Academic Appointments

Professional Education

  • Ph.D., Harvard Univeristy, Health Policy/Management (2007)
  • M.B.A., Stanford University Graduate School of Business, M.B.A. with Certificate in Public Management (1993)
  • A.B., Princeton University, English with Certificate in European Cultural Studies (1986)


All Publications

  • Predicting Postoperative Physiologic Decline After Surgery. Pediatrics Berry, J. G., Johnson, C., Crofton, C., Staffa, S. J., DiTillio, M., Leahy, I., Salem, J., Rangel, S. J., Singer, S. J., Ferrari, L. 2019


    BACKGROUND: Projecting postoperative recovery in pediatric surgical patients is challenging. We assessed how the patients' number of complex chronic conditions (CCCs) and chronic medications interacted with active health issues to influence the likelihood of postoperative physiologic decline (PoPD).METHODS: A prospective study of 3295 patients undergoing elective surgery at a freestanding children's hospital. During preoperative clinical evaluation, active health problems, CCCs, and medications were documented. PoPD (compromise of cardiovascular, respiratory, and/or neurologic systems) was measured prospectively every 4 hours by inpatient nurses. PoPD odds were estimated with multivariable logistic regression. Classification and regression tree analysis distinguished children with the highest and lowest likelihood of PoPD.RESULTS: Median age at surgery was 8 years (interquartile range: 2-15); 2336 (70.9%) patients had a CCC; and 241 (7.3%) used ≥11 home medications. During preoperative evaluation, 1556 (47.2%) patients had ≥1 active health problem. After surgery, 882 (26.8%) experienced PoPD. The adjusted odds of PoPD were 1.2 (95% confidence interval [CI]: 1.0-1.4) for presence versus absence of an active health problem; 1.4 (95% CI: 1.0-1.9) for ≥11 vs 0 home medications; and 2.2 (95% CI: 1.7-2.9) for ≥3 vs 0 CCCs. In classification and regression tree analysis, the lowest rate of PoPD (8.6%) occurred in children without an active health problem at the preoperative evaluation; the highest rate (57.2%) occurred in children with a CCC who used ≥11 home medications.CONCLUSIONS: Greater than 1 in 4 pediatric patients undergoing elective surgery experienced PoPD. Combinations of active health problems at preoperative evaluation, polypharmacy, and multimorbidity distinguished patients with a low versus high risk of PoPD.

    View details for DOI 10.1542/peds.2018-2042

    View details for PubMedID 30824493

  • Health as a Way of Doing Business. JAMA Koh, H. K., Singer, S. J., Edmondson, A. C. 2018

    View details for DOI 10.1001/jama.2018.18935

    View details for PubMedID 30520939

  • Relationship among team dynamics, care coordination and perception of safety culture in primary care FAMILY PRACTICE Blumenthal, K. J., Chien, A. T., Singer, S. J. 2018; 35 (6): 718–23


    There remains a need to improve patient safety in primary care settings. Studies have demonstrated that creating high-performing teams can improve patient safety and encourage a safety culture within hospital settings, but little is known about this relationship in primary care.To examine how team dynamics relate to perceptions of safety culture in primary care and whether care coordination plays an intermediating role.This is a cross-sectional survey study with 63% response (n = 1082).The study participants were attending clinicians, resident physicians and other staff who interacted with patients from 19 primary care practices affiliated with Harvard Medical School.Three domains corresponding with our main measures: team dynamics, care coordination and safety culture. All items were measured on a 5-point Likert scale. We used linear regression clustered by practice site to assess the relationship between team dynamics and perceptions of safety culture. We also performed a mediation analysis to determine the extent to which care coordination explains the relationship between perceptions of team dynamics and of safety culture.For every 1-point increase in overall team dynamics, there was a 0.76-point increase in perception of safety culture [95% confidence interval (CI) 0.70-0.82, P < 0.001]. Care coordination mediated the relationship between team dynamics and the perception of safety culture.Our findings suggest there is a relationship between team dynamics, care coordination and perceptions of patient safety in a primary care setting. To make patients safer, we may need to pay more attention to how primary care providers work together to coordinate care.

    View details for DOI 10.1093/fampra/cmy029

    View details for Web of Science ID 000456084500012

    View details for PubMedID 29788350

  • Association of Team-Based Primary Care With Health Care Utilization and Costs Among Chronically Ill Patients. JAMA internal medicine Meyers, D. J., Chien, A. T., Nguyen, K. H., Li, Z., Singer, S. J., Rosenthal, M. B. 2018


    Importance: Empirical study findings to date are mixed on the association between team-based primary care initiatives and health care use and costs for Medicaid and commercially insured patients, especially those with multiple chronic conditions.Objective: To evaluate the association of establishing team-based primary care with patient health care use and costs.Design, Setting, and Participants: We used difference-in-differences to compare preutilization and postutilization rates between intervention and comparison practices with inverse probability weighting to balance observable differences. We fit a linear model using generalized estimating equations to adjust for clustering at 18 academically affiliated primary care practices in the Boston, Massachusetts, area between 2011 and 2015. The study included 83 953 patients accounting for 138 113 patient-years across 18 intervention practices and 238 455 patients accounting for 401 573 patient-years across 76 comparison practices. Data were analyzed between April and August 2018.Exposures: Practices participated in a 4-year learning collaborative that created and supported team-based primary care.Main Outcomes and Measures: Outpatient visits, hospitalizations, emergency department visits, ambulatory care-sensitive hospitalizations, ambulatory care-sensitive emergency department visits, and total costs of care.Results: Of 322 408 participants, 176 259 (54.7%) were female; 64 030 (19.9%) were younger than 18 years and 258 378 (80.1%) were age 19 to 64 years. Intervention practices had fewer participants, with 2 or more chronic conditions (n=51 155 [37.0%] vs n=186 954 [46.6%]), more participants younger than 18 years (n=337 931 [27.5%] vs n=74 691 [18.6%]), higher Medicaid enrollment (n=39 541 [28.6%] vs n=81 417 [20.3%]), and similar sex distributions (75 023 women [54.4%] vs 220 097 women [54.8%]); however, after inverse probability weighting, observable patient characteristics were well balanced. Intervention practices had higher utilization in the preperiod. Patients in intervention practices experienced a 7.4% increase in annual outpatient visits relative to baseline (95% CI, 3.5%-11.3%; P<.001) after adjusting for patient age, sex, comorbidity, zip code level sociodemographic characteristics, clinician characteristics, and plan fixed effects. In a subsample of patients with 2 or more chronic conditions, there was a statistically significant 18.6% reduction in hospitalizations (95% CI, 1.5%-33.0%; P=.03), 25.2% reduction in emergency department visits (95% CI, 6.6%-44.0%; P=.007), and a 36.7% reduction in ambulatory care-sensitive emergency department visits (95% CI, 9.2%-64.0%; P=.009). Among patients with less than 2 comorbidities, there was an increase in outpatient visits (9.2%; 95% CI, 5.10%-13.10%; P<.001), hospitalizations (36.2%; 95% CI, 12.2-566.6; P=.003), and ambulatory care-sensitive hospitalizations (50.6%; 95% CI, 7.1%-329.2%; P=.02).Conclusions and Relevance: While establishing team-based care was not associated with differences in the full patient sample, there were substantial reductions in utilization among a subset of chronically ill patients. Team-based care practice transformation in primary care settings may be a valuable tool in improving the care of sicker patients, thereby reducing avoidable use; however, it may lead to greater use among healthier patients.

    View details for DOI 10.1001/jamainternmed.2018.5118

    View details for PubMedID 30476951

  • Scaling Safety: The South Carolina Surgical Safety Checklist Experience. Health affairs (Project Hope) Berry, W. R., Edmondson, L., Gibbons, L. R., Childers, A. K., Haynes, A. B., Foster, R., Singer, S. J., Gawande, A. A. 2018; 37 (11): 1779–86


    Proven patient safety solutions such as the World Health Organization's Surgical Safety Checklist are challenging to implement at scale. A voluntary initiative was launched in South Carolina hospitals in 2010 to encourage use of the checklist in all operating rooms. Hospitals that reported completing implementation of the checklist in their operating rooms by 2017 had significantly higher levels of CEO and physician participation and engaged more in higher-touch activities such as in-person meetings and teamwork skills trainings than comparison hospitals did. Based on our experience and the participation data collected, we suggest three considerations for hospital, hospital association, state, and national policy makers: Successful programs must be designed to engage all stakeholders (CEOs, physicians, nurses, surgical technologists, and others); offering a variety of program activities-both lower-touch and higher-touch-over the duration of the program allows more hospital and individual participation; and change takes time and resources.

    View details for DOI 10.1377/hlthaff.2018.0717

    View details for PubMedID 30395507

  • WHO Surgical Safety Checklist Modification: DoChanges Emphasize Communication andTeamwork? The Journal of surgical research Solsky, I., Berry, W., Edmondson, L., Lagoo, J., Baugh, J., Blair, A., Singer, S., Haynes, A. B. 2018


    BACKGROUND: The World Health Organization's (WHO) surgical safety checklist is meant to be customized to facilitate local implementation, encourage full-team participation, and promote a culture of safety. Although it has been globally adopted, little is known about the extent of checklist modification and the type of changes made.METHODS: Nonsubspecialty surgical checklists were obtained through online search and targeted hospital requests. A detailed coding scheme was created to capture modifications to checklist content and formatting. Descriptive statistics were performed.RESULTS: Of 155 checklists analyzed, all were modified. Compared with the WHO checklist, those in our sample contained more lines of text (median: 63 [interquartile range: 50-73] versus 56) and items (36 [interquartile range: 30-43] versus 28). A median of 13 new items were added. Items most frequently added included implants/special equipment (added by 84%), deep vein thrombosis prophylaxis/anticoagulation (added by 75%), and positioning (added by 63%). Checklists removed a median of 5 WHO items. The most frequently removed item was the pulse oximeter check (removed in 75%), followed by 4 items (each removed in 39%-48%) that comprise part of the WHO Checklist's "Anticipated Critical Events" section, which is intended for exchanging critical information. The surgeon was not explicitly mentioned in the checklist in 12%; the anesthesiologist/certified registered nurse anesthetist in 14%, the circulator in 10%, and the surgical tech/scrub in 79%.CONCLUSIONS: Checklists are highly modified but often enlarged with items that may not prompt discussion or teamwork. Of concern is the frequent removal of items from the WHO's "Anticipated Critical Events" section.

    View details for DOI 10.1016/j.jss.2018.09.035

    View details for PubMedID 30528925

  • Working around hierarchy: Resident and medical assistant teaming. Health care management review Brooks, J. V., Sheridan, B., Peters, A. S., Chien, A. T., Singer, S. J. 2018


    BACKGROUND: In health care, hierarchy can facilitate getting work done efficiently. It can also hinder performance by suppressing valuable contributions from lower-positioned individuals. Team-based care could mitigate negative effects by creating space for all team members to contribute their unique expertise.PURPOSE: This article sought to understand how resident-medical assistant (MA) dyads interacted before and after primary care clinics transitioned to team-based care. We also studied how they negotiated changes in interpersonal dynamics given the challenge these changes presented to hierarchical norms.METHODOLOGY: We conducted two qualitative interview studies, with 37 residents and 30 MAs at primary care clinics transitioning to team-based care. Interviews were transcribed, coded, and analyzed together using a thematic networks approach and focused coding.RESULTS: An intervention that promoted teamwork prompted resident-MA dyads to change their interactions to counter traditional hierarchy. Residents increasingly asked MAs questions about patient care, and MAs initiated interactions and volunteered ideas more frequently. We also found that MAs and residents expressed some discomfort with the hierarchical ambiguity that their new interactions produced and used alternate scripts to buffer this discomfort and to collaborate as teammates despite formal hierarchy.CONCLUSION: Among resident-MA dyads, a team-based care intervention changed interpersonal dynamics by blurring hierarchical lines and shifting traditional boundaries in ways that were uncomfortable for both groups. They were able to work around discomfort by using new scripts that downplayed the threat to hierarchy.PRACTICE IMPLICATIONS: Organizational structures that encourage greater interprofessional collaboration may neutralize barriers that formal hierarchy in medicine can pose for effective teamwork, but this process can also bring social discomfort. Our findings suggest that health care professionals may use microlevel strategies, such as alternative scripts, to overcome formal hierarchies without openly engaging them. Together, new organizational structures and interaction techniques can help professionals work around hierarchy and improve team performance.

    View details for PubMedID 30299383

  • Successfully implementing Safety WalkRounds: secret sauce more than a magic bullet BMJ QUALITY & SAFETY Singer, S. J. 2018; 27 (4): 251–53

    View details for DOI 10.1136/bmjqs-2017-007378

    View details for Web of Science ID 000428893600001

    View details for PubMedID 29440482

  • Establishing Teams: How Does It Change Practice Configuration, Size, and Composition? The Journal of ambulatory care management Chien, A. T., Kyle, M. A., Peters, A. S., Nguyen, K. H., Tendulkar, S. A., Ryan, M., Hacker, K., Singer, S. J. 2018; 41 (2): 146–55


    Little is known about how practices reorganize when transitioning from traditional practice organization to team-based care. We compared practice-level (1) configuration as well as practice- and team-level (2) size and (3) composition, before and after establishing teams. We employed a pre-/poststudy using personnel lists of 1571 to 1711 staff (eg, job licenses, titles, and team assignment) and practice manager surveys. All personnel (physician and nonphysician) worked within 18 Massachusetts academic primary care practices participating in a 2-year learning collaborative aimed at establishing team-based care. We found that establishing team-based care can involve changing practice configurations and composition without substantially changing practice size.

    View details for DOI 10.1097/JAC.0000000000000229

    View details for PubMedID 29474254

  • A Comprehensive Theory of Integration. Medical care research and review : MCRR Singer, S. J., Kerrissey, M., Friedberg, M., Phillips, R. 2018: 1077558718767000


    Efforts to transform health care delivery to improve care have increasingly focused on care integration. However, variation in how integration is defined has complicated efforts to design, synthesize, and compare studies of integration in health care. Evaluations of integration initiatives would be enhanced by describing them according to clear definitions of integration and specifying which empirical relationships they seek to test-whether among types of integration or between integration and outcomes of care. Drawing on previous work, we present a comprehensive theoretical model of relationships between types of integration and propose how to measure them.

    View details for DOI 10.1177/1077558718767000

    View details for PubMedID 29606036

  • Surgical Team Member Assessment of the Safety of Surgery Practice in 38 South Carolina Hospitals MEDICAL CARE RESEARCH AND REVIEW Singer, S. J., Jiang, W., Huang, L. C., Gibbons, L., Kiang, M. V., Edmondson, L., Gawande, A. A., Berry, W. R. 2015; 72 (3): 298-323


    We assessed surgical team member perceptions of multiple dimensions of safe surgical practice in 38 South Carolina hospitals participating in a statewide initiative to implement surgical safety checklists. Primary data were collected using a novel 35-item survey. We calculated the percentage of 1,852 respondents with strongly positive, positive, and neutral/negative responses about the safety of surgical practice, compared results by hospital and professional discipline, and examined how readiness, teamwork, and adherence related to staff perception of care quality. Overall, 78% of responses were positive about surgical safety at respondent's hospitals, but in each survey dimension, from 16% to 40% of responses were neutral/negative, suggesting significant opportunity to improve surgical safety. Respondents not reporting they would feel safe being treated in their operating rooms varied from 0% to 57% among hospitals. Surgeons responded more positively than nonsurgeons. Readiness, teamwork, and practice adherence related directly to staff perceptions of patient safety (p < .001).

    View details for DOI 10.1177/1077558715577479

    View details for Web of Science ID 000354117900004

    View details for PubMedID 25828528

  • The Surgical Safety Checklist and Teamwork Coaching Tools: a study of inter-rater reliability BMJ QUALITY & SAFETY Huang, L. C., Conley, D., Lipsitz, S., Wright, C. C., Diller, T. W., Edmondson, L., Berry, W. R., Singer, S. J. 2014; 23 (8): 639-650


    To assess the inter-rater reliability (IRR) of two novel observation tools for measuring surgical safety checklist performance and teamwork.Data surgical safety checklists can promote adherence to standards of care and improve teamwork in the operating room. Their use has been associated with reductions in mortality and other postoperative complications. However, checklist effectiveness depends on how well they are performed.Authors from the Safe Surgery 2015 initiative developed a pair of novel observation tools through literature review, expert consultation and end-user testing. In one South Carolina hospital participating in the initiative, two observers jointly attended 50 surgical cases and independently rated surgical teams using both tools. We used descriptive statistics to measure checklist performance and teamwork at the hospital. We assessed IRR by measuring percent agreement, Cohen's κ, and weighted κ scores.The overall percent agreement and κ between the two observers was 93% and 0.74 (95% CI 0.66 to 0.79), respectively, for the Checklist Coaching Tool and 86% and 0.84 (95% CI 0.77 to 0.90) for the Surgical Teamwork Tool. Percent agreement for individual sections of both tools was 79% or higher. Additionally, κ scores for six of eight sections on the Checklist Coaching Tool and for two of five domains on the Surgical Teamwork Tool achieved the desired 0.7 threshold. However, teamwork scores were high and variation was limited. There were no significant changes in the percent agreement or κ scores between the first 10 and last 10 cases observed.Both tools demonstrated substantial IRR and required limited training to use. These instruments may be used to observe checklist performance and teamwork in the operating room. However, further refinement and calibration of observer expectations, particularly in rating teamwork, could improve the utility of the tools.

    View details for DOI 10.1136/bmjqs-2013-002446

    View details for Web of Science ID 000339176900006

    View details for PubMedID 24497526

  • Safety in Numbers: The Development of Leapfrog's Composite Patient Safety Score for U.S. Hospitals. Journal of patient safety Austin, J. M., D'Andrea, G., Birkmeyer, J. D., Leape, L. L., Milstein, A., Pronovost, P. J., Romano, P. S., Singer, S. J., Vogus, T. J., Wachter, R. M. 2014; 10 (1): 64-71


    To develop a composite patient safety score that provides patients, health-care providers, and health-care purchasers with a standardized method to evaluate patient safety in general acute care hospitals in the United States.The Leapfrog Group sought guidance from a panel of national patient safety experts to develop the composite score. Candidate patient safety performance measures for inclusion in the score were identified from publicly reported national sources. Hospital performance on each measure was converted into a "z-score" and then aggregated using measure-specific weights. A reference mean score was set at 3, with scores interpreted in terms of standard deviations above or below the mean, with above reflecting better than average performance.Twenty-six measures were included in the score. The mean composite score for 2652 general acute care hospitals in the United States was 2.97 (range by hospital, 0.46-3.94). Safety scores were slightly lower for hospitals that were publicly owned, rural in location, or had a larger percentage of patients with Medicaid as their primary insurance.The Leapfrog patient safety composite provides a standardized method to evaluate patient safety in general acute care hospitals in the United States. While constrained by available data and publicly reported scores on patient safety measures, the composite score reflects the best available evidence regarding a hospital's efforts and outcomes in patient safety. Additional analyses are needed, but the score did not seem to have a strong bias against hospitals with specific characteristics. The composite score will continue to be refined over time as measures of patient safety evolve.

    View details for DOI 10.1097/PTS.0b013e3182952644

    View details for PubMedID 24080719

  • Comparing safety climate in naval aviation and hospitals: Implications for improving patient safety HEALTH CARE MANAGEMENT REVIEW Singer, S. J., Rosen, A., Zhao, S., Ciavarelli, A. P., Gaba, D. M. 2010; 35 (2): 134-146


    Evidence of variation in safety climate suggests the need for improvement among at least some hospitals. However, comparisons only among hospitals may underestimate the improvement required. Comparison of hospitals with analogous industries may provide a broader perspective on the safety status of our nation's hospitals.The purpose of this study was to compare safety climate among hospital workers with personnel from naval aviation, an organization that operates with high reliability despite intrinsically hazardous conditions.We surveyed a random sample of health care workers in 67 U.S. hospitals and, for generalizability, 30 veterans affairs hospitals using questions comparable with those posed at approximately the same time (2007) to a census of personnel from 35 squadrons of U.S. naval aviators. We received 13,841 (41%) completed surveys in U.S. hospitals, 5,511 (50%) in veterans affairs hospitals, and 14,854 (82%) among naval aviators. We examined differences in respondents' perceptions of safety climate at their institution overall and for 16 individual items.Safety climate was three times better on average among naval aviators than among hospital personnel. Naval aviators perceived a safer climate (up to seven times safer) than hospital personnel with respect to each of the 16 survey items. Compared with hospital managers, naval commanders perceived climate more like frontline personnel did. When contrasting naval aviators with hospital personnel working in comparably hazardous areas, safety climate discrepancies increased rather than decreased. One individual hospital performed as well as naval aviation on average, and at least one hospital outperformed the Navy benchmark for all but three individual survey items.Results suggest that hospitals have not sufficiently created a uniform priority of safety. However, if each hospital performed as well as the top-performing hospital in each area measured, hospitals could achieve safety climate levels comparable with naval aviation. Major interventions to bolster hospital safety climate continue to be required to improve patient safety.

    View details for DOI 10.1097/HMR.0b013e3181c8b20c

    View details for Web of Science ID 000276557800005

    View details for PubMedID 20234220

  • Identifying organizational cultures that promote patient safety HEALTH CARE MANAGEMENT REVIEW Singer, S. J., Falwell, A., Gaba, D. M., Meterko, M., Rosen, A., Hartmann, C. W., Baker, L. 2009; 34 (4): 300-311


    Safety climate refers to shared perceptions of what an organization is like with regard to safety, whereas safety culture refers to employees' fundamental ideology and orientation and explains why safety is pursued in the manner exhibited within a particular organization. Although research has sought to identify opportunities for improving safety outcomes by studying patterns of variation in safety climate, few empirical studies have examined the impact of organizational characteristics such as culture on hospital safety climate.This study explored how aspects of general organizational culture relate to hospital patient safety climate.In a stratified sample of 92 U.S. hospitals, we sampled 100% of senior managers and physicians and 10% of other hospital workers. The Patient Safety Climate in Healthcare Organizations and the Zammuto and Krakower organizational culture surveys measured safety climate and group, entrepreneurial, hierarchical, and production orientation of hospitals' culture, respectively. We administered safety climate surveys to 18,361 personnel and organizational culture surveys to a 5,894 random subsample between March 2004 and May 2005. Secondary data came from the 2004 American Hospital Association Annual Hospital Survey and Dun & Bradstreet. Hierarchical linear regressions assessed relationships between organizational culture and safety climate measures.Aspects of general organizational culture were strongly related to safety climate. A higher level of group culture correlated with a higher level of safety climate, but more hierarchical culture was associated with lower safety climate. Aspects of organizational culture accounted for more than threefold improvement in measures of model fit compared with models with controls alone. A mix of culture types, emphasizing group culture, seemed optimal for safety climate.Safety climate and organizational culture are positively related. Results support strategies that promote group orientation and reduced hierarchy, including use of multidisciplinary team training, continuous quality improvement tools, and human resource practices and policies.

    View details for Web of Science ID 000270852700002

    View details for PubMedID 19858915

  • Comparing Safety Climate between Two Populations of Hospitals in the United States HEALTH SERVICES RESEARCH Singer, S. J., Hartmann, C. W., Hanchate, A., Zhao, S., Meterko, M., Shokeen, P., Lin, S., Gaba, D. M., Rosen, A. K. 2009; 44 (5): 1563-1584


    To compare safety climate between diverse U.S. hospitals and Veterans Health Administration (VA) hospitals, and to explore the factors influencing climate in each setting.Primary data from surveys of hospital personnel; secondary data from the American Hospital Association's 2004 Annual Survey of Hospitals.Cross-sectional study of 69 U.S. and 30 VA hospitals.For each sample, hierarchical linear models used safety-climate scores as the dependent variable and respondent and facility characteristics as independent variables. Regression-based Oaxaca-Blinder decomposition examined differences in effects of model characteristics on safety climate between the U.S. and VA samples.The range in safety climate among U.S. and VA hospitals overlapped substantially. Characteristics of individuals influenced safety climate consistently across settings. Working in southern and urban facilities corresponded with worse safety climate among VA employees and better safety climate in the U.S. sample. Decomposition results predicted 1.4 percentage points better safety climate in U.S. than in VA hospitals: -0.77 attributable to sample-characteristic differences and 2.2 due to differential effects of sample characteristics.Results suggest that safety climate is linked more to efforts of individual hospitals than to participation in a nationally integrated system or measured characteristics of workers and facilities.

    View details for DOI 10.1111/j.1475-6773.2009.00994.x

    View details for Web of Science ID 000269494600008

    View details for PubMedID 19619250

    View details for PubMedCentralID PMC2754548

  • Relationship of Hospital Organizational Culture to Patient Safety Climate in the Veterans Health Administration MEDICAL CARE RESEARCH AND REVIEW Hartmann, C. W., Meterko, M., Rosen, A. K., Zhao, S., Shokeen, P., Singer, S., Gaba, D. M. 2009; 66 (3): 320-338


    Improving safety climate could enhance patient safety, yet little evidence exists regarding the relationship between hospital characteristics and safety climate. This study assessed the relationship between hospitals' organizational culture and safety climate in Veterans Health Administration (VA) hospitals nationally. Data were collected from a sample of employees in a stratified random sample of 30 VA hospitals over a 6-month period (response rate = 50%; n = 4,625). The Patient Safety Climate in Healthcare Organizations (PSCHO) and the Zammuto and Krakower surveys were used to measure safety climate and organizational culture, respectively. Higher levels of safety climate were significantly associated with higher levels of group and entrepreneurial cultures, while lower levels of safety climate were associated with higher levels of hierarchical culture. Hospitals could use these results to design specific interventions aimed at improving safety climate.

    View details for DOI 10.1177/1077558709331812

    View details for Web of Science ID 000265690500004

    View details for PubMedID 19244094

  • Relationship of Safety Climate and Safety Performance in Hospitals HEALTH SERVICES RESEARCH Singer, S., Lin, S., Falwell, A., Gaba, D., Baker, L. 2009; 44 (2): 399-421


    To examine the relationship between measures of hospital safety climate and hospital performance on selected Patient Safety Indicators (PSIs).Primary data from a 2004 survey of hospital personnel. Secondary data from the 2005 Medicare Provider Analysis and Review File and 2004 American Hospital Association's Annual Survey of Hospitals.A cross-sectional study of 91 hospitals.Negative binomial regressions used an unweighted, risk-adjusted PSI composite as dependent variable and safety climate scores and controls as independent variables. Some specifications included interpersonal, work unit, and organizational safety climate dimensions. Others included separate measures for senior managers and frontline personnel's safety climate perceptions.Hospitals with better safety climate overall had lower relative incidence of PSIs, as did hospitals with better scores on safety climate dimensions measuring interpersonal beliefs regarding shame and blame. Frontline personnel's perceptions of better safety climate predicted lower risk of experiencing PSIs, but senior manager perceptions did not.The results link hospital safety climate to indicators of potential safety events. Some aspects of safety climate are more closely related to safety events than others. Perceptions about safety climate among some groups, such as frontline staff, are more closely related than perceptions in other groups.

    View details for DOI 10.1111/j.1475-6773.2008.00918.x

    View details for Web of Science ID 000264164400006

    View details for PubMedID 19178583

    View details for PubMedCentralID PMC2677046

  • Patient Safety Climate in 92 US Hospitals Differences by Work Area and Discipline MEDICAL CARE Singer, S. J., Gaba, D. M., Falwell, A., Lin, S., Hayes, J., Baker, L. 2009; 47 (1): 23-31


    Concern about patient safety has promoted efforts to improve safety climate. A better understanding of how patient safety climate differs among distinct work areas and disciplines in hospitals would facilitate the design and implementation of interventions.To understand workers' perceptions of safety climate and ways in which climate varies among hospitals and by work area and discipline.We administered the Patient Safety Climate in Healthcare Organizations survey in 2004-2005 to personnel in a stratified random sample of 92 US hospitals.We sampled 100% of senior managers and physicians and 10% of all other workers. We received 18,361 completed surveys (52% response).The survey measured safety climate perceptions and worker and job characteristics of hospital personnel. We calculated and compared the percent of responses inconsistent with a climate of safety among hospitals, work areas, and disciplines.Overall, 17% of responses were inconsistent with a safety climate. Patient safety climate differed by hospital and among and within work areas and disciplines. Emergency department personnel perceived worse safety climate and personnel in nonclinical areas perceived better safety climate than workers in other areas. Nurses were more negative than physicians regarding their work unit's support and recognition of safety efforts, and physicians showed marginally more fear of shame than nurses. For other dimensions of safety climate, physician-nurse differences depended on their work area.Differences among and within hospitals suggest that strategies for improving safety climate and patient safety should be tailored for work areas and disciplines.

    View details for Web of Science ID 000262186500004

    View details for PubMedID 19106727

  • Patient Safety Climate in US Hospitals Variation by Management Level MEDICAL CARE Singer, S. J., Falwell, A., Gaba, D. M., Baker, L. C. 2008; 46 (11): 1149-1156


    Strengthening hospital safety culture offers promise for reducing adverse events, but efforts to improve culture may not succeed if hospital managers perceive safety differently from frontline workers.To determine whether frontline workers and supervisors perceive a more negative patient safety climate (ie, surface features, reflective of the underlying safety culture) than senior managers in their institutions. To ascertain patterns of variation within management levels by professional discipline.A safety climate survey was administered from March 2004 to May 2005 in 92 US hospitals. Individual-level cross sectional comparisons related safety climate to management level. Hierarchical and hospital-fixed effects modeling tested differences in perceptions.Random sample of hospital personnel (18,361 respondents).Frequency of responses indicating absence of safety climate (percent problematic response) overall and for 8 survey dimensions.Frontline workers' safety climate perceptions were 4.8 percentage points (1.4 times) more problematic than were senior managers', and supervisors' perceptions were 3.1 percentage points (1.25 times) more problematic than were senior managers'. Differences were consistent among 7 safety climate dimensions. Differences by management level depended on discipline: senior manager versus frontline worker discrepancies were less pronounced for physicians and more pronounced for nurses, than they were for other disciplines.Senior managers perceived patient safety climate more positively than nonsenior managers overall and across 7 discrete safety climate domains. Patterns of variation by management level differed by professional discipline. Continuing efforts to improve patient safety should address perceptual differences, both among and within groups by management level.

    View details for Web of Science ID 000260745900004

    View details for PubMedID 18953225

  • Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems HEALTH SERVICES RESEARCH Tucker, A. L., Singer, S. J., Hayes, J. E., Falwell, A. 2008; 43 (5): 1807-1829


    To contrast the safety-related concerns raised by front-line staff about hospital work systems (operational failures) with national patient safety initiatives.Primary data included 1,732 staff-identified operational failures at 20 U.S. hospitals from 2004 to 2006.Senior managers observed front-line staff and facilitated open discussion meetings with employees about their patient safety concerns.Hospitals submitted data on the operational failures identified through managers' interactions with front-line workers. Data were analyzed for type of failure and frequency of occurrence. Recommendations from staff were compared with recommendations from national initiatives.The two most frequent categories of operational failures, equipment/supplies and facility issues, posed safety risks and diminished staff efficiency, but have not been priorities in national initiatives.Our study suggests an underutilized strategy for improving patient safety and staff efficiency: leveraging front-line staff experiences with work systems to identify and address operational failures. In contrast to the perceived tradeoff between safety and efficiency, fixing operational failures can yield benefits for both. Thus, prioritizing improvement of work systems in general, rather than focusing more narrowly on specific clinical conditions, can increase safety and efficiency of hospitals.

    View details for DOI 10.1111/j.1475-6773.2008.00868.x

    View details for Web of Science ID 000259344300003

    View details for PubMedID 18522667

    View details for PubMedCentralID PMC2654160

  • An overview of patient safety climate in the VA HEALTH SERVICES RESEARCH Hartmann, C. W., Rosen, A. K., Meterko, M., Shokeen, P., Zhao, S., Singer, S., Falwell, A., Gaba, D. M. 2008; 43 (4): 1263-1284


    To assess variation in safety climate across VA hospitals nationally.Data were collected from employees at 30 VA hospitals over a 6-month period using the Patient Safety Climate in Healthcare Organizations survey.We sampled 100 percent of senior managers and physicians and a random 10 percent of other employees. At 10 randomly selected hospitals, we sampled an additional 100 percent of employees working in units with intrinsically higher hazards (high-hazard units [HHUs]).Data were collected using an anonymous survey design.We received 4,547 responses (49 percent response rate). The percent problematic response--lower percent reflecting higher levels of patient safety climate--ranged from 12.0-23.7 percent across hospitals (mean=17.5 percent). Differences in safety climate emerged by management level, clinician status, and workgroup. Supervisors and front-line staff reported lower levels of safety climate than senior managers; clinician responses reflected lower levels of safety climate than those of nonclinicians; and responses of employees in HHUs reflected lower levels of safety climate than those of workers in other areas.This is the first systematic study of patient safety climate in VA hospitals. Findings indicate an overall positive safety climate across the VA, but there is room for improvement.

    View details for DOI 10.1111/j.1475-6773.2008.00839.x

    View details for Web of Science ID 000257756000009

    View details for PubMedID 18355257

    View details for PubMedCentralID PMC2517282

  • Workforce perceptions of hospital safety culture: Development and validation of the patient safety climate in healthcare organizations survey HEALTH SERVICES RESEARCH Singer, S., Meterko, M., Baker, L., Gaba, D., Falwell, A., Rosen, A. 2007; 42 (5): 1999-2021


    To describe the development of an instrument for assessing workforce perceptions of hospital safety culture and to assess its reliability and validity.Primary data collected between March 2004 and May 2005. Personnel from 105 U.S. hospitals completed a 38-item paper and pencil survey. We received 21,496 completed questionnaires, representing a 51 percent response rate.Based on review of existing safety climate surveys, we developed a list of key topics pertinent to maintaining a culture of safety in high-reliability organizations. We developed a draft questionnaire to address these topics and pilot tested it in four preliminary studies of hospital personnel. We modified the questionnaire based on experience and respondent feedback, and distributed the revised version to 42,249 hospital workers.We randomly divided respondents into derivation and validation samples. We applied exploratory factor analysis to responses in the derivation sample. We used those results to create scales in the validation sample, which we subjected to multitrait analysis (MTA).We identified nine constructs, three organizational factors, two unit factors, three individual factors, and one additional factor. Constructs demonstrated substantial convergent and discriminant validity in the MTA. Cronbach's alpha coefficients ranged from 0.50 to 0.89.It is possible to measure key salient features of hospital safety climate using a valid and reliable 38-item survey and appropriate hospital sample sizes. This instrument may be used in further studies to better understand the impact of safety climate on patient safety outcomes.

    View details for DOI 10.1111/j.1475-6773.2007.00706.x

    View details for Web of Science ID 000249429000012

    View details for PubMedID 17850530

    View details for PubMedCentralID PMC2254575

  • Who searches the internet for health information? 4th World Conference of the International-Health-Economics-Association (iHEA) Bundorf, M. K., Wagner, T. H., Singer, S. J., Baker, L. C. WILEY-BLACKWELL PUBLISHING, INC. 2006: 819–36


    To determine what types of consumers use the Internet as a source of health information.A survey of consumer use of the Internet for health information conducted during December 2001 and January 2002.We estimated multivariate regression models to test hypotheses regarding the characteristics of consumers that affect information seeking behavior.Respondents were randomly sampled from an Internet-enabled panel of over 60,000 households. Our survey was sent to 12,878 panel members, and 69.4 percent of surveyed panel members responded. We collected information about respondents' use of the Internet to search for health information and to communicate about health care with others using the Internet or e-mail within the last year.Individuals with reported chronic conditions were more likely than those without to search for health information on the Internet. The uninsured, particularly those with a reported chronic condition, were more likely than the privately insured to search. Individuals with longer travel times for their usual source of care were more likely to use the Internet for health-related communication than those with shorter travel times.Populations with serious health needs and those facing significant barriers in accessing health care in traditional settings turn to the Internet for health information.

    View details for DOI 10.1111/j.1475-6773.2006.00510.x

    View details for Web of Science ID 000237464400013

    View details for PubMedID 16704514

    View details for PubMedCentralID PMC1713205

  • Prospects for improved decision making about medical necessity HEALTH AFFAIRS Singer, S. J., Bergthold, L. A. 2001; 20 (1): 200-206

    View details for Web of Science ID 000166603000022

    View details for PubMedID 11194842

  • In loco parentis? The purchaser role in managed care CALIFORNIA MANAGEMENT REVIEW Bergthold, L., Koebler, S. O., Singer, S. 2000; 43 (1): 34-?
  • Structural problems of managed care in California and some options for ameliorating them CALIFORNIA MANAGEMENT REVIEW Singer, S. J., Enthoven, A. C. 2000; 43 (1): 50-?
  • What's not to like about HMOs HEALTH AFFAIRS Singer, S. J. 2000; 19 (4): 206-209

    View details for Web of Science ID 000088242700023

    View details for PubMedID 10916976

  • Unrealistic expectations born of defective institutions JOURNAL OF HEALTH POLITICS POLICY AND LAW Enthoven, A. C., Singer, S. J. 1999; 24 (5): 931-939

    View details for Web of Science ID 000083736300006

    View details for PubMedID 10615602

  • The managed care backlash and the task force in California HEALTH AFFAIRS Enthoven, A. C., Singer, S. J. 1998; 17 (4): 95-110


    Signs of a managed care backlash in California are increasing. This paper reports and interprets the recently completed work of the California Managed Health Care Improvement Task Force, focusing on the managed care backlash and the state's regulatory response. Although cost containment was a contributing factor, the causes of and solutions to the backlash differ among consumers, physicians, health care workers, politicians, and health plans. The recommendations of the task force could improve the market for health insurance. However, lasting solutions to the profound problems causing the backlash will require fundamental cultural and systemic change.

    View details for Web of Science ID 000074933100013

    View details for PubMedID 9691553

  • Economists' perspectives on health care delivery in California as of 1995 WESTERN JOURNAL OF MEDICINE Singer, S. J. 1998; 168 (5): 360-370


    The health care delivery system is made up of providers--hospitals and doctors--increasingly organized into medical groups. Medical groups interact with payors, primarily health maintenance organizations, that increasingly pass through both risk and prices from increasingly demanding purchasers. This article summarizes the present and future prospects for each of these groups.

    View details for Web of Science ID 000073747700010

    View details for PubMedID 9614794

  • Paying more twice: When employers subsidize higher-cost health plans HEALTH AFFAIRS Hunt, K. A., Singer, S. J., Gabel, J., Liston, D., Enthoven, A. C. 1997; 16 (6): 150-156

    View details for Web of Science ID A1997YH06000021

    View details for PubMedID 9444822

  • Markets and collective action in regulating managed care HEALTH AFFAIRS Enthoven, A. C., Singer, S. J. 1997; 16 (6): 26-32

    View details for Web of Science ID A1997YH06000004

    View details for PubMedID 9444805

  • Managed competition and California's health care economy HEALTH AFFAIRS Enthoven, A. C., Singer, S. J. 1996; 15 (1): 39-57


    There is evidence in California of a broad decline in health care costs to employment groups adopting managed care and managed competition--premium reductions up to 10 percent. National comparisons and utilization data generally confirm the beginning of lower costs. Large California medical groups and health systems have responded to pressure by finding ways to reduce costs and improve quality. While examples are encouraging, there is room for improvement. Two levels of competition have emerged and continue to evolve: carrier competition and delivery system competition. Each model has strengths and limitations, but the existing mix is driving down costs.

    View details for Web of Science ID A1996VB83800005

    View details for PubMedID 8920568

  • Market-based reform: What to regulate and by whom? Conference on the Problem that Will Not Go Away - Reforming US Health Care Financing Enthoven, A. C., Singer, S. J. BROOKINGS INST. 1996: 185–206
  • Increasing cost-consciousness for managed care: reforming the tax treatment of health insurance expenditures. Health care management (Philadelphia, Pa.) Enthoven, A. C., Singer, S. J. 1995; 2 (1): 109-114


    The current Internal Revenue Code encourages employees who receive health insurance as part of their benefits package to choose more costly coverage than they would buy with their own money. The authors propose an approach that corrects this problem as well as the inequities experienced by self-employed and unemployed people.

    View details for PubMedID 10165625

  • Incentives for a better health care system. Journal of health care benefits Enthoven, A. C., Singer, S. J. 1994; 3 (6): 4-7

    View details for PubMedID 10135309

  • A SINGLE-PAYER SYSTEM IN JACKSON HOLE CLOTHING HEALTH AFFAIRS Enthoven, A. C., Singer, S. J. 1994; 13 (1): 81-95


    President Clinton's Health Security Act relies on government regulation, not market forces, to control costs. The act creates an entitlement to comprehensive benefits and places the federal budget at risk for total health care costs in order to achieve universal coverage; it creates a system of new state purchasing monopsonies; and it attempts to control costs with price controls on health plan premiums, set and administered by a National Health Board that would be part of the executive branch, not insulated from political considerations. We believe there is a better way.

    View details for Web of Science ID A1994MX78800011

    View details for PubMedID 8188160


    View details for Web of Science ID A1991FV30100013

    View details for PubMedID 1885132