs, communication openness, feedback about error, non-punitive, staffing and workload, management support, teamwork across ICUs, handoffs and care transitions, organizational learning This study applied a “pattern-based” approach to analyze safety culture: profile elevation, variability and shape	CLABSI	Relationship between safety culture and hospital-associated infections depends on the climate profile characteristics assessed: climate profile shape was a significant predictor of infection risk, but profile elevation and profile variability were not (p = 0.74 and p = 0.48, respectively) The incidence rate of infection was 77% higher in units with a non-punitive climate shape (incidence risk ratio 1.77, p < 0.001) and 57% higher in units with a conflicting climate shape (incidence risk ratio 1.57, p < 0.001) “Pattern-based methods should be used for examining safety culture rather than examining narrow dimensions of safety culture and outcomes such as CLABSI”	Safety culture measured pre-intervention
Wick 2015	QI initiative; 2013–2014; one tertiary care, academic medical center	Expanded on existing comprehensive unit-based safety program infrastructure (CUSP) with goal of improving teamwork and safety culture, plus trust-based accountability model for leadership and Integrated Recovery Pathway	Not measured	Surgical site infection (SSI); urinary tract infection (UTI)	Significant decrease in hospital length of stay (LOS) of 2 days; greater than 50% reduction in SSI; significant improvement in patient experience, and improved value, as well as a trend toward reduction in VTE and UTI. Their trust-based accountability model together with CUSP components resulted in a rapid improvement in patient outcomes, patient experience, and cost. Article title is “Organizational Culture Changes Result in Improvement in Patient-Centered Outcomes: Implementation of an Integrated Recovery Pathway for Surgical Patients”	Safety culture not measured