Our examination of the relationship between patient safety climate and hospital readmission indicates that hospital staff perceptions of patient safety climate are associated with an important clinical outcome among patients admitted with AMI and HF. While previous studies established a relationship between safety climate and inpatient outcomes (Pronovost et al. 2005
; Hofmann and Mark 2006
; Vogus and Sutcliffe 2007a
;), our data indicate that better safety climate may also have measurable effects on the postdischarge outcome of readmissions. Moreover, associations between hospital staff's perceptions of safety climate and readmission rates varied by both management level and clinical work role. The three domains of safety climate that demonstrated the most statistically significant associations with HF and AMI were unit safety norms, overall emphasis on safety, and collective learning. It is notable that each of these domains is manifest at a collective level rather than an individual level, in contrast to more individual-focused domains such as fear of shame or blame and individual provision of safe care. This may indicate that organizational rather than interpersonal factors are particularly operative in the relationship between safety climate and readmission.
The relationship identified in our analysis may be attributable in part to two determinants of readmission. First, previous research shows that discharging patients despite inadequate readiness is associated with higher risk of readmission (Ashton et al. 1995
; Ashton and Wray 1996
; Michel et al. 2000
;). Our data suggest that institutions whose workers perceive lower safety climate may be less likely to identify or intervene to prevent premature discharges. Second, patients with chronic disease often experience both initial hospital admission and readmission as a result of inadequate self-management. Patient education at the time of initial admission is an important means to alter behavior and reduce the risk of readmission (Krumholz et al. 2002
; McAlister et al. 2004
;); however, hospitals with lower safety climate may be less likely to devote adequate effort to this educational process.
The relative accuracy of frontline staff compared with senior management in identifying weaknesses in safety climate associated with worse patient outcomes represents an important finding for health care managers wishing to improve patient outcomes. Our results, similar to previous studies measuring the accuracy of managers' perceptions of frontline processes (Singer et al. 2009d
), indicate that organizations may require dedicated initiatives in order to inform senior management involvement in improving patient care. The appropriateness of management perceptions of safety climate may be specifically important to the goal of delivering safe transitions because many evidence-based interventions to reduce readmission require new institutional processes (e.g., standardized discharge checklists) or institutional resources (e.g., follow-up phone calls to patients or pharmacist review of patients' medication regimens) and so rely on senior manager involvement.
Our finding that different work roles appear to offer unique insights into disease-specific readmission risk supports efforts to reduce hospital readmission through attention to differences between chronic disease exacerbations and other acute conditions. Our data do not allow for a determination of which elements of the nurse–patient relationship or nurses' work role account for perceptions more reflective of hospitals' HF readmission outcomes, but a potential explanation may lie in the relatively extensive patient interaction offered in the nursing role and associated insight into patients' safety for discharge. In addition, of the diagnoses studied, HF management is perhaps the most dependent on patient education at discharge—a responsibility that often rests largely with nursing and may explain the relative accuracy of nurses' perceptions.
The notable absence of an observed association between safety climate and pneumonia readmission may be explained by some of the unique characteristics of this diagnostic category. First, pneumonia education at discharge is relatively limited compared with the extensive self-management and lifestyle change instruction recommended for HF and cardiac risk reduction following AMI. This may limit the role that safety climate might play in reducing pneumonia readmission risk through more conscientious patient education at the time of discharge. In addition, factors other than hospital-level factors may determine the likelihood of pneumonia readmission (e.g., patient demographics or comorbidities), making pneumonia relatively less sensitive to changes in safety climate. The lack of an association in contrast to HF and AMI is distinctive and merits further study.
It should be noted that we did not uniformly identify a significant relationship between safety climate and readmission and that a full conceptual model to explain the relationship we have identified remains to be fully developed. It is likely that the effect of safety climate on readmission is indirect. Several process strategies such as enhanced patient education, medication reconciliation, and confirmed follow-up have been shown to reduce readmission (Coleman et al. 2006
; Schnipper et al. 2006
; Jack et al. 2009
; Koehler et al. 2009
;). The effectiveness of these process strategies may be modified by variation in safety climate, particularly in clinical settings outside a research trial. An exploration of interactions between safety climate and discharge process strategies on the incidence of readmission merits further study.
Our study has some limitations. Though our data were derived from a random hospital sample, this sample differed from U.S. hospitals overall and so may not be directly generalizable. Study hospitals were more likely to be large academic centers, and hospitals in the Midwest were underrepresented compared with the national average. However, it is unclear how these characteristics of the sample might affect the relationship between safety climate and readmissions. While attempts were made to mitigate nonresponse bias by oversampling physicians, survey response rates did vary by work role, with physicians less likely to respond. Our study is subject to the limitations inherent in any cross-sectional analysis, including the possibility of unmeasured. While we cannot exclude this possibility, our analysis does account for issues of reverse causality encountered in cross-sectional research through the use of safety climate measures obtained 1 year before analyzed readmission rates.
In summary, we have identified positive associations between better hospital patient safety climate and reduced 30-day risk-standardized hospital readmission for patients hospitalized with HF or AMI. This finding supports ongoing initiatives to measure and improve hospital patient safety climate and supports the validity of both the safety climate survey and the risk-standardized readmission measures. More research is needed to further clarify the relationship between safety climate and readmission as well as to build and test possible causal models explaining this relationship. The potential for improvement in safety climate to reduce readmission may be important to policy makers in the context of federal health care reform legislation identifying reduction of avoidable hospital readmission as a means to reduce costs and improve quality of health care.