The safety culture of the Ljubljana community health centre’s employees

Patient safety is one of the key aspects of healthcare quality and a serious global public health concern (1). It is defined as the reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum (2). Patient safety culture is a part of the patient safety concept. It is defined as a product of attitudes, values, competencies and patterns of individual and group behaviour that determine healthcare in an organization (3). To improve patient safety, an important first step is to address and understand the safety culture of an organization. An understanding of the safety culture is vital to improve problematic practices or attitudes such as miscommunications, adverse events and non-punitive responses to errors, which can lead to improvements in the safety culture (4). For the past several years, safety culture has been one of the top priorities of the Slovenian Ministry of Health. A new system for managing safety deviations and safety risk is being established in 2021 (5). More and more studies are emerging regarding patient safety and safety culture in primary care (4, 6). Measuring safety culture can help in the identification of areas for improvement (4). A recent systematic review showed that patient care follow-up, communication openness and work pressure contribute significantly to improving patient safety in primary care (7).

In Slovenia, several studies have focused on quality and safety at the primary healthcare level, focusing on out-of-hours care, family practices and leadership staff (8, 9, 10, 11). Safety culture has only been evaluated at the primary healthcare level in out-of-hours primary healthcare settings. These studies showed variations in safety culture factor scores that pointed to the need to unify working conditions (12, 13, 14).

The aim of the present study was to assess patient safety culture among all employees of the largest healthcare centre in Slovenia, the Community Health Centre Ljubljana. Our study is the first to evaluate patient safety culture at the primary healthcare level in Slovenia using the Medical office survey on patient safety culture (MOSOPS).

This was the first study investigating patient safety culture at a community healthcare centre in Slovenia. It showed that the teamwork and patient care scores were the highest and the workload score was the lowest among the employees. There are some differences in the individual domains of the safety culture by individual units of the Community Health Centre Ljubljana, age, office position and the time they have worked at the current location of the medical practise.

Women generally assessed patient safety and the quality of treatment higher than men. Firth-Cozens explained this because female primary care physicians engage in more communication, which can be considered patient-centred, and have longer visits than their male colleagues (22). Other studies also found differences by gender. The Polish study found that women rated certain domains significantly better (patient care tracking and follow-up, overall perception of patient safety and quality) (23). Men had better results in information exchange with other settings. In Spain, the following domains were evaluated better by female than by male participants: information exchange with other settings, work pressure and pace, staff training, office processes and standardization, patient care tracking/follow-up, leadership support for patient safety and overall perception of patient safety. However, it was men who had a slightly better score in overall rating on patient safety (24). The Dutch study found no significant differences between male and female healthcare providers in terms of mean factor scores (25).

Employees working part time compared to full-time graded the overall quality lower. Similar results were found in a Slovenian study regarding safety culture in out-of-hours primary care clinics (12). They concluded that employees working part-time might not be so confident in their performance, and thus perceive patient safety lower. Those with more working years assessed the safety and quality of care lower. More experienced workers might be more aware of potential safety problems.

Doctors generally estimated the overall quality of healthcare higher than nurses did. In Slovenia’s primary care the doctors spend more time with the patients than nurses, which differs from secondary healthcare levels. Thus, doctors are likely to show strong awareness with respect to a multitude of patient safety aspects. This is in contrast to studies conducted at secondary and tertiary level where nurses scored the majority of patient safety culture aspects higher than doctors, most likely because spending more time with patients allows for better awareness of patient safety (26). Differences in the patient safety culture among the professional categories were also found in other studies (17, 27).

Teamwork was the highest-ranked domain (79.6%). In two studies carried out in Slovenian out-of-hours healthcare clinics and in a hospital setting, teamwork scored high (12, 28). Results correlate to the Slovenian study on ethical dilemmas in family medicine, where teamwork was assessed as well functioning (29). Teamwork is also a highly ranked domain in other countries (22, 25, 26, 27, 28, 29). Teamwork is a strategy for strengthening and promoting quality of care and healthcare practices in health systems (32). It is very important in primary care, as multi-professional healthcare stakeholders are involved in managing patients (12).

Our study showed that 60.2% of respondents expressed a positive view on communication about errors at their medical offices, which was the lowest score among all studies compared. Poland evaluated their communication about errors as the highest (80.96%) and Portugal the lowest (47%) (20, 23). Employees need to feel that they will not be blamed, punished or concealed for acknowledging errors (33, 34). There is a need to educate healthcare professionals on how to deal with errors made, teaching them about non-blaming, open and emphatic communication, and about complete and authentic apology and coping strategies (34). A positive safety culture could help in encouraging honesty and fostering learning by balancing individual and organisational accountability to achieve better quality care.

43.9% of respondents had a positive view on communication openness. Communication openness seems to be of concern only in certain countries, which might be associated with differences in cultural background (4). A non-experimental cross-sectional study in a general acute hospital in Slovenia raised concerns about how to deal with patient safety problems. The problems may be related to blaming and shaming individuals rather than a systemic approach that encourages learning and aims to prevent adverse events (28, 35). Communication breakdowns, which both affect both safety culture and act as a contributing factor for incidents, must be emphasized and addressed (4).

The lowest scores were found for the leadership support for patients’ safety (39.2%) and work pressure and pace (11.5%). Scores for both are the lowest among the countries that used MOPSOS questionnaire. Regarding work pressure and pace Poland (57.7%) and Yemen (57%) scored the highest, followed by American respondents (50%) and primary care offices in Ohio (37%) (21, 23, 30, 31). The lowest scores come from Spain (36%) and Portugal (25%) (20, 24). Regardless of the job position, staff feel rushed when taking care of the volume of patients that need to be seen and do not feel that there are enough staff to handle their patient loads and work effectively. On average, physicians rated work pressure and pace lower. A Slovenian study published in 2012 showed an average of direct physician-patient consultation/encounter of 7 minutes (36). This contrasts sharply with the typical duration in other European countries where most nations conduct 15-minute consultations, while the Scandinavian countries veer towards 20–25 minutes (37). The nations with 25 consultations or less a day find general practice manageable. The majority (60%) of Slovenian family doctors have 41-60 consultations per day and 19% have 61–80 (38). WHO evidence indicates a lower number of general practitioners in Slovenia compared with European Union (i.e. 49.78 vs 79.47 per 100,000 inhabitants) (39). The issue of insufficient staff and providers for the treatment of patients in primary care has also been raised in other studies (4). An appropriate work environment was characterised as one where workers were interrupted less often and is associated with better patient safety and less burnout. Lower workloads improve adherence to patient-safety principles (40).

There is a need for more detailed assessment of the factors contributing to workloads in primary care and of how these factors can be addressed and mitigated in order to develop interventions to improve the delivery of safe and efficient patient care (41).

The strength of this study is that it was conducted in a large community health centre, which resulted in a large sample to be used in our analyses. Moreover, this is the first study to use the Slovenian version of MOSOPS. The response rate was 67.8%, which is above the recommended response rate of 60% in research on patient safety culture (42).

There were however several limitations to this project. The Community Health Centre (CHC) Ljubljana is only one of many health centres throughout Slovenia and the sample does not accurately reflect Slovenian primary healthcare. CHC Ljubljana is stationed in an urban environment, while primary care in Slovenia is distributed within the both environments. The respondents may not have felt comfortable enough to express their safety concerns about the organization, although the risk was minimized by expressing confidentiality. The question still remains whether self-reporting questionnaires are suitable for measuring patient safety culture, as they only provide a snapshot of the culture at a certain point in time. As the majority of respondents were physicians and nurses, the results did not adequately reflect the perception of other respondents’ groups. It would be beneficial to analyse the reasons why other professions did not readily participate. Although the response rate was high, there is no information on the characteristics of the non-respondents, so this could also be a source of bias. Based on their participation, they may have better awareness of patient safety climate than those that did not participate in the survey. In addition, the categories included staff from different specialities (e.g. family medicine, dentistry, gynaecology, emergency medicine, etc.). In the future, this additional information should be recorded and analyses carried out to determine whether there are differences between respondents within the categories. The results of the present study therefore must be interpreted carefully.

It would also be necessary to examine patient safety culture with other approaches. Trbovich and Griffin recommend triangulation of both quantitative and qualitative methods to achieve a more accurate assessment of the culture (43). Other techniques such as interviews, workshops and focus groups are recommended to put survey responses in context. Research using mixed methods would to help gain further insights into the patient safety culture and to reveal the differences observed between the occupational categories.

The current patient safety culture at the Community Health Centre Ljubljana is good, with a lot of room for improvement. It revealed variety between professions, indicating that a customized approach per profession group might contribute to successful implementation of safety strategies. Improving patient safety culture should also include all stakeholders (policymakers, healthcare providers and those responsible for medical education). Patient safety culture at the national level should be studied.