Background
Conceptual framework
-
Hypothesis-1: Team learning behavior mediates a positive relationship between team psychological safety and QI implementation.
-
Hypothesis-2: Team psychological safety mediates a positive relationship between coaching-oriented team leadership and team learning behavior.
-
Hypothesis-3: Team psychological safety mediates a positive relationship between perceived support for teamwork and team learning behavior.
Methods
Study setting and sample
Measures and data sources
Team-level factors
Model Construct | Variable | Measure | Measure Type | Data Source |
---|---|---|---|---|
Control Variables | Staff-to-bed ratio | Total number of hospital staff divided by total number of hospital beds | Continuous | Administrative Dataset |
Rural | Indicator of whether a hospital is rural or other (e.g., urban or peri-urban) | Binary: 0 = N; 1 = Y | Administrative Dataset | |
QI team size | Average response to “Estimate the number of people who are on your QI team” | Continuous | QI Team Questionnaire | |
Average age | Average response to “Age (years)” | Continuous | QI Team Questionnaire | |
Hospital staff size | Total number of staff that work at the hospital | Continuous | Administrative Dataset | |
Predictors | ||||
Latent Variable: Perceived Support | Support-1 | It is easy for my team to obtain expert assistance when something comes up that we don’t know how to handle. | Aggregate (7-pt. Likert) | QI Team Questionnaire |
Support-2 | My team has the financial resources it needs carry out QI activities. | Aggregate (7-pt. Likert) | QI Team Questionnaire | |
Support-3 | Leaders at my facility strongly support the work of my team. | Aggregate (7-pt. Likert) | QI Team Questionnaire | |
Support-4 | Leaders at my facility have made QI a high priority. | Aggregate (7-pt. Likert) | QI Team Questionnaire | |
Latent Variable: Team Leadership | Lead-1 | There is a person on my team who initiates meetings to discuss the team’s progress. | Aggregate (7-pt. Likert) | QI Team Questionnaire |
Lead-2 | There is a person on my team who is available for consultation on problems. | Aggregate (7-pt. Likert) | QI Team Questionnaire | |
Lead-3 | There is a person on my team who provides feedback on team member performance, identifying strengths and weaknesses. | Aggregate (7-pt. Likert) | QI Team Questionnaire | |
Latent Variable: Psychological Safety | Safety-1 | All members of the team are encouraged to speak up and ask questions, regardless of their position in the organization. | Aggregate (7-pt. Likert) | QI Team Questionnaire |
Safety-2 | We appreciate and build upon our individual differences. | Aggregate (7-pt. Likert) | QI Team Questionnaire | |
Safety-3 | It is DIFFICULT to ask other members of my team for help. | Aggregate (7-pt. Likert) | QI Team Questionnaire | |
Safety-4 | People on this team sometimes REJECT OTHERS for being different. | Aggregate (7-pt. Likert) | QI Team Questionnaire | |
Safety-5 | If you make a mistake on my team, it is often HELD AGAINST YOU. | Aggregate (7-pt. Likert) | QI Team Questionnaire | |
Latent Variable: Learning Behavior | Learn-1 | My team openly discusses mistakes so that we can learn from them. | Aggregate (7-pt. Likert) | QI Team Questionnaire |
Learn-2 | We regularly take time to learn ways to improve how we do our work. | Aggregate (7-pt. Likert) | QI Team Questionnaire | |
Learn-3 | My team always takes time to stop and reflect on our work. | Aggregate (7-pt. Likert) | QI Team Questionnaire | |
Team Effectiveness | ||||
Latent Variable: QI Implementation | Perform-1 | This team meets or exceeds the expectations of Project Fives Alive. | 7-pt. Likert | Project Officer Survey |
Perform-2 | This team does superb work. | 7-pt. Likert | Project Officer Survey | |
Perform-3 | This team keeps getting better and better. | 7-pt. Likert | Project Officer Survey | |
QI Practice-1 | The team evaluates reasons for variation in how work is carried out. | 7-pt. Likert | Project Officer Survey | |
QI Practice-2 | The team has made an actual change in the way some aspect of work gets done. | 7-pt. Likert | Project Officer Survey | |
QI Practice-3 | The team meets frequently to work on quality improvement. | 7-pt. Likert | Project Officer Survey |
Model Description | Number of: | DF | χ2
(p-value)
a
| RMSEA
(Pr ≤ 0.05)
| CFI | BICsb | |||
---|---|---|---|---|---|---|---|---|---|
Observations (Teams) | Latent Variables | Observed Variables | Free Parameters | ||||||
CFA: LEAD with SUPPORT | 127 | 2 | 7 | 23 | 12 | 17.0
(0.149)
| 0.057
(0.376)
| 0.983 | −41.1 |
CFA: SAFETY with LEARN | 127 | 2 | 8 | 26 | 18 | 42.8
(0.001)
| 0.104
(0.016)
| 0.919 | −44.4 |
CFA: QI Implementation | 122 | 1 | 6 | 19 | 8 | 5.7
(0.677)
| 0.000
(0.828)
| 1.000 | −32.7 |
Structural Model: Complete Mediationc | 122 | 5 | 26 | 113 | 264 | 403.7
(< 0.001)
| 0.066
(0.025)
| 0.920 | − 864.6 |
Structural Model: Complete Mediationd | 122 | 5 | 26 | 116 | 261 | 371.7
(< 0.001)
| 0.059
(0.142)
| 0.936 | −882.1 |
Structural Model: Partial Mediationd | 122 | 5 | 26 | 121 | 256 | 360.8
(< 0.001)
| 0.058
(0.175)
| 0.940 | −869.0 |
Model Construct | Variable | Mean
(SD)
| Min | Max | Obs | Rwg(J)
(distribution)
| ICC1 | ω reliability |
---|---|---|---|---|---|---|---|---|
Control Variables | Hospital staff size | 252.3
(177.2)
| 43 | 1100 | 113 | n/a | n/a | n/a |
Average age | 34.13
(4.86)
| 26.75 | 48.33 | 121 | ||||
QI team sizea | 9.10
(3.47)
| 4.00 | 24.40 | 121 | ||||
Rural hospital | 23.7% |
n/a
|
n/a
| 122 | ||||
Staff-to-bed ratio | 3.16
(2.69)
| 0.54 | 21.95 | 110 | ||||
Perceived Support | Support-1 | 5.29
(1.01)
| 2.0 | 7.0 | 122 | 0.605
(slightly skewed)
| 0.354 | 0.792 |
Support-2 | 3.50
(1.40)
| 1.0 | 6.3 | 122 | ||||
Support-3 | 5.01
(1.29)
| 1.3 | 7.0 | 122 | ||||
Support-4 | 4.83
(1.29)
| 1.7 | 7.0 | 122 | ||||
Team Leadership | Lead-1 | 5.83
(0.78)
| 3.5 | 7.0 | 122 | 0.587
(moderately skewed)
| 0.213 | 0.866 |
Lead-2 | 5.66
(0.92)
| 1.7 | 7.0 | 122 | ||||
Lead-3 | 5.10
(1.05)
| 1.7 | 7.0 | 122 | ||||
Psychological Safety | Safety-1 | 6.26
(0.53)
| 4.3 | 7.0 | 122 | 0.745
(heavily skewed)
| 0.153 | 0.748 |
Safety-2 | 6.10
(0.46)
| 4.3 | 7.0 | 122 | ||||
Safety-3b | 6.25
(0.63)
| 3.7 | 7.0 | 122 | ||||
Safety-4b | 6.35
(0.57)
| 4.0 | 7.0 | 122 | ||||
Safety-5b | 6.44
(0.51)
| 4.0 | 7.0 | 122 | ||||
Learning Behavior | Learn-1 | 5.96
(0.65)
| 3.5 | 7.0 | 122 | 0.718
(moderately skewed)
| 0.149 | 0.830 |
Learn-2 | 5.54
(0.73)
| 3.0 | 7.0 | 122 | ||||
Learn-3 | 5.37
(0.77)
| 2.8 | 7.0 | 122 | ||||
QI Implementation | Perform-1 | 5.19
(1.03)
| 2.0 | 7.0 | 122 | n/a | n/a | 0.912 |
Perform-2 | 5.54
(1.19)
| 1.0 | 7.0 | 122 | ||||
Perform-3 | 4.33
(1.42)
| 1.0 | 7.0 | 122 | ||||
QI Practice-1 | 4.48
(1.61)
| 1.0 | 7.0 | 122 | ||||
QI Practice-2 | 4.54
(1.46)
| 1.0 | 7.0 | 122 | ||||
QI Practice-3 | 4.63
(1.59)
| 1.0 | 7.0 | 122 |
QI implementation
Control variables
Statistical analyses
Results
Study population and descriptive statistics
SEM model fit
-
Support-3 and Support-4 because the items had highly similar meaning and wording;
-
Safety-1 and Safety-2 because these two items were positively-worded, whereas the remaining three items for psychological safety were negatively-worded;
-
QI Practice-1 and QI Practice-2 because these questions both came from Lemieux-Charles et al. [39] and were the most technical of all the QI implementation questions.
SEM results
Factor | Partial Mediation | Complete Mediation | ||
---|---|---|---|---|
Standardized Estimates | Standard Error | Standardized Estimates | Standard Error | |
QI Implementation | ||||
on Learning Behavior | 0.284* | 0.147 | 0.220** | 0.097 |
on Psychological Safety | −0.113 | 0.138 | ||
on Team Leadership | −0.064 | 0.073 | ||
on Perceived Support | −0.156 | 0.149 | ||
on Hospital staff size |
0.016
|
0.183
|
0.003
|
0.069
|
on Average age |
−0.150*
|
0.079
|
−0.144**
|
0.070
|
on QI team size |
0.134
|
0.109
|
0.111
|
0.108
|
on Rural hospital^ |
−0.029
|
0.183
|
−0.039
|
0.181
|
on Staff-to-bed ratio |
0.163*
|
0.083
|
0.174***
|
0.065
|
Learning Behavior | ||||
on Psychological Safety | 0.530** | 0.233 | 0.779*** | 0.184 |
on Team Leadership | 0.313* | 0.170 | ||
on Perceived Support | 0.000 | 0.070 | ||
on Hospital staff size |
−0.115
|
0.118
|
−0.035
|
0.111
|
on Average age |
−0.013
|
0.066
|
−0.018
|
0.065
|
on QI team size |
0.040
|
0.131
|
0.040
|
0.148
|
on Rural hospital^ |
0.010
|
0.074
|
0.070
|
0.109
|
on Staff-to-bed ratio |
0.083
|
0.063
|
0.092
|
0.126
|
Psychological Safety | ||||
on Team Leadership | 0.386 | 0.175 | 0.492*** | 0.167 |
on Perceived Support | 0.201 | 0.142 | 0.184 | 0.152 |
on Hospital staff size |
−0.198
|
0.176
|
−0.227
|
0.142
|
on Average age |
0.046
|
0.059
|
0.044
|
0.075
|
on QI team size |
0.201***
|
0.038
|
0.187***
|
0.045
|
on Rural hospital^ |
0.003
|
0.093
|
−0.018
|
0.087
|
on Staff-to-bed ratio |
−0.002
|
0.143
|
0.013
|
0.152
|
Team Leadership | ||||
with Perceived Support | 0.414*** | 0.089 | 0.415*** | 0.081 |
with Hospital staff size |
−0.020
|
0.083
|
−0.018
|
0.083
|
with Average age |
−0.005
|
0.077
|
−0.007
|
0.077
|
with QI team size |
0.301***
|
0.086
|
0.298***
|
0.086
|
with Rural hospital^ |
0.311***
|
0.035
|
0.309***
|
0.036
|
with Staff-to-bed ratio |
0.186*
|
0.109
|
0.185*
|
0.108
|
Perceived Support | ||||
with Hospital staff size |
−0.141**
|
0.060
|
−0.137**
|
0.059
|
with Average age |
0.072
|
0.118
|
0.072
|
0.118
|
with QI team size |
0.086
|
0.148
|
0.088
|
0.147
|
with Rural hospital^ |
0.125***
|
0.028
|
0.127***
|
0.031
|
with Staff-to-bed ratio |
0.087
|
0.058
|
0.091
|
0.058
|