Do practice culture and clinician stress affect patient safety in primary care?

Initiatives to reduce medical errors in inpatient settings have found that sustained improvements in safety cannot be achieved by simply exhorting health professionals to “try harder” or making evidence-based care protocols widely available (1, 2). One obstacle to implementing changes is a toxic “blame and shame” culture that discourages physicians and staff from identifying or admitting medical errors, and therefore resists strategies to isolate and address their causes (3). To overcome this obstacle, leaders need to find ways to systematically change the culture. For example, Pronovost and colleagues incorporated interventions to create a “culture of safety” in the Comprehensive Unit-Based Safety Program that reduced medication errors, lengths of stay, and bloodstream infections in intensive care units at Johns Hopkins Hospital (4) and throughout the state of Michigan (5).

Patient safety studies in outpatient settings have mostly concentrated on minimizing prescribing errors through computerized order entry and improving communication between providers about abnormal test results (6). Compared to the inpatient setting, there are significant gaps in our understanding of what elements of primary care practice cultures and/or organizational climates may affect the incidence of medical errors.

The most ambitious observational study of the impact of organizational climate and physician stress on medical errors and care quality was the Minimizing Error, Maximizing Outcomes (MEMO) study (7, 8). MEMO was a 3-year longitudinal study of 119 practices in New York, Chicago, and Wisconsin that involved collecting data from more than 400 primary care physicians. Investigators used a 4-item scale derived to assess working conditions and organizational climate of primary care practices, and asked physicians about past errors and the likelihood of making future errors. Data from 1795 adult patients with diabetes, hypertension, or heart failure (1 to 8 patients per physician) was reviewed and analyzed for associations between care quality, medical errors (defined as missing recommended processes of care), practice culture, and physician satisfaction.

Although chaotic work environments and low control over their work were strongly associated with physician dissatisfaction, stress, and burnout in the MEMO study, and physicians perceived these factors as increasing their likelihood of making errors in the future (7), organizational climate had no consistent relationship with care quality or medical error scores (8). There are several possible explanations for the lack of association between organizational climate and patient outcomes in this study, including an overly restrictive definition of a medical error, too few patients analyzed per physician, and, of course, the possibility that practice culture did not affect the patient outcomes that were measured. Indeed, the MEMO investigators suggest that ”one interpretation of our findings is that physicians act as buffers between adverse work conditions and patient care – adverse working conditions affect them strongly, but their reactions do not translate into lower-quality care.”

There is considerably greater variation in size and structure among primary care practices than among intensive care units in the U.S., and that variation will likely make it more challenging to implement a “Comprehensive Primary Care-Based Safety Program” even if it proves possible to identify practice cultures that are more conducive to systematic interventions to reduce medical errors in outpatient settings. Nonetheless, several potential strategies have merit:

1) Experimenting with ways to permit primary care patients to report mistakes they observe in processes of care, no matter how inconsequential, so that practices can benefit from their additional perspectives.

2) Designing better systems, electronic or otherwise, to track pending test results to reduce harms associated with the failure to report abnormal results, such as delayed diagnoses.

3) Paying closer attention to adverse effects of clinicians’ chaotic work environments and sense of control (or lack thereof) over their work, two factors that track closely with career satisfaction.

4) Expanding the definition of a medical error in future studies to include not only acts of omission (e.g., not ordering a recommended test), but commission (e.g., unnecessary tests, drugs, or procedures).

5) Examining sources of variation in primary care culture across multiple practices and practice-based research networks.

Pronovost and Sexton observed several years ago about inpatient culture, “We must understand these sources of variation in order to target who to measure, how to score, where to focus efforts to improve culture, and [whom] to hold accountable for improving culture” (9). The same could certainly be said about the culture of primary care, where the science of patient safety is only beginning to move from making controlled observations of medical errors to designing interventions.

References
1. Woodward HI, Mytton OT, Lemer C, et al. What have we learned about interventions to reduce medical errors? Annu Rev Public Health 2010;31:479-97.
2. Curry LA, Spatz E, Cherlin E, et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? Ann Intern Med 2011;154:384-90.
3. Sexton JB, Thomas EJ, Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 2000;320:745-49.
4. Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program. J Patient Saf 2005;1:33-40.
5. Sexton JB, Berenholtz SM, Goeschel CA, et al. Assessing and improving safety climate in a large cohort of intensive care units. Crit Care Med 2011;39:934-39.
6. Gandhi TK, Lee TH. Patient safety beyond the hospital. N Engl J Med 2010;363:1001-3.
7. Williams ES, Manwell LB, Konrad TR, Linzer M. The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Health Care Manage Rev 2007;32:203-12.
8. Linzer M, Manwell LB, Williams ES, et al. Working conditions in primary care: physician reactions and care quality. Ann Intern Med 2009;151:28-36.
9. Pronovost P, Sexton B. Assessing safety culture: guidelines and recommendations. Qual Safe Health Care 2005;14:231-33.