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

Published online by Cambridge University Press:  02 October 2017

Martine G. Caris*
Department of Internal Medicine, VU University Medical Center, Amsterdam, Netherlands Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, Netherlands
Pim G. A. Kamphuis
Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, Netherlands
Mireille Dekker
Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, Netherlands
Martine C. de Bruijne
Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, Netherlands
Michiel A. van Agtmael
Department of Internal Medicine, VU University Medical Center, Amsterdam, Netherlands
Christina M. J. E. Vandenbroucke-Grauls
Department of Medical Microbiology and Infection Control, VU University Medical Center, Amsterdam, Netherlands
Address correspondence to Martine G. Caris, MD, Department of Internal Medicine, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, Netherlands (



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

Original Articles
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved 

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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).



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