Investigating organisational culture from the ‘outside’, and implications for investing

Dr Alex Gillespie and Dr Tom Reader consider how organizational culture can be researched from ‘outside’ an organization and what dimensions could be of particular interest for potential investment decisions

Using hospital complaints to improve patient safety

LSE colleagues from the Department of Social Psychology consider the untapped reserve of data that could be used to improve hospital patient safety: hospital complaints. Guest bloggers Dr Tom Reader and Dr Alex Gillespie explain how the analysis of this untapped data could inform future learning

Patient neglect in healthcare institutions: a systematic review and conceptual model

Background Patient neglect is an issue of increasing public concern in Europe and North America, yet remains poorly understood. This is the first systematic review on the nature, frequency and causes of patient neglect as distinct from patient safety topics such as medical error. Method The Pubmed, Science Direct, and Medline databases were searched in order to identify research studies investigating patient neglect. Ten articles and four government reports met the inclusion criteria of reporting primary data on the occurrence or causes of patient neglect. Qualitative and quantitative data extraction investigated (1) the definition of patient neglect, (2) the forms of behaviour associated with neglect, (3) the reported frequency of neglect, and (4) the causes of neglect. Results Patient neglect is found to have two aspects. First, procedure neglect, which refers to failures of healthcare staff to achieve objective standards of care. Second, caring neglect, which refers to behaviours that lead patients and observers to believe that staff have uncaring attitudes. The perceived frequency of neglectful behaviour varies by observer. Patients and their family members are more likely to report neglect than healthcare staff, and nurses are more likely to report on the neglectful behaviours of other nurses than on their own behaviour. The causes of patient neglect frequently relate to organisational factors (e.g. high workloads that constrain the behaviours of healthcare staff, burnout), and the relationship between carers and patients. Conclusion A social psychology-based conceptual model is developed to explain the occurrence and nature of patient neglect. This model will facilitate investigations of i) differences between patients and healthcare staff in how they perceive neglect, ii) the association with patient neglect and health outcomes, iii) the relative importance of system and organisational factors in causing neglect, and iv) the design of interventions and health policy to reduce patient neglect

The healthcare complaints analysis tool: development and reliability testing of a method for service monitoring and organisational learning

Background Letters of complaint written by patients and their advocates reporting poor healthcare experiences represent an under-used data source. The lack of a method for extracting reliable data from these heterogeneous letters hinders their use for monitoring and learning. To address this gap, we report on the development and reliability testing of the Healthcare Complaints Analysis Tool (HCAT). Methods HCAT was developed from a taxonomy of healthcare complaints reported in a previously published systematic review. It introduces the novel idea that complaints should be analysed in terms of severity. Recruiting three groups of educated lay participants (n=58, n=58, n=55), we refined the taxonomy through three iterations of discriminant content validity testing. We then supplemented this refined taxonomy with explicit coding procedures for seven problem categories (each with four levels of severity), stage of care and harm. These combined elements were further refined through iterative coding of a UK national sample of healthcare complaints (n= 25, n=80, n=137, n=839). To assess reliability and accuracy for the resultant tool, 14 educated lay participants coded a referent sample of 125 healthcare complaints. Results The seven HCAT problem categories (quality, safety, environment, institutional processes, listening, communication, and respect and patient rights) were found to be conceptually distinct. On average, raters identified 1.94 problems (SD=0.26) per complaint letter. Coders exhibited substantial reliability in identifying problems at four levels of severity; moderate and substantial reliability in identifying stages of care (except for ‘discharge/transfer’ that was only fairly reliable) and substantial reliability in identifying overall harm. Conclusions HCAT is not only the first reliable tool for coding complaints, it is the first tool to measure the severity of complaints. It facilitates service monitoring and organisational learning and it enables future research examining whether healthcare complaints are a leading indicator of poor service outcomes. HCAT is freely available to download and use

Stakeholders in safety: patient reports on unsafe clinical behaviors distinguish hospital mortality rates

Patient safety research has adapted concepts and methods from the workplace safety literature (safety climate, incident reporting) to explain why patients experience unintentional harm during clinical treatment in hospital (adverse events). Consequently, patient safety has primarily been studied through data generated by health care staff. However, because adverse events relate to patient injuries, it is suggested that patients and their families may also have valuable insights for investigating patient safety in hospitals. We conceptualized this idea by proposing that patients are stakeholders in hospital safety who, through their experiences of treatments and independence from institutional culture, can provide valid and supplementary data on unsafe clinical care. In 59 United Kingdom hospitals we investigated whether patient evaluations of care (N = 23,287 surveys) and the safety information contained in health care complaints (N = 2,017, containing 2.5 million words) explained variance in excess patient deaths (hospital mortality) beyond staff evaluations of care (N = 49,302 surveys) and incident reports (N = 242,859). The severity of reports on unsafe clinical behaviors (error and neglect) communicated in patient' health care complaints explained additional variance in hospital-level mortality rates beyond that of staff-generated data. The results indicate that patients provide valid and supplementary data on unsafe care in hospitals. Generalized to other organizational domains, the findings suggest that nonemployee stakeholders should be included in assessments of safety performance if they experience or observe unsafe behaviors. Theoretically, it is necessary to further examine how concepts such as safety climate can incorporate the observations and outcomes of stakeholders in safety

Identifying and encouraging high-quality healthcare: an analysis of the content and aims of patient letters of compliment

Background Although healthcare institutions receive many unsolicited compliment letters, these are not systematically conceptualised or analysed. We conceptualise compliment letters as simultaneously identifying and encouraging high-quality healthcare. We sought to identify the practices being complimented and the aims of writing these letters, and we test whether the aims vary when addressing front-line staff compared with senior management. Methods A national sample of 1267 compliment letters was obtained from 54 English hospitals. Manual classification examined the practices reported as praiseworthy, the aims being pursued and who the letter was addressed to. Results The practices being complimented were in the relationship (77% of letters), clinical (50%) and management (30%) domains. Across these domains, 39% of compliments focused on voluntary non-routine extra-role behaviours (eg, extra-emotional support, staying late to run an extra test). The aims of expressing gratitude were to acknowledge (80%), reward (44%) and promote (59%) the desired behaviour. Front-line staff tended to receive compliments acknowledging behaviour, while senior management received compliments asking them to reward individual staff and promoting the importance of relationship behaviours. Conclusions Compliment letters reveal that patients value extra-role behaviour in clinical, management and especially relationship domains. However, compliment letters do more than merely identify desirable healthcare practices. By acknowledging, rewarding and promoting these practices, compliment letters can potentially contribute to healthcare services through promoting desirable behaviours and giving staff social recognition

Analysing and learning from healthcare complaints

Around one in 10 patients experience unintended harm in hospital, and 14 per cent of such incidents lead to permanent disability or death. Alex Gillespie and Tom Reader have developed a tool for systematically analysing patient complaints, helping healthcare organisations to reduce errors and improve outcomes

Causal and corrective organisational culture: a systematic review of case studies of institutional failure

Organisational culture is assumed to be a key factor in large-scale and avoidable institutional failures (e.g. accidents, corruption). Whilst models such as “ethical culture” and “safety culture” have been used to explain such failures, minimal research has investigated their ability to do so, and a single and unified model of the role of culture in institutional failures is lacking. To address this, we systematically identified case study articles investigating the relationship between culture and institutional failures relating to ethics and risk management (n = 74). A content analysis of the cultural factors leading to failures found 23 common factors and a common sequential pattern. First, culture is described as causing practices that develop into institutional failure (e.g. poor prioritisation, ineffective management, inadequate training). Second, and usually sequentially related to causal culture, culture is also used to describe the problems of correction: how people, in most cases, had the opportunity to correct a problem and avert failure, but did not take appropriate action (e.g. listening and responding to employee concerns). It was established that most of the cultural factors identified in the case studies were consistent with survey-based models of safety culture and ethical culture. Failures of safety and ethics also largely involve the same causal and corrective factors of culture, although some aspects of culture more frequently precede certain outcome types (e.g. management not listening to warnings more commonly precedes a loss of human life). We propose that the distinction between causal and corrective culture can form the basis of a unified (combining both ethical and safety culture literatures) and generalisable model of organisational failure

Sounds of silence: data for analysing muted safety voice in speech

Transcribed text from simulated hazards contains important content relevant for preventing harm. By capturing and analysing the content of speech when people raise (safety voice) or withhold safety concerns (safety silence), communication patterns may be identified for when individuals perceive risk, and safety management may be improved through identifying potential antecedents. This dataset contains transcribed speech from 404 participants (n students = 377; n female = 277, Age M (sd) = 22.897 (5.386)) engaged in a simulated hazardous scenario (walking across an unsafe plank), capturing 18,078 English words (M (sd) = 46.117 (37.559)). The data was collected through the Walking the plank paradigm (Noort et al, 2019), which provides a validated laboratory experiment designed for the direct observation of communication in response to hazardous scenarios that elicit safety concerns. Three manipulations were included in the design: hazard salience (salient vs not salient), responsibilities (clear vs diffuse) and encouragements (encouraged vs discouraged). Speech between two set timepoints in the hazardous scenario was transcribed based on video recordings and coded in terms of the extent to which speech involved safety voice or safety silence. Files contain i) a.csv containing the raw data, ii) a.csv providing variable description, iii) a Jupyter notebook (v. 3.7) providing the statistical code for the accompanying research article, iv) a.html version of the Jupyter notebook, v) a.html file providing the graph for the.html Jupyter notebook, vi) speech dictionaries, and vii) a copy of the electronic questionnaire. The data and supplemental files enable future research through providing a dataset in which participants can be distinguished in terms of the extent to which they are concerned and raise or withhold this. It enables speech and conversation analyses and the Jupyter notebook may be adapted to enable the parsing and coding of text using provided, existing and custom dictionaries. This may lead to the identification of communication patterns and potential interventions for unmuting safety voice. This data-in-brief is published alongside the research article: M. C. Noort, T.W. Reader, A. Gillespie. (2021). The sounds of safety silence: Interventions and temporal patterns unmute unique safety voice content in speech. Safety Science