THE SAFETY CULTURE OF THE LJUBLJANA 
COMMUNITY HEALTH CENTRE’S EMPLOYEES
Špela TEVŽIČ
1*
, Antonija POPLAS-SUSIČ
2,3
, Zalika KLEMENC-KETIŠ
2,4
1
Community Health Centre Ljubljana-Vič, Šestova ulica 10, 1000 Ljubljana, Slovenia 
2
Community Health Centre Ljubljana, Metelkova 9, 1000 Ljubljana, Slovenia
3
University of Ljubljana, Faculty of Medicine, Department of Family Medicine, Poljanski nasip 58, 1000 Ljubljana, Slovenia
4
University of Maribor, Faculty of Medicine, Department of Family Medicine, Taborska 8, 2000 Maribor, Slovenia
Received: Dec 21, 2020
Accepted: May 18, 2021 
Original scientific article
*Corresponding author: Tel. + 386 40 454 713; E-mail: spela.tevzic@zd-lj.si
10.2478/sjph-2021-0021 Zdr Varst. 2021;60(3):145-151
145
KULTURA VARNOSTI ZAPOSLENIH V ZDRAVSTVENEM DOMU LJUBLJANA
© National Institute of Public Health, Slovenia. 
Tevžič Š, Poplas-Susič A, Klemenc-Ketiš Z. The safety culture of the Ljubljana Community Health Centre’s employees. Zdr Varst. 2021;60(3):145-151. doi: 10.2478/sjph-2021-0021.
ABSTRACT
Keywords: 
patient safety, safety 
culture, family 
medicine, primary 
healthcare, Slovenia 
IZVLEČEK
Ključne besede: 
varnost pacientov, 
kultura varnosti, 
družinska medicina, 
primarna zdravstvena 
raven, Slovenija
Introduction: Patient safety is one of the key aspects of healthcare quality and a serious global public health 
concern. Patient safety culture is a part of the patient safety concept. In Slovenia, primary care is easily 
accessible, and for medical care, it serves as a gatekeeper to hospital care. For several years, the quality and 
safety at the primary healthcare level have been the focus of several studies. The present study aimed to assess 
patient safety culture among all employees of the Community Health Centre Ljubljana.
Methods: We conducted a cross-sectional study in 2017 using the Slovene version of “Medical Office Survey on 
Patient Safety Culture” from the Agency for Healthcare Research and Quality. Mean percent positive scores on 
all items in each composite were calculated according to a user guide.
Results: The final sample contained 1021 participants (67.8% response rate), of which 909 (89.0%) were women. 
The mean age of the sample was 43.0±11.0 years. The dimensions most highly rated by the respondents were: 
teamwork and patient care tracking/follow-up. The lowest scores came from leadership support for patients’ 
safety and work pressure and pace.
Conclusion: Patient safety culture in the Community Health Centre Ljubljana is high, but there are certain areas 
of patient safety that need to be evaluated further and improved. Our study revealed differences between 
professions, indicating that a customized approach per profession group might contribute to the successful 
implementation of safety strategies. Patient safety culture should be studied at national levels.
Uvod: Varnost pacientov je eden ključnih vidikov kakovosti zdravstvenega varstva in globalno javno zdravje 
zanjo resno skrbi. Del koncepta je tudi kultura varnosti pacientov. V Sloveniji je primarna raven lahko dostopna 
in služi kot vrata v sekundarno in terciarno zdravstveno raven in oskrbo. Že več let sta kakovost in varnost na 
primarni ravni zdravstvenega varstva v središču več raziskav. Namen te študije je bil oceniti kulturo varnosti 
pacientov v Zdravstvenem domu Ljubljana.
Metode: V letu 2017 smo izvedli presečno raziskavo z slovenske različice “Medical Office Survey on Patient 
Safety Culture” Agencije za raziskave in kakovost zdravstvenega varstva. V skladu z navodili za uporabo smo 
izračunali povprečne deleže pozitivnih ocen za vsak dimenzijo varnosti.
Rezultati: Končni vzorec je vseboval 1.021 zaposlenih (67,8-odstotna odzivnost), od tega je bilo 909 (89,0 %) 
žensk. Povprečna starost vzorca je bila 43,0 ±11,0 let. Najbolje ocenjeni dimenziji varnosti sta bili timsko delo 
in skrb za paciente. Najnižje ocene so izhajale iz podpore vodstva in delovnih obremenitev.
Zaključek: Trenutna kultura varnosti pacientov v Zdravstvenem domu Ljubljana je visoka, vendar obstajajo 
nekatera področja, ki jih je treba dodatno ovrednotiti in izboljšati. Naša raziskava je razkrila razlike med 
poklici, kar kaže, da lahko prilagojen pristop prispeva k uspešnemu izvajanju varnostnih strategij. Preučiti je 
treba kulturo varnosti pacientov na državni ravni.
This article was presented at the ISCPC conference, which took place virtually on the 12th of February, 2021. The conference was 
organised by the Community Health Centre Ljubljana and Medical Faculty, University of Ljubljana, Slovenia.

*Corresponding author: Tel. + 386 40 454 713; E-mail: spela.tevzic@zd-lj.si
1 INTRODUCTION
Patient safety is one of the key aspects of healthcare 
quality and a serious global public health concern (1). It 
is defined as the reduction of risk of unnecessary harm 
associated with healthcare to an acceptable minimum 
(2). Patient safety culture is a part of the patient safety 
concept. It is defined as a product of attitudes, values, 
competencies and patterns of individual and group 
behaviour that determine healthcare in an organization 
(3). To improve patient safety, an important first step 
is to address and understand the safety culture of an 
organization. An understanding of the safety culture is 
vital to improve problematic practices or attitudes such 
as miscommunications, adverse events and non-punitive 
responses to errors, which can lead to improvements in 
the safety culture (4). For the past several years, safety 
culture has been one of the top priorities of the Slovenian 
Ministry of Health. A new system for managing safety 
deviations and safety risk is being established in 2021 (5).
More and more studies are emerging regarding patient 
safety and safety culture in primary care (4, 6). Measuring 
safety culture can help in the identification of areas for 
improvement (4). A recent systematic review showed that 
patient care follow-up, communication openness and work 
pressure contribute significantly to improving patient 
safety in primary care (7). 
In Slovenia, several studies have focused on quality and 
safety at the primary healthcare level, focusing on out-
of-hours care, family practices and leadership staff (8–11). 
Safety culture has only been evaluated at the primary 
healthcare level in out-of-hours primary healthcare 
settings. These studies showed variations in safety culture 
factor scores that pointed to the need to unify working 
conditions (12–14). 
The aim of the present study was to assess patient safety 
culture among all employees of the largest healthcare 
centre in Slovenia, the Community Health Centre Ljubljana. 
Our study is the first to evaluate patient safety culture at 
the primary healthcare level in Slovenia using the Medical 
office survey on patient safety culture (MOSOPS). 
2 METHODS
2.1 Research design and setting
We conducted a cross-sectional study in the largest 
community health centre in Slovenia. This health centre 
provides healthcare services for the municipality of 
Ljubljana, with over 450,000 registered patients. It 
consists of eight units, which are located in separate 
buildings in various parts of Ljubljana. It has around 1500 
employees of different healthcare backgrounds.
The study was approved by the National Ethics Committee 
(No. 107/07/16).
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2.2 Participants
We invited all employees of Community Health Centre 
Ljubljana to participate in the study (physicians, 
dentists, healthcare assistants (HCA), registered nurses, 
management, administrative or clerical staff, clinical 
support staff and employees working at other positions) 
(N=1507). 
2.3 Tools
We used the validated Slovenian version of MOSOPS (15). 
MOSOPS enables the measurement of patient safety 
culture at the primary level of healthcare, the detection 
of possible differences, assistance in understanding the 
safety of a particular organization, and an evaluation of 
the impact of specific interventions for improving patient 
safety culture (16–21). The survey seeks the opinion of 
healthcare professionals about 38 items in 10 different 
dimensions (domains C, D, E and F). The survey also 
includes questions that ask respondents about problems 
exchanging information with other settings and about 
access to care (domain A and B). In addition, respondents 
are asked to rate their medical office in five areas of 
healthcare quality (patient centred, effective, timely, 
efficient, and equitable) and to provide an overall rating 
on patient safety (domain G) (21). 
Domain A and B includes 14 items which are answered on a 
scale from “daily” to “not in the past 12 months”. Domains 
C to G are answered on a 5-point Likert scale (1 – strongly 
disagree, 5 – strongly agree). Domain C consists of four 
sub-domains (Teamwork, Work Pressure and Pace, Staff 
Training, and Office Processes and Standardization) and 
domain D of 3 sub-domains (Communication Openness, 
Patient Care Tracking/Follow-up, and Communication 
about Errors). Domain E should only be answered by 
employees without leadership function. Those with a 
leadership function should answer domain F, which has 
two sub-domains (Organizational Learning, and Overall 
Perceptions of Patient Safety and Quality). Domain G 
describes overall ratings on quality and patient safety (19).
Permission to use this questionnaire was given by the 
Agency for Healthcare Research and Quality (AHRQ); 
permission was granted on June 8, 2016. AHRQ is an 
agency within the United States Department of Health 
and Human Services. Its mission is to produce evidence 
to make healthcare safer, better, and more accessible, 
equitable and affordable. 
Data on demographic characteristics (gender, age, 
function, work experience, working hours, and location of 
work) was also collected.
2.4 Data collection
The survey was completed electronically; the link was 
sent to the participants’ email addresses in February 2017. 

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A reminder was sent after two weeks. Participation was 
anonymous, as possible identifiers such as e-mail and IP 
address were removed by the administrative coordinator 
of the project. It was not possible for the researchers to 
link the participants to their responses.
2.5 Statistical analysis
We performed a univariate analysis with frequency 
distributions and descriptive statistics. For positively 
worded items, the percent positive response was the 
combined percentage of respondents who answered 
strongly agree or agree, or always or most of the time. 
Negatively worded items (C3, C6, C8, C10, C12, C14, D4, 
D7, D10, E1, E2, E4, F3, F4, and F6) were reversed so that 
higher scores always indicated a more positive evaluation 
of the safety culture. The overall patient safety rating was 
calculated as the combined percentage of respondents 
who answered very good or excellent. We calculated a 
percent positive score for each of the composites and the 
overall patient safety rating for each job position within 
each medical office.
We also made a bivariate analysis, namely a t-test for 
independent samples and a one-way analysis of variance, 
which shows the correlation between two variables. For 
multivariate analysis we used multiple linear regression.
3 RESULTS
3.1 Demographic characteristics
There were 1021 participants in the final sample (67.8% 
response rate), of which 909 (89.0%) were women (Table 
1). The mean age of the sample was 43.0±11.0 years, the 
mean time in their current post was 11.6±10.1 years, and 
the mean number of weekly working hours was 36.0±10.0. 
The mean length of time they had been working at the 
current medical office location was 18.8±12.0 years.
3.2 Attitudes to patient safety culture
The dimensions most highly rated by the respondents 
were: teamwork (79.6%), and patient care tracking/follow-
up (77.8%). They were followed by overall perception of 
patient safety and quality (74.6%), communication about 
error (60.2%), staff training (55.9%), office processes and 
standardization (54.9%) and communication openness 
(43.9%). The lowest scores came from leadership support for 
patients’ safety (39.2%) and work pressure and pace (11.5%). 
The overall rating on quality had positive scores 
(percentage of ‘very good’ and ‘excellent’ responses) 
from 37.3% of respondents. Patient safety and quality of 
treatment were assessed as very good, and employees did 
not report any problems. The exchange of information 
with other services is mostly without any problems. 
Teamwork is graded well. Several more problems were 
brought up in the field of education, i.e. performing tasks 
for which the staff is not trained. The work process was 
moderately well assessed. In terms of communication, 
patient care was best rated, and communication openness 
the least. Organizational learning has been highly rated, 
which means that they are being able to learn from 
mistakes or from work experience. Responders believed 
that management cares about patient care mistakes that 
happen over time and that it places a high priority on 
improving the patient care processes. On average, the 
respondents assessed the quality parameters as good. 
The focus on patient, performance, timeliness and 
effectiveness was well assessed. They considered fairness 
as very good. 
3.3 Associations between the domains of safety culture 
and the respondents’ characteristics 
Bivariate analyses showed that some variables were 
associated with different domains (Table 2). On average, 
women assessed patient safety and quality of care better 
than men. Older workers (41 to 55 years old) assessed 
workload higher than younger ones (aged 26 to 40). Staff 
training was assessed better by employees over 55 years 
old than by younger ones. Management’s support was 
evaluated better among older employees. Those who 
Gender
male
female
Medical office position
Physician, dentist
Healthcare assistants 
Management 
Administrative or clerical staff 
Registered nurse 
Other clinical staff or clinical support staff
a
Other position
Community Health Centre Ljubljana unit
Center
Moste-Polje
Management
Šentvid
Vič-Rudnik
Bežigrad
Unit SNMP
Šiška
Table 1. Sample characteristics.
a
 – e.g. clinical psychologist, radiological engineer, etc.
112 (11.0)
909 (89.0)
277 (27.2)
211 (20.7)
34 (3.3)
45 (4.4)
295 (28.9)
127 (12.5)
31 (14.1)
209 (20.5)
222 (21.7)
37 (3.6)
47 (3.6)
195 (19.1)
129 (12.6)
38 (3.7)
144 (14.1)
n (%) Variable

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worked fewer hours per week (from 5 to 16) graded the 
overall quality lower than those who worked more hours 
a week (22 to 40 hours per week). Patient safety and 
quality of care were better assessed by those employed at 
their current job for more than 11 years. Teamwork was 
assessed better by those employed for less than one year. 
Patient safety and quality of care are better assessed by 
those who have more work experience. Teamwork was 
also assessed better by those who had fewer than 3 years 
of working experience. Staff training and management 
support were assessed better by those with working 
experience of more than 16 years. Doctors assessed 
workloads lower than all other employee profiles. Doctors 
assessed communication openness better than healthcare 
assistants and registered nurses. Doctors assessed 
leadership support worse than employees on other 
positions. The overall quality assessment was on average 
higher among doctors than among registered nurses.
A 
B 
C1 
C2 
C3 
C4 
D1 
D2 
D3 
E 
G1
Patient safety and 
quality of treatment
Exchange  
of information
Teamwork 
Work pressure  
and pace
Staff training 
Office processes and 
standardization
Communication  
openness
Patient Care Tracking/
Follow-up
Communication 
about Errors
Leadership support 
for patients’ safety
Overall ratings  
on quality
Table 2. Associations between patient safety culture and the characteristics of respondents. 
Legend: ns - non-significant; Unit - Ljubljana Community Health Centre unit; Time - number of on-site working hours per week; Length - 
length of time working at the current working position; Service: years of service; Position: Medical office position
t=-2.173 
p=0.030
ns 
ns 
ns 
ns 
ns 
ns 
ns 
ns 
ns 
ns
F=2.607 
p=0.011
F=5.540 
p<0.001
F=3.243 
p=0.002
F=9.109   
p<0.001
F=4.180 
p<0.001
F=6.722 
p<0.001
F=2.799 
p=0.007
F=3.712 
p=0.001
ns 
F=2.604; 
p=0.012
ns
F=3.104 
p=0.026
Ns 
F=7.592 
p<0.001
Ns 
F=3.592 
p=0.006
Ns 
F=5.285 
p<0.001
Ns 
F=3.473 
p=0.008
F=2.401; 
p=0.048
Ns
ns 
ns 
ns 
F=5.193 
p=0.001
F=6.350 
p=0.000
ns 
ns 
ns 
ns 
F=9.113 
p<0.001
ns
F=3.697 
p=0.005
ns 
ns 
ns 
ns 
ns 
ns 
ns 
ns 
ns 
F=4.229 
p=0.001
ns 
ns 
F=7.302 
p<0.001
F=8.614 
p<0.001
F=7.036 
p<0.001
F=3.872 
p=0.009
F=3.229 
p=0.022
ns 
ns 
F=8.781; 
p<0.001
ns
ns 
ns 
F=3.345 
p=0.010
F=18.299 
p<0.001
ns 
F=9.541 
p<0.001
F=10.297 
p<0.001
ns 
F=3.428 
p=0.009
F=6.690 
p<0.001
F=4.037 
p=0.003
Statistically significant differences
gender unit lenght age time servis position
Domain Domain name
4 DISCUSSION
This was the first study investigating patient safety culture 
at a community healthcare centre in Slovenia. It showed 
that the teamwork and patient care scores were the 
highest and the workload score was the lowest among the 
employees. There are some differences in the individual 
domains of the safety culture by individual units of the 
Community Health Centre Ljubljana, age, office position 
and the time they have worked at the current location of 
the medical practise. 
Women generally assessed patient safety and the quality 
of treatment higher than men.  Firth-Cozens explained 
this because female primary care physicians engage in 
more communication, which can be considered patient-
centred, and have longer visits than their male colleagues 
(22). Other studies also found differences by gender. The 
Polish study found that women rated certain domains 
significantly better (patient care tracking and follow-up, 
overall perception of patient safety and quality) (23). Men 
had better results in information exchange with other 
settings. In Spain, the following domains were evaluated 
better by female than by male participants: information 

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exchange with other settings, work pressure and pace, 
staff training, office processes and standardization, 
patient care tracking/follow-up, leadership support for 
patient safety and overall perception of patient safety. 
However, it was men who had a slightly better score in 
overall rating on patient safety (24). The Dutch study 
found no significant differences between male and female 
healthcare providers in terms of mean factor scores (25). 
Employees working part time compared to full-time 
graded the overall quality lower. Similar results were 
found in a Slovenian study regarding safety culture in out-
of-hours primary care clinics (12). They concluded that 
employees working part-time might not be so confident in 
their performance, and thus perceive patient safety lower. 
Those with more working years assessed the safety and 
quality of care lower. More experienced workers might be 
more aware of potential safety problems. 
Doctors generally estimated the overall quality of 
healthcare higher than nurses did. In Slovenia’s primary 
care the doctors spend more time with the patients than 
nurses, which differs from secondary healthcare levels. 
Thus, doctors are likely to show strong awareness with 
respect to a multitude of patient safety aspects. This 
is in contrast to studies conducted at secondary and 
tertiary level where nurses scored the majority of patient 
safety culture aspects higher than doctors, most likely 
because spending more time with patients allows for 
better awareness of patient safety (26). Differences in the 
patient safety culture among the professional categories 
were also found in other studies (17, 27).
Teamwork was the highest-ranked domain (79.6%). In two 
studies carried out in Slovenian out-of-hours healthcare 
clinics and in a hospital setting, teamwork scored high 
(12, 28). Results correlate to the Slovenian study on 
ethical dilemmas in family medicine, where teamwork was 
assessed as well functioning (29). Teamwork is also a highly 
ranked domain in other countries (22, 25–29). Teamwork is 
a strategy for strengthening and promoting quality of care 
and healthcare practices in health systems (32). It is very 
important in primary care, as multi-professional healthcare 
stakeholders are involved in managing patients (12).
Our study showed that 60.2% of respondents expressed 
a positive view on communication about errors at their 
medical offices, which was the lowest score among all 
studies compared. Poland evaluated their communication 
about errors as the highest (80.96%) and Portugal the 
lowest (47%) (20, 23). Employees need to feel that 
they will not be blamed, punished or concealed for 
acknowledging errors (33, 34). There is a need to educate 
healthcare professionals on how to deal with errors made, 
teaching them about non-blaming, open and emphatic 
communication, and about complete and authentic 
apology and coping strategies (34). A positive safety 
culture could help in encouraging honesty and fostering 
learning by balancing individual and organisational 
accountability to achieve better quality care. 
43.9% of respondents had a positive view on communication 
openness. Communication openness seems to be of 
concern only in certain countries, which might be 
associated with differences in cultural background (4). 
A non-experimental cross-sectional study in a general 
acute hospital in Slovenia raised concerns about how to 
deal with patient safety problems. The problems may 
be related to blaming and shaming individuals rather 
than a systemic approach that encourages learning and 
aims to prevent adverse events (28, 35). Communication 
breakdowns, which both affect both safety culture and act 
as a contributing factor for incidents, must be emphasized 
and addressed (4). 
The lowest scores were found for the leadership support 
for patients’ safety (39.2%) and work pressure and 
pace (11.5%). Scores for both are the lowest among the 
countries that used MOPSOS questionnaire. Regarding 
work pressure and pace Poland (57.7%) and Yemen (57%) 
scored the highest, followed by American respondents 
(50%) and primary care offices in Ohio (37%) (21, 23, 30, 
31). The lowest scores come from Spain (36%) and Portugal 
(25%) (20, 24). Regardless of the job position, staff feel 
rushed when taking care of the volume of patients that 
need to be seen and do not feel that there are enough 
staff to handle their patient loads and work effectively. On 
average, physicians rated work pressure and pace lower. 
A Slovenian study published in 2012 showed an average 
of direct physician-patient consultation/encounter of 
7 minutes (36). This contrasts sharply with the typical 
duration in other European countries where most nations 
conduct 15-minute consultations, while the Scandinavian 
countries veer towards 20–25 minutes (37). The nations 
with 25 consultations or less a day find general practice 
manageable. The majority (60%) of Slovenian family 
doctors have 41-60 consultations per day and 19% have 
61–80 (38). WHO evidence indicates a lower number of 
general practitioners in Slovenia compared with European 
Union (i.e. 49.78 vs 79.47 per 100,000 inhabitants) (39). 
The issue of insufficient staff and providers for the 
treatment of patients in primary care has also been raised 
in other studies (4). An appropriate work environment was 
characterised as one where workers were interrupted less 
often and is associated with better patient safety and less 
burnout. Lower workloads improve adherence to patient-
safety principles (40).  
There is a need for more detailed assessment of the 
factors contributing to workloads in primary care and 
of how these factors can be addressed and mitigated in 
order to develop interventions to improve the delivery of 
safe and efficient patient care (41). 

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The strength of this study is that it was conducted in a large 
community health centre, which resulted in a large sample 
to be used in our analyses. Moreover, this is the first study 
to use the Slovenian version of MOSOPS. The response rate 
was 67.8%, which is above the recommended response rate 
of 60% in research on patient safety culture (42). 
There were however several limitations to this project. 
The Community Health Centre (CHC) Ljubljana is only 
one of many health centres throughout Slovenia and the 
sample does not accurately reflect Slovenian primary 
healthcare. CHC Ljubljana is stationed in an urban 
environment, while primary care in Slovenia is distributed 
within the both environments. The respondents may not 
have felt comfortable enough to express their safety 
concerns about the organization, although the risk was 
minimized by expressing confidentiality. The question 
still remains whether self-reporting questionnaires are 
suitable for measuring patient safety culture, as they 
only provide a snapshot of the culture at a certain point 
in time. As the majority of respondents were physicians 
and nurses, the results did not adequately reflect the 
perception of other respondents’ groups. It would be 
beneficial to analyse the reasons why other professions 
did not readily participate. Although the response rate 
was high, there is no information on the characteristics 
of the non-respondents, so this could also be a source of 
bias. Based on their participation, they may have better 
awareness of patient safety climate than those that did 
not participate in the survey. In addition, the categories 
included staff from different specialities (e.g. family 
medicine, dentistry, gynaecology, emergency medicine, 
etc.). In the future, this additional information should be 
recorded and analyses carried out to determine whether 
there are differences between respondents within the 
categories. The results of the present study therefore 
must be interpreted carefully.
It would also be necessar y to examine patient safety culture 
with other approaches. Trbovich and Griffin recommend 
triangulation of both quantitative and qualitative methods 
to achieve a more accurate assessment of the culture 
(43). Other techniques such as interviews, workshops and 
focus groups are recommended to put survey responses 
in context. Research using mixed methods would to help 
gain further insights into the patient safety culture and to 
reveal the differences observed between the occupational 
categories. 
5 CONCLUSION
The current patient safety culture at the Community 
Health Centre Ljubljana is good, with a lot of room for 
improvement. It revealed variety between professions, 
indicating that a customized approach per profession 
group might contribute to successful implementation of 
safety strategies. Improving patient safety culture should 
also include all stakeholders (policymakers, healthcare 
providers and those responsible for medical education). 
Patient safety culture at the national level should be 
studied. 
ACKNOWLEDGEMENTS
We thank all the workers of the Community Health Centre 
Ljubljana in Slovenia for participating in the study.
CONFLICT OF INTEREST
The authors declare that no conflicts of interest exist.
FUNDING
None.
ETHICAL APPROVAL
The study was approved by the National Ethics Committee 
of the Republic of Slovenia (No. 107/07/16). 
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