To conduct a longitudinal study implementing six elements of the OSACH system identified as leading indicators and evaluating the effectiveness of this intervention on improving selected health and safety workplace indicators.
What are the current OHSMSs and leading indicators being used by participant sites?
What are the facilitators and barriers to changing current OHSMSs in participant sites?
Which of the six leading indicators could be added or changed at each site?
Is the tailored OHSMS intervention using the six leading indicators effective in improving health and safety workplace indicators over one year, specifically absenteeism, workers’ compensation composite, training and professional development opportunities, manager/supervisor training, and health and safety climate?
A quasi-experimental longitudinal research design will be used. There will be two phases of the project. The first phase will focus on assessing current OHSMSs in participating hospitals using the key leading indicators, determining potential facilitators and barriers to changing current OHSMSs, and identifying the leading indicators that could be added or changed to the existing OHSMS in place. Phase I will conclude with the development of an intervention designed to support optimizing current OHSMSs in participating hospitals based on identified gaps. Phase II will pilot test and evaluate the tailored intervention.
The setting will include two acute care hospitals in Eastern Ontario. Sites will be chosen based on size (small, medium, large) and location (urban and rural) to obtain a variation in types of hospital.
Phase I assessment and development
Data collection in phase I will include 1) semi-structured interviews and document reviews; 2) surveys; and, 3) administrative data.
Semi-structured interviews and reviewing of hospitals documents
To answer research questions #1 and #2, semi-structured interviews will be used to assess the current OHSMS and leading indicators being used, and determine potential facilitators and barriers in the participating hospitals. The information obtained from the interviews will also identify gaps and areas for improvement (research question #3) to be addressed in phase II. Sample: The Chief Executive Officer (CEO), members of the administrative team (e.g. Vice-Presidents, Directors) and members of the Occupational Health and Safety Department and/or the Joint Health and Safety Committee will be invited to participate. If interview participants are unable to provide the necessary information, they will be asked to provide the name(s) of the most appropriate person to contact. Interview Questions: An interview guide will be developed. Interview questions to assess key leading indicators will be developed using the template by Bennet and Foster (2005) and the corresponding elements found in the OSACH (2009) Assessment Tool. Based on the answers and documentation provided by each site, each leading indicator will be given a rating of 0 (never completed) to 10 (100% completed) to ensure consistency. A similar categorization was used by Bennett and Foster  to identify areas of potential improvement and to allow comparison to data collected in phase II. The objective is full implementation of each indicator; therefore, a score of 10 indicates no improvement is required.
Data collection: Each interview will take place over 1 week in order to complete the preliminary assessments with two research assistants (RA) (one team of one consultant and one RA for each site). Each team will conduct the interviews together to ensure no important cues or interpretations are missed. In order to ensure consistency during the assessment, a meeting will take place with the two teams and the PI to review the questions and ensure a clear understanding of what data is required. The consultant will facilitate the interview and the RA will take notes. The RA will also be trained for their role during the intervention phase. Participants will be asked to provide documentation to support their answers, such as meeting minutes, emails, etc. Document review will be recorded using a standard form to ensure consistent measurement. Interviews will be audio-recorded should the consultant and RA need to review the recording for missing information or clarification. Transcription will not be required.
To evaluate the effectiveness of the tailored intervention (research question #4), survey data will be collected at the beginning of phase I, and near the end of phase II using an online survey. Sample: A power analysis was conducted using G*Power  to determine the appropriate sample size. A paired t-test will be used to assess for statistical significance in the outcome variables pre- and post- intervention. For the paired t-test statistic with an alpha significance level of .05 and a power level of .95, it was determined that a moderate effect size (r = .50) between groups would be detected with a total sample size of 45 participants. Each site will be assessed separately. Therefore, 45 participants are required at each site with a total of 90 required participants. To compensate for a 50% response rate commonly found in survey research, a minimum of 180 participants is recommended. The number of employees in each hospital identified in the region varies with a range from 270 to 4000. Therefore, to ensure the appropriate sample size obtained, all employees (full-time, part-time and casual) and physicians in the participating sites will be invited to participate. Hospital volunteers will be excluded.
While health and safety culture is the product of values, beliefs, competencies and patterns of behavior that determine the commitment to an organization’s health and safety , the health and safety climate is the result of that higher level health and safety culture . The Health and Safety Climate Assessment Tool was developed through a joint industry and United Kingdom Health and Safety Executive research project to assess health and safety culture in offshore environments. The Public Services Health and Safety Association (PSHSA) (formerly OSACH) implemented a modified version of the tool  at four Ontario healthcare organizations as a means to improve health and safety outcomes. The assessment tool is organized based on three sections: Attitude Assessment and Questionnaires, Focus Groups and Interviews and/or Surveys and Behaviour and Observational Assessment. In this project, only the first section, Attitude Assessment and Questionnaires, will be used. Participants are asked to respond to 43 questions on a 5-point Likert scale from strongly agree to strongly disagree. The questions inform the results for nine dimensions: 1) management commitment, 2) communication, 3) priority for safety, 4) safety rules and procedures, 5) supportive environment, 6) involvement, 7) personal priorities and need for safety, 8) personal appreciation of risk, and 9) physical work environment. A demographic questionnaire will include questions about the participant’s age, years of experience in current role, years of experience at hospital, education, and employment status (full-time, part-time, casual).
Each participant will receive an email with an URL link to an online survey using Fluid Survey. An individual identification code will be provided to enable follow-up with non-respondents and linking data for analysis from the pre- and post-intervention data collection as a means to evaluate the effectiveness of the intervention. An introductory screen will briefly describe the survey, project purpose, participant confidentiality, and researcher contact information. As suggested by Dillman et al. , a follow-up reminder email will be sent to non-respondents 12 days after the initial email, followed by a final email reminder two weeks later.
Descriptive statistics will be used to summarize the characteristics of participants. Means and standard deviations will be calculated for each of the dimensions. An algorithm will be used to calculate a score out of ten for each of the nine dimensions, zero being the worst score and ten being the best score. These scores will then be plotted on a graph representing an overall ‘snapshot’ of the organization’s current health and safety climate. Reliability analysis using Cronbach’s alpha will be conducted on the multi-item scales to determine the reliability of the measurement tools in this sample.
To evaluate the effectiveness of the tailored intervention (research question #4), administrative data will be collected at the beginning of phase I, and near the end of phase II. In a recent project, PSHSA  recommended a set of core, consensus-based health and safety workplace indicators. From this set, the following administrative data will be collected:
Participant hospitals will be asked to provide the following data on absenteeism: Eligible employee groups defined as employees eligible for sick time benefits (e.g. not casual or contract staff). Sick leave hours include paid time for sick leave (i.e. absence due to medical leave, not other reasons such as family emergency) up until 15 weeks (75 days). Regular paid hours are defined as the hours regularly worked by the employee group. The following calculation will be used to determine the percentage of sick hours (absenteeism): Percentage sick hours = (Sick Leave Hours for all eligible employee groups / Regular paid hours for all eligible employee groups) × 100.
Workers compensation composite 
Written permission will be obtained by the Principal Investigator from participant hospitals prior to requesting the following data from WSIB to create a composite index measure:
Average lost-time claims accepted per 100 FTEs (200,000 h) annually (frequency)
Average number of days lost per 100 FTEs (200,000 h) annually (severity)
Number of lost-time claims accepted per 100 FTEs (200,000 h) annually (frequency)
Number of health care no lost-time (NLT) claims accepted per 100 FTEs (200,000 h) annually (frequency)
Number of days lost per 100 FTEs (200,000 h) annually (severity)
Number of injuries for injury categories over the previous year. These categories include sprains and strains, bruises and contusions, fractures, traumatic injuries, disorders, and complications, multiple traumatic injuries, fall on same level, overexertion, bodily reaction, assaults, violent acts, or harassment, struck by an object or equipment.
Training & Professional Development Opportunity 
Participant hospitals will be asked to provide data on training and professional opportunity hours and total number of eligible employees.
Manager/supervisor training 
Participant hospitals will also be asked to provide data on total number of managers and supervisors and the number trained in due diligence.
Analysis of phase I
Following the completion and analysis of the interviews, document review, administrative data and survey results, an all-day face-to-face meeting will be held with the research team and participating sites. The purpose will be to review the results, identify gaps, identify which leading indicators need to be changed or added, and develop the tailored intervention for each site. Ultimately the objective is the implementation of all six leading indicators. However, it may not be realistic to address several missing indicators, given the time frame of this project. The research team, in collaboration with the OHS director/manager, will determine the indicators which could be improved, and how to address the gaps identified. A teleconference will take place with the research team, PSHSA, and knowledge users within two weeks of the intervention being implemented to finalize the plan.
Phase II intervention
The tailored intervention will be implemented and monitored over 12 months. The internal work will be completed by appropriate individuals within each site, while our team of consultants and RAs will provide support in the implementation. The implementation and monitoring will initially be a joint effort between the consultants and RAs. This initial monitoring time will also be used by the consultant to equip the RA with the necessary knowledge to monitor the intervention. All subsequent monitoring will be the responsibility of the RA. The intervention will deliver various elements of the leading indicators to each participating hospital; however, the elements will vary depending on the identified gaps, facilitators and barriers in phase I. The goal of the intervention will be to improve OHSMS in each hospital to meet the specific quantified benchmarks based on the assessment questions from phase I. Each RA will meet with the personnel responsible for implementation in each participant site monthly, answer questions, and ensure the intervention is being implemented as planned. Similar to phase I, participants will be asked to provide copies of documentation to illustrate examples of each indicator. The hospital documents will be reviewed by the RA and recorded using the same standard form to ensure consistent measurement. Similar to phase I, each indicator will be assessed at the end of the intervention with a rating of 0 (never completed) to 10 (100% completed) to compare to the rating in phase I. The data to assess each indicator will be collected over 12 months. During the 12-month intervention, teleconference meetings will take place with the researchers, PSHSA, and knowledge users every 5 months (e.g. 11th and 16th month) to provide updates on the progress of the project and discuss any issues that arise. At the end of the intervention (19th month), a teleconference meeting will take place between researchers, PSHSA, knowledge users, and collaborators to discuss the intervention overall and confirm questions for the interviews, document review, surveys and administrative data being collected to assess the intervention.
Approach to evaluation of intervention in phase II
Semi-structured interviews will be used to assess the implementation process and tailored intervention. Sample: The CEO and Director/Manager of the Occupational Health and Safety Department will be invited to participate. Data collection: Each interview will be approximately 1.5 h in length and will be conducted by the project PI and RA to ensure no important cues or interpretations are missed. The RA will take notes. The interview guide will be followed. Interviews will be tape-recorded to allow the PI and RA the opportunity to review the recording for missed information or clarification. Transcription will not be required.
In order to assess the effectiveness of the intervention (research question #4), data collection from phase I will be repeated at the end of the intervention. Sample: Surveys will be distributed to all employees to assess for overall changes pre- and post-intervention. For participants who completed surveys in both time points, data will be linked in order to assess change over time. Data analysis: Descriptive statistics will be used to summarize the characteristics of participants. Means and standard deviations will be calculated for each dimension. An algorithm will be used to calculate a score for each of the nine dimensions, zero being the worst score and ten being the best score. These scores will then be plotted on a graph presenting an overall ‘snapshot’ of the organization’s current health and safety climate. Reliability analysis, using Cronbach’s alpha, will be conducted on the multi-item scales to determine the reliability of the measurement tools in this sample. Frequencies and percentages will be used to summarize the evaluation of the OHSMS. Paired t-tests will be used to test for significant changes in each variable measured with participants who completed surveys at both time periods. Unpaired t-tests will also be conducted on the pre- and post-intervention data to allow for the inclusion of data from individuals who only participated in one data collection period.
End of phase II
Following the completion and analysis of the interviews, document review, administrative data and survey, a final teleconference will take place with the entire team one month prior to the final symposium to review the results, discuss recommendations, and prepare the final report. A final one-day symposium will be held with all team members in the final month. Knowledge users who were not part of the project (e.g. non-participant hospitals and healthcare organizations) and policy makers (e.g. representatives from Ministry of Labour (MOL), Ministry of Health and Long-term Care (MOHLTC), Ontario Hospital Association (OHA)) will be invited to the one-day symposium. The purpose of the symposium will be to present the project results and ensure the results are made available to all healthcare organizations and future government initiatives.