1. Trinity University of Asia, Quezon City, Philippines.

* Correspondence: cdcalacday@tua.edu.ph

Keywords: patient safety, government hospitals, improved, healthcare practices

1. INTRODUCTION

The US Institute of Medicine Committee on Quality of Health Care released a report in 1999 entitled “To Err is Human: Building a Safer Health System” which states that 44,000 to 98,000 Americans die in hospitals each year due to medical errors that could have been prevented [1]. These medical errors are adverse drug events, improper transfusions, surgical injuries and wrong-site surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken patient identities [2]. Patient safety is the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health care to an acceptable minimum (WHO, 2018)[3]. According to the World Health Organization (WHO), it is alarming to know that healthcare industry in general is far left behind by other high-risk industries such as aviation, nuclear energy and shipping in terms of addressing issues concerning safety [4]. It is estimated that there is one in three hundred (1/300) chance of patient being harmed while receiving patient care while only there is only one in one million (1/1,000,000) chance of being harmed while in aircraft [5]. The World Health Organization then considers Patient Safety as a global health priority [6].The Philippine Department of Health (DOH) released an Administrative Order 2008-0023 that aims “to ensure that patient safety is institutionalized as a fundamental principle of the health care delivery system in improving health outcomes [7]. This AO emphasized building a culture of patient safety and implementing patient safety programs in facilities that are in accordance with the DOH National Patient Safety Committee and the Philippine Health Insurance Corporation (PHIC/Phil health) Bench book on Safe Practice and Environment [8]. Patient Safety Culture is defined by the Agency for Healthcare Research and Quality as the “product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization’s health and safety management [9]. As healthcare institutions continually seek to improve patient safety and quality, hospital leadership recognizes the importance of creating a culture of safety [10]. Acquiring a culture of patient safety requires leadership, and staff to understand their organizational values, beliefs, and norms about what is important and what attitudes and behaviors are expected and appropriate [11]. Patient Safety Culture is composed of communication openness where staff freely speak up, feedback and communication about error, frequency of events reported, handoffs and transitions, management support for patient safety, non-punitive response to error, organizational learning-continuous improvement, overall perceptions to patient safety, staffing, supervisor/manager expectations and actions promoting patient safety, and teamwork within and across units [12].The study aimed to describe the current status of Patient Safety Culture in some of the Level 2 and Level 3 hospitals in Metro Manila through the use of the Hospital Survey on Patient Safety Culture developed by the Agency for Healthcare Research and Quality (AHRQ) in 2004 which is also being used internationally by different hospitals for providers and other staff to assess the patient safety culture in their respective facilities [13]. Frontline staff of different hospitals were asked to answer the five-page survey [14]. The frontline staff were divided into three groups for this study: Group a – nurses, Group B – doctors and Group C – pharmacists and radiologic technologists [15].

2. MATERIALS & METHOD

The study utilized a descriptive, cross-sectional design, comparison of assessment data was done between the results from three (3) groups of different disciplines in Healthcare i.e. Doctors, Nurses, Pharmacists and Radiologic Technologists coming from Level 3 and Level 2 hospitals. The study utilized the ‘Hospital Survey on Patient Safety Culture (HSOPSC)’ of the Agency for Healthcare Research and Quality of the United States Department of Health and Human Services. According to the AHRQ website, hundreds of hospitals across the United States and around the globe have already implemented the survey. The survey consists of five (5) pages with eight (8) sections/dimensions including the demographics, work area/unit, supervisor/manager, communications, frequency of events reported, patient safety grade, hospital, number of events reported, and background information. A total of twenty-one (21) hospitals in Metro Manila are Level 3 and Level 2 hospitals, fourteen (14) of which are Level 3 and seven (7) are Level 2.  The researcher recruited two (2) Level 3 hospitals and two (2) Level 2 hospitals in the National Capital Region through random sampling. These hospitals were from the cities of Manila, Muntinlupa, and then Marikina. Respondents were composed of ten (10) nurses – group A, ten (10) doctors – group B and a combination of ten (10) pharmacists and Radiologic technologists for group C from each hospital those of which have direct involvement in patient care. A total of thirty (30) respondents were gathered from each hospital, the list of the mentioned hospital staff were acquired from each hospital and respondents were selected randomly through the Ran between formula in excel. The questionnaires were given sealed and can only be seen by the respondent to maintain confidentiality and privacy.

3. RESULTS & DISCUSSION

3.1 Result Interpretations

The majority of the respondents were rendering 1 to 5 years of service to their respective hospitals/institutions with 67 respondents out of 120 and composes the 55.8% of the respondents. When years of service to their current area was taken still the majority of the respondents fall to 1 to 5 years of service to their respective units with 70 out of 120 respondents comprising the 58.3% of the respondent population. Same findings were seen when the length of service in their current profession was asked. Majority of the responses were 1 to 5 years in their current profession without of 120 responses and 53.3% of the respondent population. Average work hours of the respondents range from 40 to 59 hours per week with some answering going further than the average work hours. The Level of hospitals and number of respondents were fixed to 2 Level 2 and 2 Level 3 hospitals for even distribution and respondents to 10 nurses, 10 doctors, and 10 pharmacists and radiologic technologists each hospital. According to the presentation of Prof. Jennifer T. Pagano of the University of the Philippines College of Nursing during the 2nd Patient Safety Congress which happened last March 28-29, 2019 entitled “Promoting Health Professional Practice Environments”, thirty (30) percent of nurses plan to leave their units, hospitals and the country in the next 6 months. These are because of varying reasons ranging from salary, leadership and management to amount of workload. Although the presentation or study only focused on nurses, this can be a good baseline to support the results of the current study which states that the majority of the respondents are serving the hospital for only 1 to 5 years and the minority of the group ranges from 11 years to 21 years or more. Philippine College of Physicians (PCP) President Anthony Leach on said the problem has been recognized by the healthcare industry for some time now. While the so-called brain drain started when the US opened its doors to migrant doctors and the Vietnam War required nurses, Dr. Leach on said the problem continues because healthcare workers still seek “greener pastures.” Despite the shortage in the country, Philippine nurses continue to supply 25% of the needs abroad, based on 2010 figures. On the Assessment of respondents in the seven (7) dimensions the respondents’ assessment of the patient safety culture in the dimension of their work area/unit shows positive results. Nine (9) out of eighteen (18) questions were answered with agree showing positivity in specific areas such as teamwork within the unit, treating each other with respect, staff providing longer hours of work to provide patient care, mistakes leading to positive changes, evaluation of attempts to improve patient safety and belief that their procedures and systems are good in preventing errors from happening. Yet, the respondents were also neutral on issues about having enough staff to handle workload, feeling their mistakes are being held against them, that mistakes happen by chance, feeling that when an event is reported they are written up instead of the problem and being written on their personal files, and working in crisis mode in trying to do too much too quickly. No question was answered with disagree. A similar study of Grant, Donaldson and Larsen noted that physicians reported a higher perception of teamwork than nursing and other staff members in the inpatient and operation room (OR) settings than in the outpatient department. This finding can be interpreted that area of assignment where an employee used to work might have influence their perception of safety culture. Data about the respondents’ assessment of patient safety culture in the dimension of their supervisors/managers also show positive results. The respondents agree that their managers say a good word when they are seen doing a good job, and their supervisors consider staff suggestions to improve patient safety. Results also show that they disagree to negative statements such as the manager wants them to work faster even taking shortcuts and that the supervisor overlooks patient safety problems happening over and over. Senior management support and engagement was identified as one of the primary factors associated with good hospital-wide quality outcomes and QI programmer success. Conversely, articles suggest that managers’ involvement (from the Board, middle and frontline) has little, no or a negative influence on quality and safety. Another noted that if other champion leaders are present, management leadership was not deemed necessary. The respondents’ answers to patients’ safety culture in the dimension of communications were divided. Positive answers were about questions pertaining to staff being able to freely speak if they see something that will negatively affect patient care, staff being informed of errors that happen in the unit, and that they discuss ways to prevent errors from happening again. The respondents provide neutral answers to the questions pertaining to being given feedback about changes that were put to place based on event reports and that the staff feel free to question actions of those with authority. A similar study has been carried out by Al-Hamada in Riyadh. His study’s result has shown that the non-punitive response to error received the lowest positive response (21.1%). Van Geist & Cummins reported that many errors in healthcare go unreported for many reasons including fear, humiliation, the presence of a punitive response to error, and the fact that reporting will not usually result in actual change. Law found that pharmacists, nurses and support staff feel that continuous improvement in their organization is at a bureaucratic level. She also found out that nurses, medical technicians and support group in general in a health facility perceived that they are proactive in giving priority to safety. Reporting is still a problem as evidenced by the answers of the respondents, when asked if they report events that were caught and corrected before affecting the patient and when they have made a mistake but has no potential harm to the patient, the mean scores equate to “sometimes” only. A “most of the time” answer was given to questions about reporting when a mistake is made that could harm the patient, but does not. Naturally, people are afraid to be blamed, thus they tend to hide incident making the situation more crucial in achieving patient safety. Law believed that healthcare providers have gone through to such effort in terms of making policies and procedures in reporting of incidents. However, she reiterated that further strategies are needed to enhance the implementation of safety practices. Further improvements shall be pushed on proper toleration and secretion of events reported especially by immediate superiors. Majority of the respondents rated their patient safety grade in the hospital as “acceptable” with 49.2% of the respondents. Although it cannot be determined how each profession answered this question, a survey study by Listyowardojo and colleagues in the University Medical Center Groningen (UMCG) in the Netherlands determined how different professional groups perceive safety culture. Results of the study revealed that there were differences in ratings of organizational and safety cultures across professional groups. Physicians and non-medical workers tended to rate the dimensions of organizational and safety culture more positively than the nurses, clinical workers and laboratory workers did. It is very important to know the relationship between safety culture among healthcare providers in public and private hospitals to build a proof of relationship which can possibly affect healthcare providers’ perception to safety culture. Results on the patient safety culture assessment in the hospital management dimension were also divided. The respondents agree to questions pertaining to teamwork with hospital units, the hospital management provides a work climate that promotes patient safety, and that that the actions of the hospital show that patient safety is a top priority. A study by Ramos and Calidgid concludes that nurses value Teamwork within Units and Organizational Learning-Continuous Improvement as important aspects of PSC. Respondents answered “neither” to questions pertaining to things falling between cracks or overlooked when transferring patient from one unit to another, important patient care information lost during shift changes, problems occurring in exchange of information across units and the hospital management only seem interested after an adverse event happen. Communication problems seem to be one on the issues about patient safety that needs to be addressed. “There’s an increased number of the healthcare providers who perceived recording and evaluating incident and communication at reactive level. This may be because of fear of reprisal attached from reporting of incidents”, communication problems have been identified as major contributing factors to adverse events according to Cook. A compelling result on the number of event reported was shown in this study. Majority answered “no events reported” followed by only “1 to 2 events reported”. Again, it can be implied that this result may represent under-reporting in all hospitals. There are many reasons for avoiding error reporting, including legal and institutional concerns, as well as personal guilt and regret. Other examples are damage to professional prestige, risk of job loss and fear of getting reprimanded or questioned these barriers substantially limit the monitoring of errors and improvement of patient safety therefore, it is difficult to establish an institutional or national error reporting system. On the differences when the profiles were taken as test factor, there is no significant difference in the assessment of respondents in each of the six mentioned variables of patient safety culture when their length of service in the hospital was taken as test factor except for the dimension hospital management. There was no significant difference on the assessments of the respondents in each of the seven mentioned variables of patient safety culture when their length of service in the current unit/area was taken as test factor. There was no significant difference on the assessments of the respondents in each of the six mentioned variables of patient safety culture when their average number of work hours per week was taken as test factor except for one variable, again, the hospital management. There was no significant difference on the assessments of the respondents in each of the seven mentioned variables of patient safety culture when their length of service in the current position was taken as test factor. There was no significant difference on the assessments of the respondents in each of the six mentioned variables of patient safety culture when the level of hospital was taken as test factor except for the patient safety grade dimension. There is a difference in how the respondents grade or rate the patient safety culture in their institution with great consideration of the level of hospital they are serving, there was no significant difference on the assessments of the respondents in each of the six mentioned variables of patient safety culture when their profession was taken as test factor except again, for the hospital management dimension. This means that different respondents have varying opinions about the hospital management. A nurse might have a different opinion with a doctor, a pharmacist or a radiologic technologist on how they view their hospital management in relation to patient safety culture.

3.2 Discussion

The findings as to why there are more staff with only 1 to 5 years of service in the hospitals, units and current profession can be attributed to the “brain drain” phenomenon happening in the country where our skilled and professional workers leave the country [16]. Philippine College of Physicians (PCP) President, Dr. Anthony Leach on said the problem has been recognized by the healthcare industry for some time now. While the so-called brain drain started when the US opened its doors to migrant doctors and the Vietnam War required nurses, Dr. Leach on said the problem continues because healthcare workers still seek “greener pastures [17].”It was argued that member’s perceptions of their organizational experiences vary with the length of time they have been employed by an organization [18]. As a new employee enters an organization he or she likely to have some views of organizational practices that are different from the organizational codes [19]. Work hours can be attributed to the Labor Code of the Philippines wherein it is stated that an employee’s work should not exceed 40 hours per week and anything going beyond that shall be compensated [20]. The shortage of healthcare workers in the Philippines, most of the staff go beyond their work schedule without further compensations. Studies have cited that nurses, for example, have to come to work earlier for endorsements and go beyond their schedule for another set of endorsements and charting [21]. Residents go for “perpetual duties” where they stay on duty for 36 hours or more because of their residency program in which their duties are called “pre-duty-from” where they should have a pretty of 8 hours before going to the real duty of 24 hours immediately from their pre-duty [22]. An article posted in Business World online in 2017 narrates the story of resident doctors who have extended duties of up to 36 hours are also called “perpetual duties” [23]. These findings have since been backed up in a 2013 report by Dr. P. Mural Doraiswamy of the Duke University Medical Center, who cited that doctors who were forced to work more than 24 hours made up to five times more serious diagnostic errors versus those on shorter shifts [24]. According to the Philippine News Agency [25], inflexible working hours, unclear tasks or organizational objectives, inadequate health and safety policies, poor communication and management practices are detrimental to the staffs’ mental health and views on institutional management [26]. There is a positive response by the respondents regarding safety culture composites such as teamwork within units, organizational learning, feedback and communication about error, teamwork across the units, and lastly handoffs & transitions compare to the AHRQ database. However, there is a huge negative difference in terms of communication openness and non-punitive response to error [27]. The culture of the work environment is a major influence in the reporting practices of the healthcare workers. Much have been done to enhance reporting including anonymous online reporting, text reporting, etc. But unless the environment has not been deemed conducive for reporting, numbers will still be at a minimum level. Healthcare workers are active in the attainment of patient safety goals and they believe in the system of their institutions though these alone cannot produce a good patient safety culture [28]. It is essential that the healthcare workers feel free to voice out their suggestions and examination of the system. Although this study cannot determine how the professionals vary in their responses, according to Listyowardojo, [29] various professional groups perceive safety culture differently. It showed that there are differences in scores of organizational and safety cultures across professional groups. Adverse consequence of reporting is believed to be the prime barrier to error reporting [30]. Studies reported that many errors in healthcare go unreported for many reasons including fear, humiliation, the presence of a punitive response to error, and the fact that reporting will not usually result in actual change. Thus, it discourages many health professionals, specifically nurses to report events because of the presence of a punitive environment when it comes on reporting of these incidents. Naturally, people are afraid to be blamed, thus they tend to hide incident making the situation more crucial in achieving patient safety [31]. Neutral answers may also indicate that fear is evident in disclosing negative issues about the organization. There were “agree” and neutral answers but only very small numbers of “disagree” answers when the questions seem very controversial or sensitive to the reputation of the hospital this may also be an evidence on the current reporting environment of the institution. Findings of the study show that the variables with the significant differences in relation to the profile of the respondents were the hospital management, and patient safety grade [32]. This means that the nurses, doctors, pharmacists and radiologic technologists’ perception vary with regards to the hospital management and patient safety grade. Although it cannot be determined which points they vary in, literature cites that different professions have different cultures that undeniably affected their answers [33]. These differences have to be addressed in order to create a unified culture across all professions and units. Literature also shows that there is lower reporting percentage in government hospitals than private hospitals [34]. It was further reiterated that there is a high percentage of healthcare providers in private than public hospitals reported errors and incidents. This finding implies that the type of hospital would also affect the perception of safety culture. However, still, most of these incidents were not evaluated promptly as it happened especially when no harm occurred. This explicitly show that safety culture among healthcare providers is not yet fully established [35].

4. CONCLUSIONS

The Philippine Department of Health (DOH) issued Administrative Order 2008-0023 aimed at “ensuring that as a fundamental principle of the health care delivery system to improve health outcomes Institutionalizing patient safety The order focuses on creating a culture of patient safety and implementing patient safety programs in facilities that the DOH National Patient Safety Committee and the Philippine Health Insurance Corporation (PHIC) /Phil health). The cross-sectional study found that respondents’ assessment of patient safety culture with seniority in the current unit/area as a testing factor in relation to hospital management, average number of patient hours worked per week Respondents’ assessment of safety culture as a test factor in relation to hospital management Respondents’ assessment of patient safety culture as a test factor in relation to hospital level of patient safety, and respondents’ assessment of patient safety culture with respondents, occupation as a Test Factor in Hospital Management. When their duration of service in the current unit or region was taken into consideration as a test factor, there was no discernible difference in the feedback that the respondents provided regarding any of the seven characteristics that were described in relation to the culture of patient safety. When the average number of work hours per week of the respondents was used as a test factor, there was no significant change in the judgments of the respondents about any of the six elements of patient safety culture that were presented. The only variable that was different was the hospital management. When their duration of service in their current position was taken into consideration as a test factor, there was no discernible change in the evaluations that the respondents provided for each of the seven characteristics that were listed, which pertain to the culture of patient safety. When the level of hospital was taken into consideration as a test factor, there was no significant variation in the assessments of the respondents about any of the six variables of patient safety culture that were presented. The only exception to this was the patient safety grade dimension. With the exception of the hospital management dimension, there was no significant difference in the assessments of the respondents in each of the six variables of patient safety culture when their profession was taken as a test factor. However, there is a difference in how the respondents grade or rate the patient safety culture in their institution. This is because there is a great deal of consideration given to the level of hospital that they are serving.

5. RECOMMENDATIONS

The first step to change is always the awareness of what is happening, thus the reporting culture must be strongly supported. Policies come from data and evidences, without outcome data, there will be no formulation of new policies or enhancement of existing procedures. The hospital management first and foremost should support any patient safety initiatives. They should appraise and recondition their current patient safety system including governance and reporting systems. The hospital administration must reduce the fear of blame culture and create a milieu of free communication and continuous learning. If the problem of personnel not reporting events is to be resolved, any barriers to reporting should be identified and addressed. Error-reporting should not be viewed as a means of learning from mistakes and the first step towards a better service towards patient satisfaction and safety. It is also recommended that hospitals use this questionnaire to assess the current patient safety culture in their own institutions. They can start with each units/areas to reflect the status of the hospital in terms of patient safety. When planning patient safety initiatives, differences in professional groups shall be addressed. Since various professions view patient safety differently, the approach must be acknowledging their differences in terms of profession, job position and area of work.

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