Table 3.

Studies that address the relationship between safety culture, infection prevention and control processes (IPC), and healthcare-associated infections (HAIs)

First author, year	Design, number of sites or units, and study period	Intervention(s)	Safety culture measurement and domains	Infection prevention and control process(s) measured	Healthcare-associated infection(s) measured	Study-reported findings and relation to safety culture	Comments
Berenholtz 2011	QI initiative; 112 ICUs in 72 hospitals; 2003–2006	Comprehensive Unit-based Safety Program. A 5-step intervention to improve safety culture and communication: (1) education of staff on the science of improving patient safety; (2) asked teams to identify defects (anything clinically or operationally that should not recur); (3) engaging senior executives; and (4) asked staff to choose and learn from 1 defect per month; and (5) asked teams to implement tools to help improve teamwork and communication An intervention focused on reducing the incidence on VAP. Implementation of 5 evidence-based recommendations: (1) semirecumbent positioning; (2) gastrointestinal stress ulcer prophylaxis; (3) deep venous thrombosis prophylaxis; (4) adjustment of sedation; and (5) daily assessment of readiness to extubate	Safety Attitudes Questionnaire (domains or measurements not reported in this article)	VAP bundle compliance	VAP	The median VAP significantly decreased from 5.5 cases per 1000 ventilator days to 0 cases per 1000 ventilator days at both 16–18 months and 28–30 months after implementation Compliance with evidence-based therapies increased from 32 at baseline to 75% at 16–18 months after implementation, and 84% at 28–30 months after implementation “This project demonstrated significant reductions in VAP rates that were likely the result of translating evidence into practical behavior and building them in a multifaceted quality improvement intervention that also included safety culture and communication improvements”	Safety culture measured at baseline and annually thereafter, but results not reported in this article This study is part of the Michigan Keystone Project by Pronovost et al.
Brilli 2013	QI initiative; 1 urban children’s hospital; 2009–2012	Implementation of a “Zero Hero” patient safety program: (1) training in basic error prevention; (2) training leaders in leadership methods; (3) training frontline staff in coaching their peers on effective use of the error prevention techniques Deployment of microsystem-based teams focused on each HAI subset. Implementation of HAI prevention bundles	Safety Attitudes Questionnaire (domains not reported in this article)	Compliance with established HAI prevention bundles (results not reported in this article)	Number of HAI events, including CLABSI, VAP, SSI, and CAUTI	Decrease in annual HAIs (76 events in 2009 vs 50 events in 2012; not statistically significant) Decrease in CLABSI, CAUTI, SSI rates (not statistically significant) Significant decrease in VAP rates (from 0.04 per 1000 ventilator days in 2009 to 0.0 per 1000 ventilator days in 2012; p < 0.01) Significant improvement in overall safety climate scores after the intervention (72% in 2009 vs 76% in 2011; p < 0.05)	Safety culture was measured at baseline and 6 months after the conclusion of the “Zero Hero” training Single-site study Did not statistically analyze the association between SC and outcomes
Choi 2013	QI initiative; pediatric hematology-oncology unit in a single children’s hospital; 2005–2011	A multidisciplinary CLABSI working group was created. Team members developed techniques to improve the safety culture related to catheter care, identified best practices for the insertion and maintenance of catheters, and disseminated the information to clinical care providers Central line maintenance bundle was implemented A root cause analysis was conducted for every CLABSI event	Hospital Survey on Patient Safety (HSOPSC)	CLABSI bundle adherence	CLABSI	Significant decrease (45%) in CLABSI rates after the intervention (from 2.92 per 1000 patient days to 1.61 per 1000 days; p < 0.004) Self-reported complete adherence to recommended maintenance bundle practice increased from 51% in the early intervention period to 86% in the later period Responses to HSOPS reflected improvement in nearly all domains when comparing pre- and post-intervention data: overall unit safety (40 to 89%; p < 0.07); organizational learning and continuous improvement (64 to 85%, p < 0.31); teamwork within the unit (79 to 95%; p < 0.37); hospital management support for patient safety (51 to 93%, p > 0.25) “By adopting and effectively implementing uniform maintenance of catheter care practices, learning multidisciplinary teamwork, and promoting a culture of patient safety, the CLABSI incidence was significantly reduced and maintained”	Safety culture was measured bi-annually Single-site study Did not statistically analyze the association between SC and outcomes
Cumbler 2013	QI initiative; 13-bed acute care for the elderly medicine unit in academic medical center; 2010–2012	Improve adherence and culture through: (1) real-time peer feedback and request for correction when nonadherence was observed; (2) shared responsibility for hand hygiene auditing using random assignment of responsibility to all members of nursing staff; (3) follow-up communication by unit leadership for failure to correct or repeated nonadherence by individual of any role or rank; (4) delivery of nonadherence “tickets” and positive reinforcement of adherence with individually wrapped “lifesavers”; unit dashboard; unit champions	Not measured	Hand hygiene adherence with rotating auditors	CLABSI, CAUTI	Hand hygiene rates increased from 78 to 97.2%; no CLABSI or CAUTI for 2 years. “Peer pressure and conforming norms can be harnessed to drive improvement through social punishment and intermittent immediate rewards” “Hand hygiene should be interpreted in the context of the social milieu but is amenable to change using simple psychological principles”	Safety culture not measured. One unit in a single-site study
Day 2009	QI initiative; 1 academic medical center; fall 2017	Evidence-based guideline with 5 recommendations: (1) hand hygiene campaign to draw awareness of HCWs and patients to importance of hand hygiene; (2) education of HCWs regarding protocols and techniques; (3) HCW hand hygiene performance feedback; (4) product selection and availability to enhance performance; (5) leadership interventions to promote and support hand hygiene	Not measured	Compliance with hand hygiene guidelines	Infection rates including MRSA and VRE (measured, but results not reported in this article)	Hand hygiene compliance improved from 45 to 85% during the first 6 months of a multimodal intervention Safety culture mentioned in the results-discussion section: “Multimodal interventions over a period of time can support changing the culture” “Chief nursing officers and other leaders can change the organizational culture related to hand hygiene by utilizing an evidence-based practice guideline …”	Safety culture not measured Single-site study
DePalo 2010	QI initiative; 23 ICUs in 11 hospitals; 2006–2008	Adaptation of Michigan Keystone Project. Intervention was Comprehensive Unit-based Safety Program: educating staff on the science of safety, identifying hazards, identifying senior executive partners, learning from defects and implementing teamwork tools	Not measured	VAP bundle compliance (CLABSI bundle compliance either not measured or not reported in this article)	CLABSI, VAP	Mean CLABSI rates decreased 74% (from 3.73 infections per 1000 catheter-days to 0.97) VAP rates decreased 15% (from 3.44 to 2.92 VAPs per 1000 ventilator days); VAP rates decreased as ventilator bundle compliance rates increased Safety culture mentioned in the abstract and result sections: “Hospital executives and intensive care unit staff…worked together to implement evidence-based interventions and change safety culture in ICUs”	Safety culture not measured
Foulk 2012	QI initiative; 35-bed surgical step-down unit in 1 hospital; 2009–2011	Shared governance model for nursing including unit level quality and safety council, raising hand hygiene awareness, a game called “hot hands” in which the charge nurse for each shift would give out red, laminated hands to any staff members witnessed not performing proper hand hygiene. Also created music video with catchy “jingle about hand hygiene”	Not measured	Hand hygiene adherence	Clostridioides difficile infections	Increase from 73 to 98% in hand hygiene compliance in unit; decreased C. difficile rate 1.23 to 0.61. “Nurturing a workplace where creativity and innovation drive the staff to strive for excellence in nursing measures has positive effects on the care provided to patients”	Safety culture not measured One unit in a single-site study Measurement methods for processes and outcomes not described Statistical significance of changes not reported
Gilmartin 2016	Cross-sectional research; 614 hospitals; 2011	None	Two tools: (1) Leading a Culture of Quality for Infection Prevention (LCQ-IP) and nine subscales with factors loading on organizational climate, leadership and psychological safety; and (2) Relational Coordination Survey (RCS) which measures relational coordination between infection preventionists, physicians, bedside nurses, environmental services, and hospital administration	Adherence to central line insertion bundles. Specifically, hand hygiene, using maximal barrier precaution, using chlorhexidine to prepare the skin, and selecting the optimal catheter site	CLABSI	There was a positive association (beta = 0.23, p < 0.01) between adherence to central line bundle and organizational context (which was a second-order model combining items from the two major culture tools) There was no statistically significant relationship between CLABSI and organizational context (beta = − 0.20, p = 0.78)	Single time measurement of safety culture) Infection preventionists were the respondents for culture measurement Includes large number of hospitals
Jain 2011	QI initiative; 150 Veterans Affairs hospitals; 2005–2010	MRSA bundle consisted of universal active nasal surveillance for MRSA, contact precautions for patients colonized or infected with MRSA, hand hygiene, and “a change in the institutional culture whereby infection control would become the responsibility of everyone who had contact with patients”	Not measured	MRSA screening adherence	MRSA VAP, MRSA BSI, MRSA UTI, MRSA skin or soft tissue, VRE C. difficile	“A program of universal surveillance, contact precautions, hand hygiene, and institutional culture change was associated with a decrease in health care-associated transmissions of and infections with MRSA in a large health care system” “The increase in adherence to active surveillance in the months after issuance of the VHA directive and the subsequent declines in healthcare–associated MRSA infections were consistent with an institutional culture change that resulted in health care workers being more aware of health care-associated MRSA infections and increasing their adherence to hand hygiene and contact precautions”	Safety culture not measured Mentioned positive deviance as recommended approach to culture change but no further description. Includes large number of hospitals caring for veterans and a wide variety unit type (ICU and non-ICU)
Johnson 2014	QI initiative; 1 academic medical center; 2006–2012	Education, checklist and audit tools, reminders, audit and feedback, staff accountability, product selection and accessibility, organizational culture (including patient and family engagement)	Not measured	Hand hygiene adherence	CLABSI	Adherence to hand hygiene improved from 58 to 98%, and CLABSI decreased from 4.08 to 0.42 per 1000 device days “Another key element of our QI project was to effect an organization-wide culture change, resulting in all healthcare workers recognize failure to practice good hand hygiene is unacceptable and all healthcare workers categories and hierarchies levels will be held accountable”	Safety culture not measured Single-site study
Joyce 2011	QI initiative; 6 hospitals within 1 health system; 2008–2010	Education, audit and feedback, evidence-based best practice bundles (CLABSI, CAUTI, SSI, VAP), daily multidisciplinary rounds with bedside huddles, large graphic dashboard, overall effort intended to improve teamwork, communication and engagement	Not measured	Compliance with bundles, completion of rounds, hand hygiene, checklist compliance	CLABSI, CAUTI, VAP, SSI, mortality rates	CAUTI average monthly incidence declined from 43.9 to 15.8 (64% reduction, p < 0.001) SSI and VAP monthly incidence also declined (24.9 to 18.8, p = 0.13 and 2.4 to 1.5, p = 0.29, respectively) CLABSI average monthly incidence increased from 3.2 to 5.0 (p = 0.15) Non-risk adjusted mortality dropped from 1.63 deaths per 1000 discharges to 1.41 (p = 0.16) implementation of the initiative resulted in a significant reduction in hospital-acquired infections (infection dropped from 74.4 to 41.2)	Safety culture not measured
Lin 2018	QI initiative; 15 hospitals; 2013–2015	CUSP with individualized bundles of interventions to reduce SSI	AHRQ Hospital Survey on Patient Safety Culture (HSOPSC)	Chlorhexidine wash, wipe before operation, and surgical preparation; appropriate antibiotic choice, dose, and timing; standardized post-surgical debriefing; and differentiating clean-dirty-clean with anastomosis tray and closing tray	SSI	The collaborative colorectal SSI rate decreased (from 12.08 to 4.63%; p < 0.01). Safety culture increased significantly in 10 of 12 domains: Overall Perception/Patient Safety; Teamwork Across Units; Management-Support Patient Safety, Nonpunitive Response to Error, Communication Openness; Frequency of Events Reported; Feedback/Communication about Error); Organizational Learning/Continuous Improvement; Supervisor/Manager Expectations and Actions Promoting Safety and Teamwork Within Units. There was a change in SSI rates and a change in safety culture, but correlations between the 2 were negligible or weak for most domains of safety culture	Safety culture measured two points in time 18 months apart. Did not find significant associations
Mayer 2011	QI initiative; 2 ICUs (pediatric ICU and surgical ICU) in 1 academic medical center; 2007–2009	TeamSTEPPS, an Agency for Healthcare Research and Quality (AHRQ)- supported training program that focuses on 4 core areas of competency: team leadership, situation monitoring, mutual support, and communication	Three tools: (1) Hospital Survey of Patient Safety Culture (HSOPSC): teamwork-specific domains, overall perception of safety, and communication openness; (2) Employee opinion survey (EOS): teamwork domains; and (3) National Database of Nursing Quality Indicators (NDNQI): teamwork items. Also observation of teamwork performance using Teamwork Evaluation of Non-technical skills (TENTS) Staff interviews were also performed to address components of teamwork aligned with the training and outcome objectives	Average time for placing patients on extracorporeal membrane oxygenation (ECMO) and average duration of adult surgery rapid response team events	Nosocomial infection rate (without further details)	Improvement seen in all clinical process and outcome measures Nosocomial infection rate post-implementation was below the upper control limit for 7 out of 8 months in both the PICU and the SICU Observed team performance improved significantly for leadership, mutual support, and overall leadership. No significant change in communication, situation monitoring, and overall teamwork HSOPSC score significantly improved for at least one unit in overall perception of safety, communication openness, teamwork within unit. Similarly, significant improvement was shown in two EOS teamwork measures “Significant improvement on overall perceptions of safety, teamwork within units and staff interactions across several measures”	Single-site study Safety culture measured at baseline and 12 and 18 months with several established tools Did not statistically analyze the association between safety culture and outcomes
Medina 2014	QI initiative; 8 units in 1 academic medical center; 2011–2013	Bundle in which chlorhexidine bathing was primary intervention. Other 4 simultaneous support strategies included staff education, making sure there was strong leadership support, ensuring availability of resources, and increasing staff awareness and accountability (including “visibility walls”)	None	Hand hygiene, use of pre-insertion checklist, compliance with chlorhexidine bathing and central line maintenance practices	CLABSI	CLABSIs rates decreased from 1.46 to 0.52 infections per 1000 patient days after the 8-month intervention period No findings related to culture beyond the abstract which states “4 strategies were used to promote a change in practice and culture”	Safety culture not measured
Millson 2019	QI initiative; intervention at single dialysis clinic with 5 control sites; 2017–2018	Comprehensive Unit-based Safety Program (CUSP)* “Objectives were to improve understanding of safety culture on the unit and align clinical practice with CDC core interventions…”	Hospital Survey of Patient Safety Culture (HSOPSC) modified for dialysis clinics. Domains: teamwork, communication, management support, continuous improvement, organizational learning	Monthly infection prevention practice audits, hemodialysis bundle, and procedures considered critical to prevent CLABSI	Bloodstream infections	Infection rates decreased from 2.33 to 1.07 events per 100 patient months, and the standardized infection ratios decreased from 1.96 to 0.99 in the 12 months after implementation Baseline data from 6 sites indicated a strong negative relationship between staff perception of safety and BSI rates (p = 0.017). The lower the staff perceived the safety culture, the higher the BSI rated tended to be at the beginning of the project “Enhanced patient safety culture is correlated with improved patient outcomes”	Safety culture measured pre-intervention and compared with baseline infection rates Demonstration project Setting is dialysis clinics
Pronovost 2011	Summary description of several QI initiatives studies involving hundreds of hospitals and ICUs; 2001–2009	Comprehensive Unit-based Safety Program*. Also, culture was addressed at 3 levels: (1) the microsystem or unit by forming safety teams with focused training; (2) engaging senior executives; and (3) creating a social community at the state level	Not described in this paper	Adherence to central line insertion bundles	CLABSI	Multiple collaborative efforts across public and private stakeholders led to a nationwide 63% reduction in CLABSI in ICUs “Programs to improve quality must address culture.” Programs focused at 3 levels (microsystem, leadership, and social community) helped create new norms regarding bloodstream infections.	Safety culture either not measured or not described in this paper
Raveis 2014	Qualitative research; in-depth interviews at 11 hospitals; 2010–2011	None (premise of study was to understand how best to implement process changes that impact outcomes)	Interviews with 116 staff addressed how to change safety culture	HAI prevention strategies including change in policies, process implementation, facilitators, barriers	HAIs not specified, although the importance of linking IPC adherence to patient outcomes was a key theme	Three themes related to implementation of IPC practices: (1) implement institution-wide; (2) promote culture change to sustain adherence; and (3) contend with opposition to new infection control mandates Promoting an institutional culture to sustain adherence should be done by (1) linking IC adherence to patient outcomes, (2) generating group accountability and ownership, (3) taking action for the collective good, and (4) facilitating teamwork	Safety culture assessed using qualitative process Process and outcome measurements not specific
Rawat 2017	QI initiative; longitudinal; 56 intensive care units (ICUs) at 38 hospitals; October 2012 to March 2013, April 2013–March 2015	Comprehensive unit-based safety programs (CUSP); two state collaborative with goals to decrease ventilator-associated events (VAEs) by improving compliance with evidence-based interventions, unit teamwork, and patient safety culture	Hospital Survey on Patient Safety Culture (HSOPSC); domains of teamwork and safety culture	Head-of-bed elevation (HOB), use of subglottic suctioning for endotracheal tubes (Sub-G ETT), oral care (OC) 6 times per day, chlorhexidine mouth care (CHG) two times per day, performance of spontaneous awakening trials (SAT), and performance of spontaneous breathing trials (SBT)	Infection-related ventilator-associated complication (IVAC) and ventilator-associated pneumonia (PVAP)	After 24 months of implementation, infection-related ventilator-associated complication (IVAC) and possible and probable ventilator-associated pneumonia (PVAP) rates decreased from 3.15 to 1.56 and 1.41 to 0.31 cases per 1000 ventilator-days (p = 0.018, p = 0.012), respectively. The six technical interventions, or bundle of evidence-based practices, were executed using models designed to change care practices and improve safety culture	Safety culture measured annually. Did not statistically analyze the association between SC and outcomes; however, they planned to do so. Thus results related to associations are not reported in this paper
Robinson 2018	QI initiative; in 7 adult ICUs one hospital 2010–2015	Implementation of a quality and safety RN champion model aimed to educate, support, and engage frontline RNs to implement and ensure continued compliance of the VAP Evidence Based Practice bundle in each of the 7 ICUs	Not measured	VAP Evidence Based Practice bundle Oral CHG/Peridex with subglottic suctioning; head of bed at more than 30°; perioperative deep oral suction and oral care every 4 h and at end of case; leaving gastric tubes in place in patients who will remain intubated, intermittent gastric suctioning; updated signage on beds of patients traveling to the OR; and hand-off tools	Ventilator-associated pneumonia (VAP)	Reduction of 39.5% in ICU length of stay (LOS) over 6 years utilizing the RN champion model. Bundle compliance versus confirmed VAP data showed total bundle compliance rate of 95% and decrease in confirmed cases from 19 to 4 in the 4th quarter of 2015 “The integration of this RN champion model positively changed culture by educating healthcare providers and reinforcing quality and safety initiatives with the goal of improving patient outcomes”	Single site
Rosenberg 2015	QI initiative; 109-bed children’s service within academic medical center (ICU and non-ICU units); 2012–2014	CLABSI insertion and maintenance bundles, rounding, multi-disciplinary team, bedside champions, publicly posted unit-based feedback, accountable action plan, family engagement	Not measured	Adherence to central venous catheter bundles	CLABSI	Significantly decreased variation, increased bundle reliability, and decreased annual CLABSI rates from 2.7 to 0.5 per 1000 line days over time “We believe that key elements contributing to initial success with evolving QI capacity and resources were likely multifactorial, including staff and leadership engagement, culture change, consistent guidelines, and accountability” “Basic QI techniques drove an equally important part of this culture change, including transparent, respectful data sharing on both reliability and outcomes, and peer and leadership education at all levels of children’s services, including increasing awareness among nursing, house staff, and physicians about the preventable nature of CLABSI.”	Safety culture not measured Single children’s service
Southworth 2012	QI initiative; 1 teaching hospital; 2003–2008	Daily rounding, checklists, promoting culture of advocacy by nurses and enhanced autonomy, empowerment to speak up, observation of insertions, resident education	National Database of Nursing Quality Indicators (NDNQI) Domains: Nurses satisfaction with relationship between physicians and nurses, nurse autonomy	Adherence to CLABSI bundle	CLABSI	An important feature of the culture change was for the nurse to feel empowered to speak up if expectations for proper procedure were not met. During implementation of the new process, there was no decrease in nurse satisfaction with relationships between nurses and physicians or nurse autonomy “Although the evidence described the processes necessary to decrease the occurrence of CLABSIs, it was the change in culture by our nursing staff and physicians that drove the change. The performance expectations for CLABSI went from accepting an average number of 8 or 9 infections per quarter to tolerating zero infections. This culture change was very clearly demonstrated in fiscal year 2008, when the ICU went 12 months without a single CLABSI”	Annual measurement of NDNQI Statistical significance of changes in safety culture not reported Did not statistically analyze the association between safety culture and outcomes
Thomas-Hawkins 2015	Cross-sectional research; 422 registered nurses in outpatient dialysis facilities; September–November 2007	None	Hospital Survey on Patient Safety Culture (HSOPSC): Handoff and Transitions scale; patient safety scale. Respondents were nurses.	Handoff and transitions safety	Vascular access infection	Negative ratings of overall patient safety culture in dialysis units were independently associated with increased odds of frequent occurrences of vascular access infection. Negative patient safety culture ratings were also associated with medication errors by nurses, patient hospitalization, vascular access infection, and patient complaints	Measured safety culture single time