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Research Outputs

Work Package 5

Research Topic

Prof. Dianne ParkerSafety Culture and performance

Lead: Schools of Psychology and Community Based Medicine,
University of Manchester, UK

Contact: Professor Dianne Parker

Description of work


The term culture is used in many different ways in discussions of safety in healthcare. The culture of an organisation may be a major asset in the continuous struggle for safety or, conversely, a major obstacle to any meaningful change. However, there is little hard evidence that safety culture really does impact on safety. The most widely used definition is provided by the UK Health and Safety Commission and was originally provided by the Advisory Committee on the Safety of Nuclear Installations (ACSNI). It captures some of the essential features of safety culture:

The safety culture of an organisation is the product of the individual and group values, attitudes, competencies and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation’s health and safety programmes. Organisations with a positive safety culture are characterised by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventative measures (Health and Safety Executive, 1993).

We regard this definition as an acceptable one for the purpose of undertaking collaborative work in the field.

Culture in organisations

Safety culture did not spring up fully formed but emerged from organisational culture; when we talk of safety culture we are implicitly drawing on a wider academic context and also, implicitly, linking it with the wider culture of the organisation. We know that how people think in an organisation – their values, assumptions and beliefs – have the potential to influence how they behave when delivering services. Recently completed studies offer illuminating insights into how cultural issues set the context for success, failure and recovery in health care organisations. An emergent finding underpinning and linking these studies is that organisational performance appears to be intimately tied up with local cultural patterns and the quality of interorganisational working. Taken together these findings suggest that culture matters in a contingent manner for the delivery of high performance in health care. That is, health care organisations do better on those aspects of performance that are valued within the dominant senior management team culture. It has yet to be proved that safety culture has a similar relationship to safe performance and this is the area that
this work package will address.

The health and safety executive in the UK (1993) point out that ‘…the commitment to and the style and proficiency of an organisation’s safety programmes matter as much as the formal definition of those programmes and that this commitment and style are the product of individual and group values, attitudes, competencies and patterns of behaviour’. Therefore safety culture is partly dependent on the attitudes, behaviours, beliefs, values and underlying assumptions of individuals and everyone contributes to the safety culture in their own way. A strong organizational and management commitment is also implied and therefore safety needs to be taken seriously at every level of the organisation.

There will be particular challenges to studying this in primary care because since culture is usually linked to a group, department or organizational unit and in many countries physicians work alone, defining and changing the culture will be problematic.

Studying the culture/performance link in and across health care organisations poses substantial theoretical and methodological difficulties, not least in terms of conceptualising and operationalising both ‘culture’ and ‘performance’ as well as in inferring the nature of any causality in uncovered relationships. Performance is as contested a domain as culture, and can encompass measures of clinical process, health outcomes, safety, access, efficiency, productivity, employee and user satisfaction, and financial balance, to name but a few. In addition, different channels of communication may convey different performance information; for example, the apparently ‘hard’ information contained in league tables may differ from the ‘softer’ intelligence circulating around informal networks. Even given definitions of culture and performance, and associations between the two, it is still difficult to disentangle the nature of any causal linkages. It is certainly likely that any relationships between culture and performance will be complex, contingent and recursive.

If we are going to measure the relationship between safety culture and some organisational processes and outcomes, we need to first identify the culture tools that are available for study. We then need to evaluate how scientifically robust they are. This is a critical step because the relationship between the measurement of safety cultural attributes and outcomes is contingent on a clear understanding of the aspects of culture that one is purporting to measure. Sociologists, psychologists, social anthropologists and organisational researchers have led the way in unpacking the concept in terms of understanding its source, development, maintenance and repercussions. Because our collaboration is multidisciplinary in nature, it will be able to draw on a range of perspectives, theories and methods relevant to addressing the way that safety culture and performance can be measured and assessed. Our interdisciplinary research collaborators bring together a creative combination of perspectives and research methods relevant to the topic This expertise includes the development of the only safety culture instrument which has been developed for the measurement of safety culture in primary care – MaPSaF - which has been developed by members of the Manchester group of the LINNEAUS-PC collaboration. MaPSaF has been translated and used in the Netherlands and a summative instrument based on the Hospital survey on patient safety culture has also been used in the Netherlands. The expertise within the group is therefore considerable.

We will focus on the development of a consensus approach to the measurement of culture, using and evaluating already established safety culture instruments such as MaPSaF, to understand the way that culture is categorised and conceptualised in different European primary care organisations. We will organise a series of workshops where we will share our experience of measuring culture and use consensus approaches to modify existing instruments which can be used in different European settings to measure safety culture. Ultimately we want to develop methods for investigating the relationship between culture and performance. This will only be possible if we develop a consensus approach to the measurement of safety culture. We will then need to develop a similar approach to the identification of performance measures which currently have only been developed for in-patient care. Members of the collaboration have significant expertise in the field of quality improvement and developing indicators for the measurement of quality outcomes and there is invariably a close relationship between quality and safety. Consensus methods will therefore be essential for agreeing the use of performance indicators relevant to safety in primary care.

This work programme will therefore co-ordinate the development of pilot work within the collaboration to modify safety culture tools for pan-European use and produce consensus statements on aspects of performance that should be assessed when investigating the relationship between safety culture and performance.

Tools and Guidance notes


MaPSaF is a tool for measuring the organisational culture with regard to patient safety in primary care settings, such as GPs' surgeries/practices.  The tool helps users in primary care settings assess the current level of maturity of their approach to patient safety, and use the output as a basis for discussions on how to improve factors contributing to patient safety.

The Agency for Healthcare Research and Quality (AHRQ) patient safety culture assessment tools can be used to:

  • Raise staff awareness about patient safety.
  • Diagnose and assess the current status of patient safety culture.
  • Identify strengths and areas for patient safety culture improvement.
  • Examine trends in patient safety culture change over time.
  • Evaluate the cultural impact of patient safety initiatives and interventions.
  • Conduct internal and external comparisons.

Both tools and associated Guidance Notes for use in primary care in Europe can be found on the LINNEAUS website.

Conference proceedings

  • Presentation: What is a Safe Environment/Safety Culture? at LINNEAUS Manchester conference.
  • Presentation: What is Patient Safety Culture and how can you assess and improve it? at LINNEAUS workshop in Warsaw
  • Presentation: Assessing Patient Safety Culture in Primary Care in Europe at LINNEAUS workshop at WONCA, Warsaw.

LINNEAUS deliverable(s)

  • LINNEAUS Deliverable No 2 - Guide for the use of patient safety culture tools.

Other LINNEAUS reports