Organizational health and patient safety: a systematic review

Introduction

Over 400,000 deaths and millions of injuries from preventable medical errors occur every year in the United States (US) (1). These errors have been cited as the third leading cause of death in the US and mitigating efforts have missed the mark, as preventable deaths and adverse events have persisted at worrying rates (2-4). Many interventions have been applied at the frontlines, suggesting that the impetus of these errors lies at the bedside (1,5-12). An understanding that these preventable medical errors may be symptoms of underlying organizational factors is lacking (13).

The World Health Organization (WHO) notes that overall system characteristics are poorly studied and evaluated yet impact every intervention that is done within hospital systems (14). It has been noted that years of linear analyses and regulatory mandates have not altered the rates of adverse events for the last 50 years and suggest that a systems approach be adopted for the furtherance of patient safety (13). In this context, “linear” refers to the conceptualization of clear cause and effect without consideration of complex confounding variables. The objective of this systematic review is to describe the current state of the science regarding the communication of organizational-level issues that influence organizational health and compromise patient safety. Patient safety is an important consideration in the provision of patient-centered care (15). This will illuminate gaps in knowledge that future research endeavors can then address. We present the following article in accordance with the PRISMA reporting checklist (available at http://dx.doi.org/10.21037/jhmhp-20-57).

Methods

A comprehensive review of the literature was done to isolate pertinent studies that address the communication of organizational-level events that influence organizational health and compromise patient safety. The literature search was done in August of 2019 using the CINAHL, PubMed, and Cochrane Library databases to isolate studies that were published between 2009–2019. The key terms used were “hospital”, “organizational culture”, “organizational health”, “communication”, “adverse events”, “error”, and “system-level”. The inclusion criteria used were: peer-reviewed articles concerning humans and written in English from 2009 to 2019. Exclusion criteria applied were books, book reviews, commentaries, literature reviews, letters to the editor, non-English articles, and presentation abstracts. These were excluded related to their representation of less rigorous evidence and in the case of non-English articles, related to their incomprehensibility by the primary researcher. Please see Table S1 for a depiction of the search strategy. After 21 duplicates were removed, 2,131 titles were manually evaluated by one researcher for their alignment with matters concerning organizational health and patient safety. Of these, a total of 82 remained for abstract review, and 31 articles were manually chosen for evaluation by one researcher via thematic analysis related to their fit with the inclusion criteria and the delineated area of research concerning organizational health and patient safety (16). Issues of bias were mitigated via bracketing of values and personal opinions to promote neutrality. Peer review by second researcher was sought to bolster rigor and rule out the presence of implicit bias. Please see Figure S1 for a flow chart showing the process of article selection and Table S2 for a visual summary of the articles used in the systematic review.

Results

Thematic analysis was used to identify themes and categories within the textual data of the chosen articles (16). The identified themes included: nature of change, communication, impact of environment, human factors, interdisciplinary collaboration (IC), role of leadership, organizational and team culture, patient safety, and system-level factors. Nearly half (15 of the 31) of the articles discussed the role of communication and almost all (30 of 31) addressed patient safety.

Nature of change

A review of the literature reveals that change within the realm of healthcare is unpredictable and non-linear (17-19). Meaning that because of the complex nature of hospital systems and the convoluted interconnections between subsystems, interventions may have outcomes that are not straightforward or expected (17). Parsons and Cornett (2011) describe that a multiplicity of dynamic and shifting factors over time is the impetus for these unpredictable effects (19). Furthermore, it is suggested that the very health of hospitals hinges on an ongoing evolution and transformation (19). Individualized resistance to change is described as an inhibitor to safety implementation efforts (18) and organizational-level factors are noted as both precarious and difficult to change (20). Finally, practice change holds the potential to negatively impact staff morale, however, the presence of effective communication can help mitigate this effect (12).

Effects of communication

Communication is a well-represented theme within the reviewed literature. Effective communication is portrayed as an integral component of bolstering patient safety and ineffective communication is described as a significant contributor to patient harm (11,20-26). More specifically, poor communication is regarded as something that damages relationships and organizational processes, in addition to potentiating ethical conflicts (20,23). Communication is complex and hindered by unclear policies and conflict avoidance (23,25,27). Although poor communication patterns are difficult to reverse, efforts of change can be supported by relationships, delineation of clear expectations, and organizational dimensions (23,24). Effective communication informs a systems approach to patient safety and supports organizational goals, while transparent communication regarding adverse events helps organizational learning for the betterment of patients (23,27).

Impact of environment

The internal and external environments of hospitals are regarded as influencers of patient safety (18,21,26-28). Review of the literature suggests that psychosocial work environments and team culture have strong associations with patient complications and preventable medical errors (18,26). Positive work environments that support transparency are associated with higher rates of adverse event reporting (27). Preliminary data reveal that failure-to-rescue rates of patients with similar demographics and disease states vary widely from hospital to hospital, suggesting that mortality is a nonlinear event impacted by the environment in which patients find themselves (18). Some environmental factors cannot be modified—such as rural hospitals or those serving minorities being associated with poor outcomes (28).

Human factors

Issues pertaining to human factors impact matters of patient care. The term human factors refer to the limitations and needs of humans as they interact with machines and technology. Pertinent considerations include anthropometric, motor, perceptual, cognitive, social, cultural, and psychological needs (29). People are described as being as unique as their varied backgrounds. In turn, organizations are filled with a plethora of diverse people (23). Systems do not always accommodate the needs of these users, necessitating the creation of innovative workarounds. Heavy reliance on workarounds and poor use of working memory hold the potential to impact the safety of patient care (17). One such issue was described by Topaz and colleagues (2016), who noted that electronic health record usability issues can lead to medical errors and adverse events (30).

Interdisciplinary collaboration

Collaboration within and across disciplines is a recurrent theme in the literature. Interdisciplinary work is described as an essential element for effective and safe patient care delivery, but something that is challenging and not supported in most hospitals (17,24,31-34). Furthermore, IC is described as a necessary component for the promotion of change and something that influences patient care environments (18,24,26,34,35). Inadequate IC is explained as being positively associated with ethical conflicts and increased adverse events (20,26). Workarounds and negotiation are noted as sometimes necessary to accommodate IC, however, organizational-level change is expressed as something that can support IC (17,24). Adequately supported IC is associated with transparency and increased patient safety perceptions (21).

Role of leadership

Leadership is described as a behavior rather than a prescribed role (36). Leaders are shown as the ones who set the tone of an organization and whose actions reveal the etiology of system-level priorities and processes (19,24,33,37). Leaders are responsible for nurturing ethical patient care environments and supporting sustained changes that promote quality nursing care and a safety culture (20,21,24,26,30,31,33,35,38). Supportive and committed management processes have been shown to increase patient safety, whereas poor leadership or frequent leadership turnover have been respectively linked to compromised patient safety and organizational impacts (19,21).

Organizational and team culture

Elements pertaining to culture are heavily represented in the literature. Organizational and team cultures are described as complex, difficult to change, and instrumental influencers of nurse satisfaction, health care quality, and the occurrence of adverse events (12,18,21,24,26,27,32). When wishing to promote change within a hospital environment, culture and prevalent behaviors must be considered (35,39).

Organizational learning is discussed as a key feedback loop and promoter of patient safety (21,24,33,36). Prevalent hierarchical structures tend to perpetuate ethical conflicts and stifle organizational learning (20,36). Ingrained power differentials encourage conflict avoidance, impact moral actions, and affect patient care (25). Although sometimes challenging to establish, shared governance provides a foundation upon which safety culture can be built (17,19,20,34).

Although perceptions of conflict and horizontal violence can be insidious, they hold the potential to impact hospital organizations (23,25,39). Hospitals are ripe with competing expectations, where efficiency and ethicality are often at odds (23,25). Such incompatible expectations can lead to fragmented care with reduced nurse efficacy, increased medication errors, and compromised patient safety (17,23,25,30). Siloed care delivery is viewed as a hindrance, rendering patient care ineffective and compromised (17,30).

Although the effects of a blame culture are not fully understood, it is associated with stifled communication, perpetuated errors, and hindered patient safety (12,21,25,36). Despite the knowledge that individuals should not be blamed for poor communication or conflict, sanctions aligned with a blame culture persist (21,23,40). Conversely, trust has been described as influencing organizational factors such as communication, system functionality, organizational learning and performance, and safety culture (17,40). Trust is approached differently from one organization to the next but should be sought in moderation, as excessive blind trust can be as detrimental as inadequate trust (40).

Patient safety

Patient safety largely involves freedom from preventable medical errors that pose the risk of death or harm to individuals or the public (11,12,21,34). It is thought that adverse events from errors are perpetuated by system-level issues, such as employee satisfaction or unprofessional environments or attitudinal patterns, and are largely underreported (32,36,38). Other pertinent contributors include horizontal violence and staff who feel their levels of autonomous control are waning while responsibilities escalate (38,39). Although missed nursing care is a frequent issue, medication errors are one of the most common preventable medical errors documented to date (7,12). Incident reporting and personal attention to detail have been found ineffective tools in mediating the occurrence of adverse events (24,34). Although much attention has been given to the patients who have been personally affected by adverse events, healthcare providers who have executed preventable medical errors also experience negative consequences such as anxiety, and reduced confidence in performance and professional skills (41).

Perception of patient-safety culture includes elements of mission and vision and has been shown to be cultivated by academic facilities and through on-the-job experience (21). Academic hospitals with over 200 beds, increased nurse-to-patient ratios, and enhanced technology, have been associated with lower failure-to-rescue rates (18). Patient safety cultures are multifactorial and supported by teamwork, IC, and communication (21,24). Safety research studies are challenging to conduct; however, new solutions are waiting to be discovered and should include a systems-level approach with attention to cost-benefit analyses (12,35,42). Nurses may be at the helm of such efforts (20).

System-level factors

Hospitals are complex adaptive systems with many interacting subsystems that impact patient care and adaptively produce more than the mere sum of their parts (17,19,20,43,44). As the number of interacting subsystems rises, the risk for adverse events, such as medication errors, increases (22). However, this risk can be mitigated by the effective integration of these subsystems (17). Hospital organizational-level factors, such as communication, impact staff, patients, care quality, ethical dilemmas, and the occurrence of preventable medical errors. To address this, a system approach is necessary, as efforts to improve systemic issues such as patient care and safety cannot be accomplished by isolated individuals (17,19-21,24,27,28,34,37,39,45). It has also been suggested that organizational factors, as opposed to individuals, can perpetuate horizontal violence, ethical conflicts, and moral compromise (12,20,24,39). Likewise, positive care characteristics that set apart magnet facilities are supported by organizational-level factors (19). It is important that nurses are educated about Systems Theory in order to analyze, act, and promote organizational-level initiatives for the betterment of patients (42). Please see Table S3 for a summary of the factors thought to impact organizational health and patient safety.

Discussion

A review of literature from the last decade suggests that consideration should be given to the unpredictability and nonlinearity of change as well as the impacts of system-level factors such as culture, communication, human factors, and the environment on staff, patients, and the occurrence of preventable medical errors. Given the complex nature of hospitals, well-intended interventional efforts may have unforeseen consequences (14,43,44). Effective communication that is bolstered by trust can improve system functionality and breakdown the propensity for (and impacts of) siloed care delivery (17,30,40). It is clear that leadership’s embrace and assistance with a system-level approach and IC is key to the furtherance of patient safety (17,18,21,24,26,31-35,37). This hinges on leadership as a behavior that prioritizes and supports processes that optimize system-level health and a culture of safety (21,24,36,37). In this way, leadership can set the tone of their respective organizations by nurturing environments that work toward these goals (19,21). This can be largely helped by fostering opportunities for open and frequent communication between both individuals and systems within hospital organizations (21-24,27).

Strengths and limitations

The synthesized results are tempered by methodological limitations in the reviewed studies. Only 12 of the 31 articles used a guiding theory or framework (6,19,20,23,24,30-32,36,37,42,46). Merely two of the quantitative studies considered confounding variables, adjusting for age (18) and time of year (11). Just one qualitative study reviewed issues pertaining to trustworthiness (19,47) and less than half discussed issues of bias (6,12,17,18,21,24,26,27,31,33,41). Finally, it was not clear that all studies ascribed to a standardized definition of adverse events or preventable medical errors. Trustworthiness of this systematic review was bolstered through the detailed description of the article selection process and analysis to support consistency and transferability. Although manual thematic analysis holds the potential for bias, this was limited through bracketing of values and preconceived opinions to promote neutrality (47).

Conclusions

Demise from preventable medical errors have been cited as the third leading cause of death in the US (3). Many efforts to allay risks from these errors have been applied at the bedside and have been largely unsuccessful (2,48). Literature suggests that organizational-level factors are the impetus for preventable medical errors, and as such, mitigating efforts should be crafted with an organizational approach in mind (12,17,19,21,22,24,27,28,39,45,46). Although strides have been made in recognizing the impact that organizational-level factors have on patient care, many interventional efforts continue to be applied with a parochial focus (2).

Conducting this systematic review revealed areas for further investigation. Only one article directly discussed the effects of preventable medical errors on staff, and the ultimate impact such effects have on patient care (41). Further research is needed to learn the perceptions of hospital personnel regarding the impetus and effects of medical errors on them and the delivery of patient care. Additionally, much focus in the literature is given to the role of communication, however, the content and methods of communication are largely unknown. Specifically, how are threats to organizational health communicated and to whom? What communication channels and technology are used? Lastly, it is clear that general organizational-level elements have an impact on patient safety and the occurrence of preventable medical errors. Continued research is needed to elucidate details regarding the distinguishable features of these elements and how they impact organizational health so that future interventional work may be pursued. This article was completed in accordance with the AME Publishing Company Submission Guideline.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Naleef Fareed, Ann Scheck McAlearney, and Susan D Moffatt-Bruce) for the series “Innovations and Practices that Influence Patient-Centered Health Care Delivery” published in Journal of Hospital Management and Health Policy. The article has undergone external peer review.

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at http://dx.doi.org/10.21037/jhmhp-20-57

Peer Review File: Available at http://dx.doi.org/10.21037/jhmhp-20-57

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jhmhp-20-57). The series “Innovations and Practices that Influence Patient-Centered Health Care Delivery” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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