STANFORD, Calif. -- Despite the many pronouncements at the nation's hospitals about the importance of patient safety, a study by researchers at the VA Palo Alto Health Care System and the Stanford Center for Health Policy/Center for Primary Care and Outcomes Research finds that hospitals have a lot of work to do in translating this avowed commitment into a work culture that truly promotes patient safety.

After comparing the results of safety-climate surveys administered to hospital personnel and to naval aviators -- a group known for their exemplary safety record -- researchers found that the hospital personnel were three times as likely, on average, to give "problematic" responses, suggesting potential safety concerns at their organization. The disparity was even greater when examining the responses of hospital personnel working in high-hazard settings, such as the ER and ICU.

"If hospitals want to achieve a uniform safety climate, they have a lot more work to do," said David Gaba, MD, director of the Patient Safety Center of Inquiry at VA Palo Alto, professor of anesthesia at Stanford University and first author of the paper, published in the current issue of the journal Human Factors. "Certainly we don't have to make health care just like naval aviation, but we can learn from the way they do things."

While there has been considerable study into the "safety culture" of health-care organizations, the Stanford study is the first to compare hospitals with a recognized "high-reliability organization"-- one that makes very few errors despite dealing with considerable hazards and unpredictability. U.S. naval aviation is considered a prime example of a high-reliability organization; its rate of major accidents since 1999 is approximately 1.5 per 100,000 hours flown. "If hospitals truly aspire to be high-reliability organizations, they ought to have a safety climate that's similar to successful HROs," said Gaba.

The research stems from a collaboration among the Naval Postgraduate School in Monterey, Calif., the Patient Safety Center of Inquiry, and the Center for Health Policy/Center for Primary Care and Outcomes Research, of which Gaba is a fellow. Gaba knew that the Naval Postgraduate School periodically administers an anonymous safety-climate survey, called the Command Safety Assessment Survey, to all squadron personnel. To see how hospitals measured up, he and colleagues from VA and Stanford developed a similar survey for hospital personnel and included 23 of the Navy's survey questions, adapted to the hospital environment.

The resulting survey was administered in 2001 to about 6,300 hospital personnel at 15 California hospitals, including physicians, nurses, technicians and senior management; nearly 3,000 of the surveys were completed. The researchers then compared the responses with those of 6,900 naval aviators who completed the Command Safety Assessment Survey between 1998 and 2001.

The researchers hypothesized that the rate of "problematic" responses would be significantly higher among the hospital personnel; in fact, the hospitals' results were worse than expected. The average rate of problematic responses was 5.6 percent for the naval aviators, 17.5 percent for all hospital personnel, and 20.9 percent for high-hazard hospital personnel.

"The magnitude and consistency of the difference surprised us," Gaba said.

The difference was particularly striking on certain questions. Given the statement, "Management provides adequate safety backups to catch possible human errors during high-risk activities," 23.7 percent of the hospital personnel disagreed, versus just 2.7 percent of the naval aviators. For the statement, "Management has a clear picture of the risks associated with [the organization's] operations," 21.9 percent of the hospital personnel disagreed, versus just 1.9 percent of the aviators.

Most of the hospital personnel and aviators surveyed indicated that their organization was committed to safety. Gaba said this proves that simply voicing a commitment to safety isn't enough; rather, hospitals must implement standardized processes and rigorous training and assessment of personnel. Consider, he said, that all naval aviators are graded on every landing, and if their grade falls below a threshold, they must become recertified. In contrast, he said, most hospitals don't regularly assess the performance of their personnel.

Hospitals' ability to create a climate of safety is limited by several factors, the paper notes. While the Navy has one central command that sets all policies and procedures, for example, the hospital sector is highly decentralized. Another challenge: Physicians are largely autonomous because, in most cases, hospitals don't employ them and can't exert much control over how they practice.

Gaba acknowledged that health care is fundamentally different from naval aviation and said, "the idea is not to make medicine like a cookbook." Still, he said, "our research shows we're missing out on the benefits of standardized procedures."

The paper describes safety-promotion strategies that have proven successful in other industries and are now being tested in hospitals. In one program, senior managers periodically shadow front-line workers, enabling managers to appreciate the complexity and hazards of front-line work. Other approaches emphasize rigorous employee training and assessment, particularly using simulation exercises and technologies.

The study was funded by the Agency for Health Care Research and Quality and the Veterans Health Administration's Patient Safety Centers of Inquiry program. Collaborators include Sara Singer, Anna Sinaiko and Jennie Bowen from Stanford, and Anthony Ciavarelli, Ed.D, at the Naval Postgraduate School.

The Center for Health Policy and the Center for Primary Care and Outcomes Research are sister centers at Stanford University that conduct innovative, multidisciplinary research on critical issues of health policy and health-care delivery. Operating under the Stanford Institute for International Studies and the Stanford School of Medicine, respectively, the centers are dedicated to providing public- and private-sector decision-makers with reliable information to guide health policy and clinical practice. For more information, go to http://healthpolicy.stanford.edu.