Objective: To understand fundamental attitudes towards patient safety culture and ways in which attitudes vary by hospital, job class, and clinical status.Design: Using a closed ended survey, respondents were questioned on 16 topics important to a culture of safety in health care or other industries plus demographic information. The survey was conducted by US mail (with an option to respond by Internet) over a 6 month period from April 2001 in three mailings. Setting: 15 hospitals participating in the California Patient Safety Consortium. Subjects: A sample of 6312 employees generally comprising all the hospital's attending physicians, all the senior executives (defined as department head or above), and a 10% random sample of all other hospital personnel. The response rate was 47.4% overall, 62% excluding physicians. Where appropriate, responses were weighted to allow an accurate comparison between participating hospitals and job types and to correct for non-response. Main outcome measures: Frequency of responses suggesting an absence of safety culture ("problematic responses" to survey questions) and the frequency of "neutral" responses which might also imply a lack of safety culture. Responses to each question overall were recorded according to hospital, job class, and clinician status. Results: The mean overall problematic response was 18% and a further 18% of respondents gave neutral responses. Problematic responses varied widely between participating institutions. Clinicians, especially nurses, gave more problematic responses than non-clinicians, and front line workers gave more than senior managers. Conclusion: Safety culture may not be as strong as is desirable of a high reliability organization. The culture differed significantly, not only between hospitals, but also by clinical status and job class within individual institutions. The results provide the most complete available information on the attitudes and experiences of workers about safety culture in hospitals and ways in which perceptions of safety culture differ among hospitals and between types of personnel. Further research is needed to confirm these results and to determine how senior managers can successfully transmit their commitment to safety to the clinical workplace.

Context Twenty-five years ago, private insurance plans were introduced into the Medicare program with the stated dual aims of (1) giving beneficiaries a choice of health insurance plans beyond the fee-for-service Medicare program and (2) transferring to the Medicare program the efficiencies and cost savings achieved by managed care in the private sector. Methods In this article we review the economic history of Medicare Part C, known today as Medicare Advantage, focusing on the impact of major changes in the program’s structure and of plan payment methods on trends in the availability of private plans, plan enrollment, and Medicare spending. Additionally, we compare the experience of Medicare Advantage and of employer-sponsored health insurance with managed care over the same time period. Findings Beneficiaries’ access to private plans has been inconsistent over the program’s history, with higher plan payments resulting in greater choice and enrollment and vice versa. But Medicare Advantage generally has cost more than the traditional Medicare program, an overpayment that has increased in recent years. Conclusions Major changes in Medicare Advantage’s payment rules are needed in order to simultaneously encourage the participation of private plan, the provision of high-quality care, and to save Medicare money.

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Abstract:We compared results of safety climate survey questions from healthcare respondents with those from a high reliability organization, naval aviation. Separate surveys containing a subset of 23 similar questions were conducted among employees from 15 hospitals and from naval aviators from 226 squadrons. For each question a "problematic response" was defined that suggested an absence of a safety climate. Overall the problematic response rate was 5.6% for naval aviators, versus 17.5% for hospital personnel (p<0.0001). The problematic response was 20.9% in high-hazard domains such as emergency department or operating room. Problematic response among hospital workers was up to 12 times greater than among aviators on certain questions. While further research on safety climate in health care is warranted, hospitals may need to make substantial changes to achieve a safety climate consistent with the status of high reliability organizations.