Association Between Hospital Safety Culture and Surgical Outcomes in a Statewide Surgical Quality Improvement Collaborative

J Am Coll Surg. 2019 Aug;229(2):175-183. doi: 10.1016/j.jamcollsurg.2019.02.046. Epub 2019 Mar 9.


Background: The "safety culture" within hospital systems is increasingly recognized as important to delivery of high-quality care. We examine the safety culture in a statewide hospital quality improvement collaborative and its associations with surgical outcomes.

Study design: A modified Safety Attitudes Questionnaire was sent to administrators, quality improvement teams, nurses, anesthesiologists, and surgeons in 49 hospitals participating in the Illinois Surgical Quality Improvement Collaborative in 2015. Associations between positive safety culture, as measured by percentage of positive responses on the Safety Attitudes Questionnaire, and the following NSQIP 30-day adverse outcomes: hospital-level risk-adjusted morbidity, mortality, death, or serious morbidity and readmission rates. Linear regression models with hospitals clustered by system were used to assess the relationship between safety culture and patient outcomes.

Results: Operating room safety culture scores were highest (97.7% positive) compared with the other domains, and ratings of hospital management were lowest (75.9% positive). Hospital administrators consistently had the most positive perception of the safety culture (90.5% positive) and front-line providers were less positive: physicians (85.3%), advanced practice providers (88.1%), and nurses (80%). Teamwork was rated as a strength by patient care providers (physicians 88.3%, advanced practice providers 90.2%, and nurses 82.2%), but was perceived as weakest by administrators. Higher percentage of positive Safety Attitudes Questionnaire responses was significantly associated with lower risk of postoperative morbidity (p = 0.007) and death or serious morbidity (p = 0.04). No significant association between safety culture and the risk of mortality (p = 0.23) or readmissions (p = 0.52) was observed.

Conclusions: Hospital safety culture can influence certain surgical patient outcomes. Improving the safety culture within a hospital can represent a previously unrecognized approach that can be leveraged to strengthen surgical quality improvement efforts at the hospital level.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Cross-Sectional Studies
  • Hospitals / standards*
  • Humans
  • Illinois
  • Organizational Culture*
  • Outcome Assessment, Health Care
  • Perioperative Care / standards*
  • Quality Improvement / organization & administration*
  • Quality Improvement / statistics & numerical data
  • Quality Indicators, Health Care / statistics & numerical data*
  • Safety Management*
  • Surgical Procedures, Operative / standards*