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Supporting patient safety culture in healthcare requires higher employee engagement

The relationship between employee engagement and patient safety culture has long been a topic of interest to leaders in the healthcare industry, and one that's critical to observe as an uptick in COVID-19 hospitalizations and deaths tests an already burnt-out workforce.

Press Ganey analysis of recent survey data shows unequivocally tight alignment between the two measures. The most highly engaged healthcare employees perceive the environment they work in, the leaders and peers they work with, and their overall organization as the support system for a strong patient safety culture. They typically score near the ceiling for items that help define this culture, while the most disengaged employees languish in the basement for those same items. Similar relationships have been found in external research, such as "Associations Between Safety Culture and Employee Engagement Over Time: A Retrospective Analysis" (Biddison et al., 2016). Taking things a step further, "The Association Between Health Care Staff Engagement and Patient Safety Outcomes: A Systemic Review and Meta-Analysis" (Janes et al., 2021) shows significant relationships between cultural indicators of engagement and safety as well as errors and adverse events.

The importance of continuous improvement in employee engagement and patient safety cannot be understated. Better performance in both arenas accelerates advances in quality, patient experience, and efficiency outcomes—a concept known as the "virtuous cycle." Our data and insights will take you beyond these linear relationships and demonstrate correlation through comparative performance aspects, by examining specific safety culture item performance against where respondents rank in engagement. We'll then show you how to develop a measurement strategy to enhance the employee experience and boost patient safety.



Analyses were based on segmenting the benchmark-eligible respondent population into quartiles based on their engagement composite scoring. Average Culture of Safety item scores were then calculated at the respondent level based on engagement performance quartile. Percentile rankings were based on performance compared to Press Ganey's 2021 National Healthcare Average benchmark. All differences are statistically significant (p < .01). The analyses included a total of 564,751 respondents across 3,747 facilities representing 171 clients. Note that while Press Ganey’s Culture of Safety offering typically contains 19 items, one is shared with the engagement composite. This item was removed from item-level safety culture analyses.

How workforce engagement protects the patient and drives safety culture in healthcare

Press Ganey assesses 18 items in our Culture of Safety set, divided into three categories: (Error) Prevention and Reporting, Resources and Teamwork, and Pride and Reputation. Across all domains, one overarching message rings true: An engaged workforce is more likely to be proactive in providing error-free care because they experience the psychological safety of a positive and supportive work environment, feel confident in hospital leadership, and work together. When employees are faced with poor guidance and encouragement from healthcare leaders and they don't believe they're involved in providing the best possible patient care, they're more apt to be reactive and are far less engaged. Not only does this leave hospitals open to employee turnover, but it also places them in danger of a safety incident.

(Error) prevention and reporting

Eight of Press Ganey's 18 Culture of Safety measurements fall under the Prevention and Reporting theme. These items are broadly related to topics that deal with patient safety errors and concerns, such as proactively raising awareness, active prevention, or making changes when errors have occurred.

The differences in performance are striking: Respondents in the top quartile of engagement, on average, score between the 97th and 99th percentile rank for Prevention & Reporting items. Conversely, the average score for respondents in the bottom quartile of engagement functionally translates to performing most poorly in Prevention & Reporting item performance, scoring at the first or second rank.

It's notable that highly engaged workforces are much more likely to feel that patient and employee safety is prioritized by management and that safety concerns and mistakes are seen as opportunities to learn and improve rather than to place blame. An engaged employee knows that using their voice is encouraged and will not avoid calling out a problem.

Safety Culture data on error prevention and reporting

Resources and teamwork

Of the 18 Culture of Safety items that Press Ganey ranks, seven are under the Resources & Teamwork theme. These items address topics such as unit cohesion, cross-functional teamwork, and adequate staffing. 

Similar findings emerge here as in the previous set of items, although with slightly more spread in associated percentile ranks. Most respondents in the top quartile of engagement still score in the top end of the safety item distribution (94th to 97th ranks), although the average rank for the adequate staffing item is the 87th percentile.

Respondents in the bottom quartile of engagement, on average, have scores that fall between the first and third percentile ranks for Culture of Safety items.

Communication and the ability to work well together are at the core of teamwork appraisals, with highly engaged workforces reporting that these factors create strong partnerships across units and at the individual healthcare worker level.

Safety Culture data on resources and teamwork


Pride and reputation

The final subset of Culture of Safety items contains three measures. These pertain to the commitment to providing high-quality care and error-free service.

Since these items can be considered as somewhat outcome-styled measures, the comparative performance patterns between them and the engagement composite (another outcome measure) are also stark. Respondents in the top quartile of engagement have Pride and Reputation scores that are, on average, associated with the upper end of the Culture of Safety distribution (98th to 99th percentile rank). Respondents in the bottom quartile of engagement have average scores associated with the floor (first percentile rank) of the Culture of Safety item distributions.

These three measurements reinforce the necessity of a strong patient safety culture that's put into practice by managers. Moreover, they show that organizations must not only commit to excellence and safety, but also demonstrate such commitment to their employees.

Safety Culture data on pride and reputation


5 steps to an impactful employee experience

To effect change with data, you must begin with a strategic plan. Whether focused on improving Leapfrog scores for accreditation or following the desire to become a "best place to work" in healthcare, it serves organizations well to broaden their scope of focus if they are underperforming on safety culture in healthcare items. To design a strategy that will eliminate the disengaged employee from your workforce and propel provider engagement in safe, reliable care, follow this five-step approach.

1. Use a single measurement tool.

By observing all aspects of the employee experience, including engagement, safety culture, resilience, and diversity, equity, and inclusion, you can identify the most impactful KPIs for your overall engagement score. This provides your organization with the necessary platform for integrated data analytics.

2. Develop a data hierarchy.

Leverage key drivers to understand which aspects of the employee experience will have the largest overall impact on organizational outcomes. You can then prioritize the most pressing challenges based on recent history.

3. Create a triaging strategy.

Investigate which units are struggling the most with the top identified challenges, and use lessons from their failures to prevent the same situations from reoccurring on a broader scale.

4. Share the data hierarchy and triaging strategy with leaders.

Be sure to make information available across ordinarily siloed leadership roles to help your teams expedite the decision-making process and move more quickly to action.

5. Continuously listen to the voice of your employees.

Asking your workforce’s opinions once a year is just a starting point for building a better employee experience. Developing a cadence for regularly surveying—or "pulsing"—your workforce is a must to determine and update key drivers and KPIs, assess progress toward goals, and troubleshoot in the moment.

Putting it all together

A recent partnership between Press Ganey and an organization wishing to improve its operations by forging a data hierarchy exemplifies the importance of intelligently using employee experience data to improve outcomes and potentially save lives.

The organization began by employing Press Ganey's critical metrics map tool to find its top safety culture driver: Error Prevention and Reporting. When looking at results for that theme, it identified 11 units that were not working well together (based on their team index score) and lacked trust in their leader (based on findings of their leader index). During this exercise, it was mentioned that one of the 11 units had recently had a safety event where a patient was physically harmed and caregivers were emotionally harmed. This data was used as a potential "early warning system" for the other 10 units and to engage those leaders and staff in discussions about how to improve their culture and avert further harm.

To begin your data journey or examine how the results of your organization's most recent employee engagement survey can be used to ensure exceptional safety outcomes, reach out to a patient safety culture expert.

About the author

Marty oversees the Experience solutions team in Strategic Consulting, partnering with clients to improve culture, employee and physician engagement, and diversity, equity, and inclusion. He drives improvement by reducing turnover, sustaining change, and develop tools and techniques to create an inclusive and equitable environment. Prior to joining Press Ganey, Marty was Vice President of Engagement Services at Avatar Solutions.

Profile Photo of Martin Wright