News Release

Hospital safety culture critical in improving surgical results

Journal of the American College of Surgeons study finds non-technical factors significantly influence quality of patient care

Peer-Reviewed Publication

American College of Surgeons

CHICAGO (Dec. 9, 2015): To achieve better results for surgical patients, hospitals tend to focus on technical issues like surgeons' skills and operating room equipment. However, a non-technical factor, the so-called 'safety culture,' may be equally important in delivering high-quality patient care, a team of investigators report in a study published online in the Journal of the American College of Surgeons in advance of print publication.

"The non-technical skills of care coordination, teamwork and ownership over the delivery of care are measured as safety culture," said lead study author Martin Makary, MD, MPH, FACS, professor of surgery and health policy & management at Johns Hopkins University School of Medicine, Baltimore. "Anybody who cares for patients knows that a hospital's culture contributes to a patient's outcome, and this study affirmed that observation."

Dr. Makary defined safety culture as "the organizational characteristics of delivering great care" and the attitude of "how we do things around here." He added, "It's a compilation of burnout, perceptions of management, the connectedness of care and staff's willingness to speak up when they have a concern."

The study results, first presented last year at the annual meeting of the American Medical Research Symposium in Dallas, measured 12 different safety culture factors that influenced rates of a specific complication, surgical site infection (SSI) after colon procedures, at seven Minnesota hospitals. The hospitals' average size was 168 beds. SSI rates after surgery at the hospitals ranged from 0-30 percent, with an average rate of 11.3 percent, and surgical unit safety culture scores ranged from 16-92 on a percent-positive scale.

The study is one of the first to evaluate the impact of an organization's teamwork and safety culture on patient outcomes. Researchers used a cross-sectional sample from the Minnesota Hospital Association to combine safety culture survey data with SSIs after colon operations during 2013. The hospitals were surveyed using the Hospital Survey on Patient Safety Culture, a staff survey the Agency for Healthcare Research and Quality released in 2004 to help hospitals assess the culture of safety in their institutions.

Of the 12 safety culture factors measured, 10 were found to influence the rates of SSI after colon operations: overall perceptions of patient safety; teamwork across units; organizational learning; feedback and communication about error; management support for patient safety; teamwork within units; communication openness; supervisor/manager expectations of actions promoting safety; non-punitive response to error; and frequency of events reported. The two safety factors not associated with infection rates were handoffs and transitions -- the transfer of care of a patient from one care team to another, such as from the recovery room to the hospital floor, or from one nursing shift to the next -- and staffing.

Feedback and communication after errors (the learning hospital response) had the widest variation among surveyed hospitals, ranging from 21-79 percent positive, while the smallest variation was in scores for teamwork across units with a range from 24-49 percent positive.

The study illustrated the significance of three characteristics of good safety culture, Dr. Makary said: an ability and willingness to learn from past mistakes; a high degree of interest in adopting best practices; and an ability to collaborate to benchmark performance.

"The study supports what many surgeons have known for a long time, and that is that the organizational culture matters," Dr. Makary said. "While we have traditionally only studied the incremental patient benefits of different medications and surgical interventions, it turns out that organizational culture has a big impact on patient outcomes."

One notable study limitation was that the researchers only investigated one type of surgical outcome. "There are hundreds of outcome variables that can be measured with a safety culture," Dr. Makary said.

The study findings can help shape future research into evaluating the role of organizational culture more deeply, Dr. Makary concluded. "Variation in organizational culture may be an important factor in understanding the broader endemic issue of variation in medical quality."


Study coauthors are Caleb J. Fan, Timothy M. Pawlik, MD, MPH, PhD, FACS, and Elizabeth C. Wick, MD, FACS, of Johns Hopkins; Tania Daniels, PT, MBA, Nora Vernon, RN, MS, Katie Banks and Peggy Westby of the Minnesota Hospital Association, St. Paul; and J. Bryan Sexton, PhD, of Duke University Health System, Durham, N.C.

The study at Johns Hopkins was supported by Mr. and Mrs. John Rodda and the Rodda Family Partnership Ltd.

'FACS' designates that a surgeon is a Fellow of the American College of Surgeons.

Citation: Association of Safety Culture with Surgical Site Infection Outcomes. Journal of the American College of Surgeons.

About the American College of Surgeons

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 80,000 members and is the largest organization of surgeons in the world. For more information, visit

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