Perception of Patient Safety Culture at the Primary Care Level: The Case of the Community Health Centre Ljubljana

Patient safety is a critical component of quality healthcare, and efforts to improve it are essential for achieving universal health coverage and improving patient outcomes. The World Health Organization defines patient safety as a “framework of organised activities that creates cultures, processes, procedures, behaviours, technologies and environments in healthcare that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make errors less likely and reduce impact of harm when it does occur” (1).

Prioritising patient safety in healthcare settings has gained greater recognition in recent years (2). Achieving optimal patient safety requires a safety culture that promotes open communication, transparency, and continuous learning (1). It entails a shared understanding that safety is a top priority and everyone’s responsibility (3), necessitating systems that encourage error reporting, root cause analysis, and effective preventive strategies (1, 3).

Patient safety in primary healthcare in Slovenia varies significantly from secondary to tertiary levels. Acting as a gatekeeper to hospital care, primary care is accessible and involves frequent patient contact (4, 5) with diverse health issues. Health providers are often required to make complex decisions with limited information (6). Hence, it is crucial to be comfortable with uncertainty, explore probabilities, and minimise risks (7).

Patient safety culture remains unregulated in Slovenia, and thus there is a need for more quality assessment with regard to enhancing the quality of work in this sector. Unfortunately, punitive measures and fault-based liability persist (8). As Slovenia increasingly focuses on “value-based healthcare” to optimise patient treatment outcomes, a stakeholder expert panel has been formed to develop a roadmap for its implementation (9).

The safety culture in Slovenian out-of-hours primary healthcare settings was recently assessed, with the results showing the need to standardise working conditions (10, 11). While leaders in Slovenian primary healthcare organisations generally express positive perceptions of safety culture, there remains room for improvement in communication and stress recognition (12). The only study evaluating the perception of patient safety culture among employees at the Community Health Centre Ljubljana (CHCL) was conducted in 2017, and this revealed an overall good patient safety culture. However, variations between professions were noted, and certain areas require further evaluation (4).

Regularly assessing patient safety culture is crucial for identifying areas of improvement and ensuring optimal patient care (13, 14). This study thus aimed to evaluate employee perceptions of patient safety culture at the CHCL and explore the relationships among different dimensions of patient safety and the sociodemographic characteristics of the study participants.

This study provides valuable insights into the perception of safety culture at CHCL, highlighting areas that require attention to enhance patient safety. While five dimensions of MOSPSC are identified as strong (Information exchange with other settings, Organisational learning, List of patient safety and quality issues, Patient care tracking/ follow-up, and Teamwork), there are still areas in need of improvement, namely Work pressure and pace, Leadership support for patient safety, Communication openness, Office processes and standardisation, and Overall ratings on quality and patient safety. Additionally, the research indicates variations in the MOSPSC domains based on CHCL’s individual units, employee age, different professional profiles, and length of employment.

The present study found no significant relationship between any of the safety culture composites and gender, similar to a study in Greece (19). In contrast, Polish (20), Spanish (21) and Slovenian (4) studies revealed that women rated certain domains higher than men. Our study showed a positive relation between seniority and responses referring to Staff training, Office processes and standardisation and Patient care tracking/follow-up. A study in Spain also showed the best perception of safety culture was among respondents 56 to 69 years old (21). We found differences in the patient safety culture among the professional profiles and so did other studies (4, 21–23).

Information exchange with other settings (93.5%) received the highest score, indicating effective communication and collaboration. This is an essential component of a strong patient culture in healthcare, as it enables healthcare providers to share important patient information and coordinate care across different settings (16). Teamwork (75.0%) and Organisational learning (90.2%) were also among the highest rated MOSPSC dimensions which is consistent with studies from Spain (21), Brazil (24), Yemen (25), Iran (26), and Poland (20). These findings highlight the importance of comprehensive primary care in promoting and strengthening teamwork, as multi-professional healthcare stakeholders are involved in managing patients (10). Moreover, this dimension is essential because it influences the health professionals’ satisfaction and participation, and promotes personal and professional well-being (24). In addition, the emphasis on organisational learning is also an important aspect of promoting quality and safety. Through ongoing evaluation and improvement of healthcare practices, healthcare professionals can continuously learn and adapt to changing patients’ needs and healthcare environments (21).

The dimension List of patient safety and quality issues considers daily tasks such as access to care, patient identification, accessibility of medical records, medical equipment, medication and diagnostics (16), and these were assessed as having a strong safety culture (88.1%). This dimension was the highest scoring for all professional categories in the Spanish study (21). A strong safety culture was also evident in the Patient care tracking/ follow-up dimension (76.2%), especially when compared to two Brazilian studies (56.1%) (23) and (60.1%) (24) and a Yemeni study (52%) (26). This dimension ensures that patients receive timely and appropriate care (17). In our study, doctors assessed it worse (p=0.049) than registered nurses and healthcare assistants, and it is essential to identify the reasons for this discrepancy, which may involve a lack of communication and coordination among healthcare providers.

We identified a weak safety culture in Work pressure and pace (10.7%) and Leadership support for patients’ safety (27.1%), with the lowest scores. Notably, the dimension of Work pressure and pace is a significant concern for patient safety in primary care, consistently associated with low scores across various studies (4, 20, 21, 24, 25, 27). Research highlights challenges in primary care settings, emphasising issues such as inadequate staffing levels to manage patient loads (4, 14, 26, 27). Healthcare professionals in CHCL gave the lowest scores for this dimension, aligning with the shortage of personnel and high workload among family medicine doctors (8) and nurses in Slovenia, with negative impacts on healthcare quality and safety (28). Understanding and addressing factors influencing workload is crucial for developing interventions to improve efficiency, reduce work pace, and prevent burnout (17, 27). For the sustainability of the Slovenian healthcare system it is essential to transfer health competences and responsibility from healthcare professionals to empowered patients (8, 29). To this end, CHCL recently introduced a model of peer support with trained lay individuals who are CHCL’s volunteers and ambassadors, with the aim of empowering patients, family members and informal caregivers in the local community (29).

In the Overall ratings on quality and patient safety dimension (49.4%), administrative staff scored significantly lower than employees in other profiles, aligning with Hickner’s et al. study (17). Continuous education and training are instrumental in improving the skills and knowledge of all employees (14). Regarding the overall quality assessment, Equitability (69.8%) obtained the highest score. This can be attributed to the CHCL’s pivotal role as Slovenia’s largest primary health centre, in promoting health equity and reducing disparities. By addressing social determinants, it can enhance the health and well-being of its diverse population.

While the overall MOSPSC composite percent positive score of 59.6% falls below the threshold for a positive assessment, it surpasses the observed scores in other primary healthcare settings (23, 24). In contrast, studies in Poland (20), Yemen (25), Iran (26), and Greece (19) reported positive overall MOSPSC composite percent positive scores. Nonetheless, CHCL has demonstrated ongoing efforts over the years to enhance patient safety culture and care quality. This commitment is further underscored by its recent participation in the OECD initiative, focusing on the outcomes and experiences of patients receiving care in family medicine practices (30).

A notable strength of this article could be in its chronological consistency, employing the same methodology to assess the environment at CHCL over time. In contrast with the one prior study at CHCL in 2017, where 37.3% of the respondents reported a positive score for the Overall ratings on quality and patient safety dimension (4), the current result of 49.4% is promising. However, it must be interpreted carefully, given our study’s low response rate of only 24.1%, compared to 67.8% in the 2017 study (4).

However, several limitations of this study should be acknowledged. The CHCL represents just one of numerous health centres in Slovenia, and the sample may not accurately reflect the diversity of Slovenian primary healthcare. Additionally, the findings may not be generalisable to the entire CHCL, given the study’s low response rate of 24.1%, possibly indicating organisational or leadership culture issues. The participants might not have felt entirely comfortable expressing safety concerns, despite confidentiality assurances. Those who chose to participate may also have had a heightened interest or knowledge about the topic, introducing potential bias. Encouraging healthcare professionals to identify and report errors without fear or blame is crucial, fostering a shift from an accountability to a just culture, focused on learning to prevent errors (21, 31). As most respondents were registered nurses, healthcare assistants and physicians, the results did not adequately reflect the perceptions of management and administrative staff. This aligns with the common misconception that only healthcare staff bear responsibility for patient safety and incidents. As such, delving into the reasons for the limited participation of other professional groups is crucial. A thorough understanding of the barriers these groups face in this regard can guide the development of more effective strategies to engage them in research.

Additionally, it is important to note a limitation related to the MOSPSC’s validation, which originally focused on participants in leadership positions (15). Further psychometric evaluation is necessary, considering the diverse roles within our participant population. Moreover, not using open-ended questions may limit understanding healthcare professionals’ perceptions of safety culture (24), emphasising the need for a combined quantitative and qualitative approach. Given these limitations, it is crucial to interpret the study results carefully.

This study offers insights into the perception of the safety culture at CHCL, pinpointing areas for attention to further enhance patient safety. Although five dimensions of the MOSPSC were identified as strong, there are still areas needing improvement. It is crucial for CHCL leadership to address these issues, redesign processes, and implement improvement strategies that reduce patient safety incidents. Fostering a just culture within the organisation is imperative with regard to enhancing future participation rates, where employees are comfortable reporting errors, learning from them, and promoting transparency. Continuous effort, monitoring and improvement can ultimately contribute to the delivery of safe, effective, and high-quality patient care.