Skip to main content

Patient Safety Culture and the Ability to Improve: A Proof of Concept Study on Hand Hygiene

  • Martine G. Caris (a1) (a2), Pim G. A. Kamphuis (a2), Mireille Dekker (a2), Martine C. de Bruijne (a3), Michiel A. van Agtmael (a1) and Christina M. J. E. Vandenbroucke-Grauls (a2)...

To investigate whether the safety culture of a hospital unit is associated with the ability to improve.


Qualitative investigation of safety culture on hospital units following a before-and-after trial on hand hygiene.


VU University Medical Center, a tertiary-care hospital in the Netherlands.


With support from hospital management, we implemented a hospital-wide program to improve compliance. Over 2 years, compliance was measured through direct observation, twice before, and 4 times after interventions. We analyzed changes in compliance from baseline, and selected units to evaluate safety culture using a positive deviance approach: the hospital unit with the highest hand hygiene compliance and 2 units that showed significant improvement (21% and 16%, respectively) were selected as high performing. Another 2 units showed no improvement and were selected as low performing. A blinded, independent observer conducted interviews with unit management, physicians, and nurses, based on the Hospital Survey on Patient Safety Culture. Safety culture was categorized as pathological (lowest level), reactive, bureaucratic, proactive, or generative (highest level).


Overall, 3 units showed a proactive or generative safety culture and 2 units had bureaucratic or pathological safety cultures. When comparing compliance and interview results, high-performing units showed high levels of safety culture, while low-performing units showed low levels of safety culture.


Safety culture is associated with the ability to improve hand hygiene. Interventions may not be effective when applied in units with low levels of safety culture. Although additional research is needed to corroborate our findings, the safety culture on a unit can benefit from enhancement strategies such as team-building exercises. Strengthening the safety culture before implementing interventions could aid improvement and prevent nonproductive interventions.

Infect Control Hosp Epidemiol 2017;38:1277–1283

Corresponding author
Address correspondence to Martine G. Caris, MD, Department of Internal Medicine, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands (
Hide All

PREVIOUS PRESENTATION. An abstract of the findings in this manuscript was presented as a poster at the annual ECCMID conference on April 24, 2017, in Vienna, Austria (Abstract P1513).

Hide All
1. Dodek, P, Cahill, NE, Heyland, DK. The relationship between organizational culture and implementation of clinical practice guidelines: a narrative review. JPEN J Parenter Enteral Nutr 2010;34:669674.
2. De Bono, S, Heling, G, Borg, MA. Organizational culture and its implications for infection prevention and control in healthcare institutions. J Hosp Infect 2014;86:16.
3. Pittet, D, Allegranzi, B, Sax, H, et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006;6:641652.
4. Pittet, D, Hugonnet, S, Harbarth, S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:13071312.
5. Kirkland, KB, Homa, KA, Lasky, RA, Ptak, JA, Taylor, EA, Splaine, ME. Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series. BMJ Qual Saf 2012;21:10191026.
6. Huis, A, Holleman, G, Van Achterberg, T, Grol, R, Schoonhoven, L, Hulscher, M. Explaining the effects of two different strategies for promoting hand hygiene in hospital nurses: a process evaluation alongside a cluster randomised controlled trial. Implement Sci 2013;8:41.
7. Huis, A, Van Achterberg, T, De Bruin, M, Grol, R, Schoonhoven, L, Hulscher, M. A systematic review of hand hygiene improvement strategies: a behavioural approach. Implement Sci 2012;7:92.
8. Erasmus, V, Daha, TJ, Brug, H, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol 2010;31:283294.
9. Tromp, M, Huis, A, De Guchteneire, I, et al. The short-term and long-term effectiveness of a multidisciplinary hand hygiene improvement program. Am J Infect Control 2012;40:732736.
10. Gould, DJ, Hewitt-Taylor, J, Drey, NS, Gammon, J, Chudleigh, J, Weinberg, JR. The CleanYourHandsCampaign: critiquing policy and evidence base. J Hosp Infect 2007;65:95101.
11. Creedon, SA. Hand hygiene compliance: exploring variations in practice between hospitals. Nurs Times 2008;104:3235.
12. Cantrell, D, Shamriz, O, Cohen, MJ, Stern, Z, Block, C, Brezis, M. Hand hygiene compliance by physicians: marked heterogeneity due to local culture? Am J Infect Control 2009;37:301305.
13. Homa, K, Kirkland, KB. Determining next steps in a hand hygiene improvement initiative by examining variation in hand hygiene compliance rates. Qual Manag Health Care 2011;20:116121.
14. Saint, S, Conti, A, Bartoloni, A, et al. Improving healthcare worker hand hygiene adherence before patient contact: a before-and-after five-unit multimodal intervention in Tuscany. Qual Saf Health Care 2009;18:429433.
15. Peterson, TH, Teman, SF, Connors, RH. A safety culture transformation: its effects at a children’s hospital. J Patient Saf 2012;8:125130.
16. Larson, EL, Early, E, Cloonan, P, Sugrue, S, Parides, M. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med 2000;26:1422.
17. Hlady, CS, Severson, MA, Segre, AM, Polgreen, PM. A mobile handheld computing application for recording hand hygiene observations. Infect Control Hosp Epidemiol 2010;31:975977.
18. Hand Hygiene Technical Reference Manual. Geneva: World Health Organization; 2009.
19. Curry, LA, Spatz, E, Cherlin, E, et al. What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study. Ann Intern Med 2011;154:384390.
20. Smits, M, Christiaans-Dingelhoff, I, Wagner, C, Wal, G, Groenewegen, PP. The psychometric properties of the ‘Hospital Survey on Patient Safety Culture’ in Dutch hospitals. BMC Health Serv Res 2008;8:230.
21. Law, MP, Zimmerman, R, Baker, GR, Smith, T. Assessment of safety culture maturity in a hospital setting. Healthc Qual 2010; 13 Spec No: 110115.
22. Westrum, R.. A typology of organisational cultures. Qual Saf Health Care 2004;13:ii22ii27.
23. Parker, D, Lawrie, M, Hudson, P. A framework for understanding the development of organisational safety culture. Safety Science 2006;44:551562.
24. Organizational tools. World Health Organization website. Published 2017. Accessed May 10, 2017.
25. Young-Xu, Y, Neily, J, Mills, PD, et al. Association between implementation of a medical team training program and surgical morbidity. Arch Surg 2011;146:13681373.
26. Neily, J, Mills, PD, Young-Xu, Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010;304:16931700.
27. Epps, HR, Levin, PE. The TeamSTEPPS approach to safety and quality. J Pediatr Orthop 2015;35:S30S33.
28. Kilbride, HW, Powers, R, Wirtschafter, DD, et al. Evaluation and development of potentially better practices to prevent neonatal nosocomial bacteremia. Pediatrics 2003;111:e504e518.
29. Cumbler, E, Castillo, L, Satorie, L, et al. Culture change in infection control: applying psychological principles to improve hand hygiene. J Nurs Care Qual 2013;28:304311.
30. Kilbride, HW, Wirtschafter, DD, Powers, RJ, Sheehan, MB. Implementation of evidence-based potentially better practices to decrease nosocomial infections. Pediatrics 2003;111:e519e533.
31. Hoyt, DB. Looking forward. How Memorial Hermann Health System innovative approach to improved surgical quality and patient safety. Bull Am Coll Surg 2013;98:78.
32. Pronovost, P. Interventions to decrease catheter-related bloodstream infections in the ICU: the Keystone Intensive Care Unit Project. Am J Infect Control 2008;36(S171):e1e5.
33. Jain, R, Kralovic, SM, Evans, ME, et al. Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections. N Engl J Med 2011;364:14191430.
34. Hessels, AJ, Genovese-Schek, V, Agarwal, M, Wurmser, T, Larson, EL. Relationship between patient safety climate and adherence to standard precautions. Am J Infect Control 2016;44:11281132.
35. Hagel, S, Reischke, J, Kesselmeier, M, et al. Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observation with automated hand hygiene monitoring. Infect Control Hosp Epidemiol 2015;36:957962.
36. Fleming, M. Patient safety culture measurement and improvement: a “how to” guide. Healthc Q 2005. 8 Spec No 1419.
37. Nieva, VF, Sorra, J. Safety culture assessment: a tool for improving patient safety in healthcare organizations. Qual Saf Health Care 2003;12(Suppl 2):ii17ii23.
38. Meddings, J, Reichert, H, Greene, MT, et al. Evaluation of the association between Hospital Survey on Patient Safety Culture (HSOPS) measures and catheter-associated infections: results of two national collaboratives. BMJ Qual Saf 2017;26:226235.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
Type Description Title
Supplementary materials

Caris et al supplementary material
Caris et al supplementary material 1

 Word (43 KB)
43 KB


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed