particularly for hospitals or units with limited bandwidth to implement new interventions given competing priorities or limited resources. Another potential explanation of the findings is that safety culture did improve in these collaboratives and was instrumental for reducing CLABSI and CAUTI but the HSOPS tool did not adequately detect or assess important components of safety culture in the participating units. This could occur if the HSOPS survey was not designed to produce a valid measure of safety culture impacting care at the bedside or if it was completed by respondents who had less influence or understanding of the safety culture impacting bedside care. Safety culture can be difficult to assess, particularly given its fluid nature impacted by changes in staff, resources and competing priorities that commonly occur in hospital units in short time frames.”

They add,“ Considering the training, time and financial resources needed to conduct and analyze these types of surveys in busy clinical units, these results showing a lack of association between HSOPS and CLABSI and CAUTI outcomes do suggest the need to reassess and potentially reprioritize components of intervention bundles and collaborative tools that focus on improving and monitoring technical aspects of care with respect to the need to collect measures of safety culture such as HSOPS as a routinely recommended tool.”

Although De Bono, et al.( 2014)’ s paper is dated, it makes some valuable assessments of organizational culture in healthcare and its implications for infection prevention and control in facilities. They observe,“ Effective IP & C relies directly upon the successful interplay of multiple management systems, which in turn are strongly influenced by corporate culture. One of the most critical components of organizational change, which has a bearing on general employee behavior, is the way the organization is designed and how the different jobs are arranged. This is particularly relevant in terms of organizational composition in which adequate numbers of well-trained staff are vital. Not surprisingly, outbreaks or increased endemicity of HAI have been associated with high staff turnover and vacancies, understaffing, heavy bed occupancy, overcrowding and increased patient turnover.”

These researchers point to a Cochrane Review which indicated that strategies aimed at achieving long-term improvement in IP & C performance must be multi-modal to both reflect and address the multi-dimensionality of the structure and the dynamic of organizational change. This poses several difficulties, De Bono, et al.( 2014) point out, the first of which is that reported behavior often is significantly different from observed behavior:“ What people say they accomplish may be quite different from what they really do. Not surprisingly, low correlation is often reported between self-reported and observed compliance of IP & C practices such as hand hygiene,” De Bono, et al.( 2014) say, adding,“ This highly optimistic‘ self-serving’ bias is also evident in other research in compliance behavior. A certain degree of social desirability is normal, but it makes reported behavior results spurious and difficult to identify and interpret.”

Second, De Bono, et al.( 2014) say, is that most of the direct and indirect relationships are rather fragmented:“ Several‘ identified’ factors, which at face value appear to be relevant for changes in behavior, may not be directly related to organizational change as a determining factor itself. Leadership, for instance, plays an important supportive role; nevertheless, it is not clear what exact style of leadership will promote or discourage compliance in IP & C behavior. Finally, most of the correlations identified in the literature are quite tenuous. The link between compliant behavior and organizational may seem to be plausible and sometimes obvious. But when empirically measured, the relationship might be weaker than expected, probably due to a long chain of mitigating factors and confounders.”

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