4. Discussion

We have described the results of a translation, an adaptation, and a validation and analyzed the reliability of the Medical Office Survey on Patient Safety Culture in Portuguese Primary Health Care. As far as we know, this is the first study on patient safety culture in primary health care in Portugal with this depth of analysis of the structure of the survey proposed by the Medical Office Survey.

The lowest positive scores were found in composites Work Pressure and Pace, Owner/Managing Partner/Leadership Support for Patient Safety, and Staff Training. The composites with highest scores were Teamwork, Patient Care Tracking/Follow Up, and Organization Learning.

The original survey had a good overall consistency, where the composite Office Processes and Standardization had the lowest values on internal consistency statistics and the composite Teamwork the highest. The exploratory factor analysis proposed a structure with eight composites, where just one item was removed, and several items were spread out by the others composites. Through confirmatory factor analysis, it was obtained another model structure where the composite Office Processes and Standardization was removed, leading to a survey with nine composites with 34 items. In terms of goodness of fit and internal consistency, there were no substance differences, both achieved good internal consistency and very good fit. It was decided to choose the structure proposed by CFA, since the differences in terms of structure to the original one are only by the removal of one composite, allowing comparison of the

Figure 3. Confirmatory factor model for model proposed by EFA (37 items).

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Table 7 shows the fit of the confirmatory factor analysis for the model proposed in Figure 2. The indices CFI and GFI showed a very good fit; RMSEA and TLI showed a good fit and PGFI

Goodness of fit indices Values CFI 0.98 TLI 0.97 PGFI 0.69 GFI 0.99

It was also obtained a good overall internal consistency (Cronbach's α = 0.91, AICC = 0.243). Considering the model proposed by EFA (Figure 1), it was obtained the CFA model in Figure 3.

RMSEA 0.064 (p value < 0.001)

The goodness-of-fit indices (Table 8) obtained for EFA model (Figure 3) are very similar to the

We have described the results of a translation, an adaptation, and a validation and analyzed the reliability of the Medical Office Survey on Patient Safety Culture in Portuguese Primary Health Care. As far as we know, this is the first study on patient safety culture in primary health care in Portugal with this depth of analysis of the structure of the survey proposed by

The lowest positive scores were found in composites Work Pressure and Pace, Owner/Managing Partner/Leadership Support for Patient Safety, and Staff Training. The composites with highest

The original survey had a good overall consistency, where the composite Office Processes and Standardization had the lowest values on internal consistency statistics and the composite Teamwork the highest. The exploratory factor analysis proposed a structure with eight composites, where just one item was removed, and several items were spread out by the others composites. Through confirmatory factor analysis, it was obtained another model structure where the composite Office Processes and Standardization was removed, leading to a survey with nine composites with 34 items. In terms of goodness of fit and internal consistency, there were no substance differences, both achieved good internal consistency and very good fit. It was decided to choose the structure proposed by CFA, since the differences in terms of structure to the original one are only by the removal of one composite, allowing comparison of the

scores were Teamwork, Patient Care Tracking/Follow Up, and Organization Learning.

In this model, coefficients ranged between 0.45 and 0.88.

ones obtained for the model proposed in Figure 2.

Table 7. Confirmatory factor analysis model fit indices.

a reasonable fit.

24 Vignettes in Patient Safety - Volume 4

4. Discussion

the Medical Office Survey.

Figure 3. Confirmatory factor model for model proposed by EFA (37 items).


Acknowledgements

Conflict of interest

Ethical approval

Author details

Margarida Eiras<sup>1</sup>

(H&TRC), Portugal

References

nology Research Centre (H&TRC).

The authors declare that there are no conflicts of interest.

\*, Ana Escoval<sup>2</sup> and Carina Silva3

\*Address all correspondence to: margarida.eiras@estesl.ipl.pt

Washington, D.C.: National Academies Press; 2000

troduction.pdf (accessed 25 may 2018)

and Technology Research Center (H&TRC), Portugal

secrecy or anonymity of staff made certain.

The authors would like to extend their gratitude to all staff that took time to complete the MOSPSC. This work is partially financed by national funds through FCT Fundação para a Ciência e a Tecnologia under the project UID/MAT/00006/2013 and by the Health and Tech-

Patient Safety Culture in Portuguese Primary Care: Validation of the Portuguese Version of the Medical Office…

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27

The research complied with every one of the dilemmas concerned with ethics. The privacy and

1 Escola Superior de Tecnologia da Saúde de Lisboa - Instituto Politécnico de Lisboa, Health

3 Escola Superior de Tecnologia da Saúde de Lisboa - Instituto Politécnico de Lisboa, Statistics and Applications Center of the University of Lisbon, Health and Technology Research Center

[1] Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System.

[2] Council of the European Union. Recommendation of 9 June 2009 on Patient Safety, including the Prevention and Control of Healthcare Associated Infections. OJEU. 2009;C(151):1-6

[3] National Patient Safety Agency: Seven steps to patient safety for primary care; 2006. Available at: http://www.aneezesmail.co.uk/PDF%20files/1791\_7StepsToPrimaryCareIn-

2 National Public Health School of New University of Lisbon, CHLC, CISP, Portugal

Table 8. Confirmatory factor analysis model fit indices for model proposed by EFA.

Portuguese results with the EUA results and other countries that get the same structure. Furthermore, this structure has a less number of items, getting a more parsimonious model.

A limitation of the study is the low response rate; however, it is not unusual for an open population study once it was Web-only administrated, although we have identified ways to publicize your survey and tracked response rates.

Another limitation of the study was the number of missing values. It reduced the representativeness of the sample and can therefore distort inferences about the population. In future studies, the results will be compared using imputation methods on missing values and the impact on the results will be evaluated.

A strength of this study is the statistical method used, particularly in exploratory factor analysis and confirmatory factor analysis, since they are the most appropriate to the data type of this study, where bias was reduced. The majority of the studies on the context of this study still use methods assuming that data are continuous.

As it is well known in Portugal, the Directory of Health has been doing patient safety culture assessment every 2 years since 2014, which allows all health units to enhance patient safety.

#### 5. Conclusions

The Portuguese version of the MOSPSC resulted in nine composites with good reliability and construct validity, where the structure differs from the original by removing one composite. In further studies, it will be performed longitudinal studies to evaluate the impact of patient safety culture interventions on staff and patients.

Patient safety culture assessment is of a vital importance for all levels of care. In Portugal, we are caring out this assessment every 2 years, which allows institutions to identify patient safety culture status in primary care, and it is also seen as an intervention to raise staff awareness about patient safety issues and a mechanism to evaluate the impact of patient safety improvement initiatives. This assessment also allows primary care institutions to compare their patient safety culture survey results with others and is a way to track changes in patient safety culture over time.
