The Influence of Safety Culture on Satisfaction with Pain Management

Purpose:

The purpose of this study was to determine to impact of hospital unit safety culture on patient satisfaction, with particular emphasis on patient satisfaction with pain management. Current CMS value-based purchasing policy emphasizes achieving high levels of patient satisfaction, as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, with financial incentives for those providers that can achieve top HCAHPS performance. Nurse perception of a strong safety culture within his/her hospital unit may be predictive of high patient satisfaction on that unit. An examination of the relationship between nurse perception of safety culture and patient satisfaction could reveal modifiable organizational factors that have potential to improve the patient experience and hospital HCAHPS performance.

 Methods:

Data came from a national sample of hospital units that administered both the Agency for Healthcare Research and Quality (AHRQ) staff safety culture survey and the HCAHPS patient satisfaction survey over a 12 month period in 2011. Survey response variables were measured at the unit (N=136) and hospital (N=45) level. Data representing the hospital characteristics and unit type were derived from the Press Ganey hospital data base, which contains hospital reported measures of organizational characteristics such as size, location, and staffing. Multivariate mixed-effects linear models were specified to determine the influence of each safety culture domain on HCAHPS sub-scales of interest. Because our analysis focused specifically on the relationship between nurse perception of safety and patient satisfaction, only nurse responses were included in the AHRQ survey sample, and only responses from inpatient units (Medical, Obstetric, Pediatrics, Critical Care, Rehabilitative, and Medical/Surgical) were included in the HCAHPS sample.

Results:

Unit safety culture was significantly and positively related to each examined HCAHPS domain. When entered into the model as separate sub-scales, the domains that comprise the safety culture instrument (teamwork, supervisor, staffing, feedback, responsiveness, learning organization and openness) did not individually demonstrate a significant influence on patient satisfaction with pain management. Average age of patient on the unit was the single significant predictor of satisfaction with pain management, and had a negative influence on perceptions. Patients on units with a higher average age perceived less adequate pain control. The percentage of patients reporting high satisfaction with pain management was highest on obstetrics units (76.6%), and lowest on units providing acute rehabilitative services (64.3%).

Conclusion:

Overall findings indicate that modifiable aspects of unit safety culture can influence the likelihood of achieving high HCAHPS top box percentages, which directly impact hospital reimbursement. Our findings highlight the impact of organizational culture and nurse work environment on overall patient satisfaction. Results surrounding the influence of safety culture on the pain management sub-scale indicate that no single domain of safety culture has a significant influence. The negative influence on age may reflect the complexity of caring for older patients, and warrants further examiniation. A notable strength of this of this study is our reliance on data from two entirely different sources (nurses and patients) that are linked by time period and hospital unit, as well as two well-validated surveys. Efforts to improve safety culture may have a positive impact on satisfaction as well as financial impact long term. Examples of interventions that have potential for positive impact include empowering nurse managers to make changes in staffing to accommodate fluctuation in workload;  improving consistency of staff assignments to increase impact on communication, teamwork and the ability to learn from past-mistakes; and efforts to reduce nursing staff turn-over. Additional staff training and awareness may be needed to improve the satisfaction surrounding pain control for patients being cared for on units with an older average patient age.