20 Şubat 2013 Çarşamba

An Asessment of The Diversification-Performance Linkage: An Empirical Comparison Between Turkish and Italian Firms






Kaynak: Yiğit İ, Behram N.K., Isci E., “An Asessment of The Diversification-Performance Linkage: An Empirical Comparison Between Turkish and Italian Firms, 9th Eurasian Business and Economics Society (EBES) Conference, Faculty of Economics, Sapienza Unıversity of Rome, 11-13 January 2013, Italy


ABSTRACT

The aim of this study is to determine whether there is a significant difference between types of diversification and performance values comparing Turkey and Italy. Diversification strategy and organizational performance relationship seems to differ across the developed and developing countries under stable conditions. Studies on this relationship in developed countries carried out by the year 2000 yielded the generally accepted conclusion that the relationship between diversification strategies and organizational performance is in the form of an inverted U curve. However, there exist studies with the conclusion that the indicators of the relationship between diversification strategies and organizational performance of developed countries differ from the indicators of developing countries due to the effects of government and business relations, market, production, labor factors, and political economic variables. The research aimed to identify the effect of institutional diversification on organizational performance was carried out on the businesses in Turkey and Italy. The dataof 418 business groups in Italy and 128 business groups in Turkey were analyzed. The data of 2007-2011 were used in the research. ROA and ROS for organizational performance and Rumelt’s measure for diversification were used. According to the results of the study, when organizational performance values are high for single businesses and unrelated diversification in Turkey, organizational performance is high for dominant businesses and related diversification in Italy.

Keywords:Diversification Strategy, Rumelt’s Diversification Measure, Organizational Performance, Emerging Country, Emerged Country

1. Introduction
Corporate diversification has remained an important strategy for many firms worldwide for the last half century. It may not be considered as just a trend; rather it is based on logical reasons. These reasons include increased profitability, reduction in risk, increased market share, increased debt capacity, higher growth, extension of business life cycle, and efficient utilization of human and financial resources. Many writers proved diversification to be a successful strategy in their studies but still a number of researches are having different views(Afza et al. 2008).Palich et al. (2000) suggested that there has been inconsistency in the findings of the diversification-performance research for more than 30 years and there is a lack of consensus. Some of empirical findings were either a positive relationship with economic performance (e.g., Pandaya and Rao, 1998; Singh et al. 2001;Piscitello, 2004), a negative relationship with economic performance (e.g.Markides 1995; Lins and Servaes 2002, Gary, 2005), a curvilinear relationship depending on the level of diversification (Varadarajan and Ramanujam, 1987;Palich et al. 2000, Kakani, 2000) or lack of a relationship (Grant et al., 1988; Montgomery 1985).

All of these mixed and inconclusive empirical research evidence shave led to a need for researchers examining how diversification strategy affects firm performance in different institutional environments and market conditions. In accordance with this need, the primary motivation of this study is to examine the relationship between diversification strategy and organizational performance in developed and emerging economy contexts. Thus we analyze and compare how diversification affects organizational performance in Turkey as an emerging economy and in Italy a developed economy.


2. Conceptual Framework
Investigations into the relationship between diversification strategy and organizational performance represent one of the most actively investigated areas in the fields of strategy and finance (Rumelt, 1974; Hoskisson and Hitt, 1990, Montgomery, 1994; Kakani 2000; Khanna and Palepu 2000; Miller 2004; Chakrabarti et al. 2007). However, despite the enormous interest in the field, the debate on whether corporate diversification creates or destroys value remains inconclusive with several studies offering differing results on the phenomena among different institutional context (Rejie, 2007) and market conditions.
The outcomes of firm diversification will vary across countries, because of the influence of the institutional environment within which diversification takes place. Khanna and Palepu (1997) suggested that the degree of market and institutional development is an important determinant of the efficacy of diversification. In general, the potential returns from diversification decrease with market and institutional development, so that diversification would not improve firm performance in perfect markets. So it is expected that firms in less institutionally developed economies will benefit more substantially from diversification than firms in more institutionally developed economies (Chakrabarti et al. 2007).

2.1. Diversification-Performance Relationship in Emerging Economy Context
Several studies propose that diversification strategy is more likely to be profitable in emerging economies (Guillen, 2000; Khanna and Palepu, 1997; Kock and Guillen, 2001). The underlying argument is that key aspects of institutional environments in emerging economies are the lack of well-established product markets, financial markets and labor markets, coupled with the lack of necessary laws and regulations and inconsistent enforcement of contracts.More specifically, to cope effectively with this institutional environment companies may wish to pursue unrelated diversification strategy as an effective means of gaining self-generated institutional support. Consequently, the nature of the institutional environment and the resultant need for firms to employ an unrelated diversification strategy element in a poorly structured institutional environment constitute the institutional environment management explanation of the diversification and performance relationship (Li and Wong, 2003).
Khanna and Palepu (1997, 2000) argue that greater diversification may not harm performance in emerging economies because of insufficient market and institutional development. By diversifying, firms create internal markets that may be more effective than inefficient external markets. These firms enjoy scope and scale advantages from internalizing functions provided by external intermediaries or institutions in advanced economies. As intermediaries are often absent or inefficient in developing economies, internalization may be viable and profitable(Chakrabarti et al., 2007).Lins and Servaes (2002) also argued that in institutionally developing economies, the absence or inefficiency of external intermediate institutions results in firms developing these institutions internally, which helps firms to lower their costs. Thus, internalization in less developed institutional environments would bring about greater net marginal benefits (Purkayastha et al., 2012).

On the other hand, the severe market imperfections in emerging economies also increase the potential agency costs associated with diversification. Higher asymmetric information might allow management and large stakeholders to more easily exploit the firm for their own purposes. Such opportunities for exploitation are likely exacerbated when the rule of law is weak, which makes contract enforcement difficult; when accounting standards are poor; and when shareholders have fewer rights. Such imperfections make it easier for diversified firms in emerging economies to engage in empire building (Lins and Servaes, 2002).

2.2. Diversification-Performance Relationship in Developed Economy Context
Recent evidence indicates that corporate diversification has not enhanced the value of firms in the US, the UK, Germany and Japan (Lang and Stulz, 1994; Berger and Ofek, 1995; Servaes, 1996; Lins and Servaes, 1999). The evidence in these papers suggest that, for the average firm operating in developed capital markets, the costs of diversification outweigh the benefits (Lins and Servaes, 2002).
Efficient markets in developed economies detect and penalize diversification costs more than the less efficient markets of institutionally developing economies. This may be because the internal intermediate institutions of diversified firms in developed economies cannot match the efficiency levels of open market institutions. Diversified firms thus have higher costs, which results in lowering their performance (Purkayastha et al., 2012; Leaven and Levine 2007; Villalonga 2004).
According to the transaction cost theory based explanation, most developed economies have strong and well developed institutions with efficient product, labor and capital markets. Hence, the market structure would be a much more efficient mechanism for transactions. In this light, there are higher costs associated with diversified firm structure and therefore it is predicted that conglomerates would be poor performers in strong and mature market. Transaction cost also predicts that diversified group structure is a beneficial organization form in emerging economies (Mishra and Akbar, 2007).
Resource-based-view theorists argue that diversification in developed economies would be efficient if it were based on specific resources, rather than generic resources, so that synergistic benefits from economies of scope can be exploited. Purkayastha et al. (2012) argued that in developed economies, only firm-specific resources would lead to sustainable competitive advantage, and hence firms should concentrate on one industry or at best on a limited number of related industries.

3. Methodology of Research
3.1. Aim and Universe of the Study
The aim of this research is to determine whether there is a significant difference between types of diversification and performance values comparing Turkey and Italy. The research aimed to identify the effect of institutional diversification on organizational performance was carried out on the businesses in Turkey and Italy, so the data of the businesses operating in Turkey were obtained from www.imkb.gov.trandwww.kap.gov.tr and the data of businesses operating in Italy were obtained from Bloomberg data base. The data of 418 business groups in Italy and 128 business groups in Turkey were analyzed. The data of 2007-2011 were used in the research.

3.2. Variables and Measurement Methods of the Research
The independent variable of the research is measure of diversification and dependent variable is organizational performance.Diversification Measure: In this research Rumelt's classification is used for measuring diversification. According to Rumelt’s measure of diversification; Specialization Ratio-SR: The ratio of the strategic business unit or group with the highest revenue to total revenues of the company, Relationship Ratio (Related Ratio-RR): denotes to, analyzing the amount of revenues, the status of interrelatedness of the areas of the strategic business units that make up this amount; Rumelt's Measure of Diversification; Analysis to measure organizational performance, financial measures utilized and reasons for using these measures are summarized below.
Researches in which Performance is measured by ROA (Return on Assets); ROA is accepted as an important indicator to measure the effectiveness of management by the researchers that measure organizational performance by ROA value only. In addition, external shareholders and business managers who need the performance of the business organization express that ROA is a sufficient criterion to evaluate the performance of organization (Tihanyi, 2003; Dubofsky, 1987; Kim and others, 2004; Ravichandran, 2009; Hill and others, 1992). On the other hand, according to Rumelt, Christensen and Montgomery ROA is a standardized measure of performance (Dubofsky, 1987). This rate shows to what extent the assets are used effectively in other words how much revenue can a company make over its assets (Fool and Others, 2008).

Researches in which Performance is measured by ROS (Return on Sales); the reason that researchers use the ROS value only or with other financial measures for organizational performance is that the ROS ratio is calculated after deducting taxes and other expenses. The ROS value is accepted as an important factor in measuring the efficiency of operational activities (Palepu, 1985; Markides and Williamson, 1994; Markides, 1995; Markides, 1996).

3.3. The Hypothesis of Study
H1: Single businesses’ organizational performance is higher in Turkey than in Italy.
H2: Dominant businesses’ organizational performance is higher in Italy than in Turkey.
H3: Related diversification’s organizational performance is higher in Italy than in Turkey.
H4: Unrelated diversification’s organizational performance is higher in Turkey than in Italy

3.4. Frequencies for Diversification in period of 2005-2009, ROA and ROS Values
At Table 1, the frequencies according to the extent of diversification, operating frequency and indicators of the average performance in each measure of diversification of the enterprises within the research, are presented. As table illustrates, in the 2007-2011 period, 99 companies of the total 128 in Turkey are single businesses, 5 of the companies are related diversified. Based on the data, single businesses have the highest ratio of 77.34% among the groups. As table illustrates, in the 2007-2011 period, 374 companies of the total 418 in Italy are single businesses, 8 of the companies are related diversified. Based on the data, single businesses have the highest ratio of 89.47% among the groups.




4. Results
4.1. Diversification Strategy (Single Businesses) and Organizational Performance
The results of Mann-Whitney U test which is one of the Rumelt’s diversification measures and was made for single businesses will be presented under this title. The tables are for comparing Turkey and Italy
4.1.1.Diversification Strategy(Single Businesses) and Return on Sales (ROA)
There isn’t a significant difference in performance (ROA) between Turkey and Italy. Yet, it is seen that the performance values of single businesses in Turkey are higher than in Italy when the median values are examined.


There is a significant difference in performance (ROS) between Turkey and Italy. Also, it is seen that the performance values in Italy are higher than in Turkey when the median values are examined.
4.2. Diversification Strategy (Dominant Businesses) and Organizational Performance
The results of Mann-Whitney U test, one of Rumelt’s diversification measures, made for dominant businesses will be presented. ROA and ROS values are shown in the tables separately and they are for comparing Turkey and Italy.
4.2.1. Diversification Strategy(Dominant Businesses) and Return on Assets (ROA)
There isn’t a significant difference in performance (ROA) between Turkey and Italy, but when the average and median values are examined, it is understood that the performance values of dominant businesses in Italy are higher than in Turkey.





4.3. Diversification Strategy (Related Diversification) and Organizational Performance
The results of Mann-Whitney U test, one of Rumelt’s diversification measures, made for related diversification will be presented. ROA and ROS values are shown in the tables separately and they are for comparing Turkey and Italy. 9th EBES Conference - Rome January 11-13, 2013, Rome, Italy
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4.3.1. Diversification Strategy (Related Diversification) and Return on Sales (ROA)
There isn’t a significant difference in performance (ROA) between Turkey and Italy, but when the average and median values are examined, it is understood that the performance values of related businesses in Italy are higher than in Turkey.




4.4. Diversification Strategy (Unrelated Diversification) and Organizational Performance
The results of Mann-Whitney U test, one of Rumelt’s diversification measures, made for unrelated diversification will be presented. ROA and ROS values are shown in the tables separately and they are for comparing Turkey and Italy.
4.4.1. Diversification Strategy (Unrelated Diversification) and Return on Sales (ROA)
There isn’t a significant difference in performance (ROA) between Turkey and Italy, but when the average and median values are examined, it is understood that the performance values of unrelated businesses in Turkey are higher than in Italy.


5. Conclusion
When the results are considered in terms of Hypothesis 1, the average of performance indicators in Turkey is higher than in Italy for single business. When the results are considered in terms of Hypothesis 4, the average of performance in Turkey is higher than in Italy for unrelated diversification. These analyses of the research reveal that the performance averages only by the developing countries seem to have similar characteristics. As emphasized by the researches mentioned above concerning the developing countries, the reason for such insignificance appears to stem from conditions that are thought to be differentiated in Turkey. The relationship between diversification and performance is thought to be affected by factors such as some of the privatization policies in Turkey, working conditions, crises conditions that coincide with the period of research, absence of perfect competition conditions markets in Turkey, some sectors in developing countries being at the end of product life cycle curve while being at point of entry in Turkey.
To see if related diversification-organizational performance relationship is different in Turkey and Italy, Hypothesis 3 was suggested. When the results are considered in terms of Hypothesis 3, the average of performance in Italy is higher than in Turkey for related diversification. Also, in terms of dominant businesses (Hypothesis 2), the average organizational performance in Italy is higher than in Turkey. However, this finding is at an average level and there isn’t a statistically significant result. Rumelt’s dominant business category includes related diversification partially. It is considered that the business groups ofItaly prefer diversification focusing on the internal resources rather than environmental opportunities because of high averages and results similar to developed countries in the literature.
On the other hand, when the results are considered in general, they are in accordance with the hypotheses in consideration of median values although there isn’t significant difference in hypotheses. The reason why the results are not at the level ofstatistical significance is based on the study period because this study has coincided with the period of economic crisis that existed in the world and Italy is a developed country which was significantly affected by this crisis.
Within the framework of the results emerging from this study, the following recommendations are proposed to researchers and executives: Results of this research can stimulate new researches into;
 The same study can be carried out including more developed and developing countries. Also, some variables such as crisis conditions, agency problems, business growth, national income and trend rate of gross national product growth.
 The same studies can be carried out using only Entropy Index or both Rumelt’s diversification measure and Entropy Index.
 In order to separate related and unrelated diversification 2-digit SIC was used in this study. Another study where 3-digit is used for this separation can be carried out.
REFERENCES
Afza, T., Slahudin, C., Nazir, M.S. (2008). Diversification and Corporate Performance: An Evaluation of Pakistani Firms. South Asian Journal of Management.15(3).pp.7-18 Berger, P. and Ofek, E. (1995).Diversification Effect on Firm Value.Journal of Financial Economics. 37. pp. 39–65. Chakrabarti, A., Singh, K. and Mahmood, I. (2007). Diversification and Performance: Evidence from East Asian Frms. Strategic Management Journal, 28, pp. 101–120. Gary, M. (2005).Implementation Strategy and Performance Outcomes in Related Diversification.Strategic Management Journal, 26.pp.643-664. Grant R.M., Jammine A.P., Thomas, H. (1988). Diversity, Diversification, and Profitability among British Manufacturing Companies, 1972-84. The Academy of Management Journal.31 (4). pp. 771-801. Guillen M.F. (2000). Business Groups in Emerging Economies: A Resource-Based View. Academy of Management Journal 43(3): 362–380. Hoskisson R. E., Hitt M. A. (1990). Antecedents and Performance Outcomes of Diversification: A Review and Critique of Theoretical Perspectives, Journal of Management, 16. 498. Kakani, R.K. (2000). Financial Performance and Diversification Strategy of Indian Business Groups.Doctoral dissertation, Indian Institute of Management, Calcutta. Khanna, T., Palepu, K. (2000). Is Group Affiliation Profitable in Emerging Markets: An Analysis of Indian Diversified Business Groups. Journal of Finance, 55, pp. 867–891. Kock C., Guillen M.F. (2001). Strategy and Structure in Developing Countries: Business Groups as An Evolutionary Response to Opportunities for Unrelated Diversification. Industrial and Corporate Change.10(1). pp. 77–113. Lang, L.H.P., Stulz R.M. (1994). Tobin's q, Corporate Diversification and Firm Performance.Journal of Political Economy.102, pp.1248-1280. Leaven, L., Levine, R. (2007). Is There A Diversification Discount in Financial Conglomerates? Journal of Financial Economics. 85. pp. 331–367. Li, M., Wong, Y.Y. (2003). Diversification and Economic Performance: An Empirical Assessment of Chinese Firms. Asia Pacific Journal of Management, 20(2). pp. 243-265. Lins, K., Servaes H. (1999). International Evidence on the Value of Corporate Diversification. Journal of Finance 54, pp. 2215-2239. Lins, K.V. and Servaes, H. (2002). Is Corporate Diversification Beneficial in Emerging Markets? Financial Management, 31, pp. 5–31.Markides, C. (1995). Diversification, Restructuring and Economic Performance.Strategic Management Journal. 16. pp.101-118 Miller D.J. (2004). Firms' Technological Resources and the Performance Effects of Diversification: A Longitudinal Study, Strategic Management Journal. 25 (11). pp. 1097-1119. Mishra A., M. Akbar, (2007). Empirical Examination of Diversification Strategies In Business Groups: Evidence From Emerging Markets", International Journal of Emerging Markets.2(1), pp.22 - 38. Montgomery, C.A. (1985). Product-Market Diversification and Market Power. Academy of Management Journal, 28, pp. 789–798. Montgomery, C.A. (1994). Corporate Diversification. Journal of Economic Perspectives, 8, pp. 163–178 Palich, L.E., Cardinal, L.B. and Miller, C.C. (2000).Curvilinearity in the Diversification-Performance Linkage: An Examination of over Three Decades of Research. Strategic Management Journal, 21, pp. 155–174. Pandaya A., Rao N. (1998). Diversification and Firm Performance: An Empirical Evaluation. Journal of Financial and Strategic Decisions, 11(2).pp.67-81. Piscitello L. (2004). Corporate Diversification, Coherence and Economic Performance.Industrial and Corporate Change, 13 (5), pp.757-787. Purkayastha S., Manolova T.S., Edelman L.F. (2012). Diversification and Performance in Developed and Emerging Market Contexts: A Review of the Literature, International Journal of Management Reviews. 14. pp. 18–38. Rejie P.G. (2007). Diversification and Firm Performance: The Moderating Influence of Ownership Structure and Business Group-Affiliation. South Asian Journal of Management. 14(3), p.66 Rumelt, R.P. (1974). Strategy, Structure and Economic Performance. Cambridge, MA: Harvard University Press. Servaes, H. (1996). The Value of Diversification During the Conglomerate Merger Wave. Journal of Finance. 51. pp. 1201-1255. Singh, M., Mathur, I., Gleason, K., Etebari, A. (2001).An empirical examination of the trend and performance implications of business diversification.Journal of Business and Economic Studies, 7(2).pp.25-80 Varadarajan, P.R. and Ramanujam, V. (1987). Diversification and Performance: A Reexamination Using a Two Dimensional Conceptualization of Diversity in Frms. Academy of Management Journal, 30, pp. 380–393. Villalonga, B. (2004). Does Diversification Cause The 'Diversification Discount'. Financial Management, 33, pp. 5–27.




Healthcare Risk Management and Patient Safety in Turkish Hospital



Chinese Business Review, ISSN 1537-1506 August 2012, Vol. 11, No. 8, 760-766


Aysegul Yildirim Kaptanoglu, Emre İsci
Marmara University, Istanbul, Turkey
Serpil Kaplan Yalçınkaya

Patient safety is an important component of risk management in hospitals. The aim of the study is to measure physician and nurse awareness about four selected patient safety indicators by authors and events reported about these relevant indicators in the hospital. The study uses standardized four patientsafety indicators like “needle sticks, cut wounds, dressing allergy, infections indicators’’. Cross section study was conducted through three month period in 2011-2012 based on voluntary response to the questionnaire that intend to measure knowledge about four health indicators. Studypopulations consisted of accessible sample of 146 different specialty physicians and 108 nurses present on duty during survey period. The association between the patient safety indicators and events reported about indicators in questionswere analyzed. Meanpatient safety knowledge questionnaire scores of health staff (nurse and physician) for needle sticks, cut wounds, dressing allergy, infections indicators were 47.13(11.8), 39.04(14.5), 38.02(10.5), 39.72(9.7), respectively. Significant statistical differences were also found between the frequency of events reported according to department and patient safety indicators (F = 8.34; p < 0.05). Measuring patient safety culture via safety indicators is essential in improving patient safety. This matter is perfectly influence the financial management of the hospital.
Keywords: patient safety, risk management, hospital management, safety indicators

HEALTHCARE RISK MANAGEMENT AND PATIENT SAFETY                             
care system by patients or diminished satisfaction by both patients and health care professionals (Reason, 2000). For a safe environment, errors can be prevented by designing the health system at all levels to make it easier for health care professionals to do the things right if they can be careless and take responsibility for their actions. When error occurs, blaming someone else would not prevent to somebody from committing the same error again next time (Larson, 2000; Elder & Dovey, 2002).
The World Health Organization pointed out that the effective reduction of health risks could add almost 10 more years of healthy life expectancy worldwide (WHO, 2004). United State, Canada, England, France, Germany and some European countries implemented methods to assess and manage risks both in hospital administration, clinical, and community healthcare systems in recent years (NHS, 2004).
The Turkish health care delivery system is in transition period nowadays (Yildirim Kaptanoglu, 2011; Glenngård, Hjalte, Svensson, Anell, & Bankauskaite, 2005). Both patients and health staff are concerned that the health care delivered is not, essentially, the care that should be received and given without managing health risks (Ugurluoglu & Celik, 2006).
Now, Turkish hospitals have specialized risk management departments whose duties is to investigate risks, incidents, and medical claims procedures. Evaluation of risk such as surgery, obstetrics was established in 2010 in the country.With thenew transition program after 2003, Turkish public hospitals became to have higher health quality systems in order to achievebetter quality and safety outputs (such as providingpatient ID bracelets, dispensers to facilitate handhygiene) (Chakraborty, 2009; Kaya, Barsbay, & Karabulut, 2010; Kringos, Boerma, Spaan, & Pellny, 2011).
The patient safety challenges within the Turkish healthcare system transition have dramatically elevated the importance of patient safety in public hospitals (Kohn, Corrigan, & Donaldson, 1999; Mohr, Abelson, & Barach, 2002). Nowadays, hospitals have established risk management departments whose duties are to investigate risks and incidents in clinics and operating theatres. This unit are also dealing with medical claims procedures. Hospital safety matter is not only for patients and staff but also for visitors including different briefly describes categories that are the following: human safety, hospital safety, clinical safety, and patient safety. These categories are interrelated, but each has inherent risks that need to be assessed and managed.
The organizational aspects of the hospital has a important role in order to improve patient safety because each hospital have different reality. Therefore to answer a question what are the patient safety culture of health staff of Bagcilar Research and Education Hospital (BREH), an study was planned.
The aim was to evaluate the perception of BREH nursing and physicians staff on the risk management and patients safety. The accreditation process was still continuing in BREH beginning from 2011.
A survey was conducted using the five-point Likert Scale as the name of the tool was “Patient Safety Knowledge of Health Staff”. This scale intends to measure the knowledge of staff about four patient safety indicators such as needle sticks, cut wounds, dressing allergy, and infections indicators. Patient safety and quality of care in these conditions is partner of the other in the health care management concept (Becher & Chassin, 2001). Without measuring hospital patient safety culture in the hospital, hospital managers, financial managers and medical directors cannot administrate hospital and make their jobs in a proper way (Firth-Cozens, 2001).

762                           HEALTHCARE RISK MANAGEMENT AND PATIENT SAFETY
Methods
The size of the study group was determined by a formula that enabled a comparison of the predicted mean score of 63 ± 10 (Sorra et al., 2007) for positive perception of the overall patient safety knowledge in the hospital within an SD of 5 points, at a 95% confidence level and with a 0.80 power. So, according to the formula, the goal was to reach at least 63 people in each physician and nurse group.
A total of 306 questionnaires were used but only 254 completed and returned as follows: 146 physicians and 108 nurses. Study population met the survey criteria.
The response rate was 83.45% and this high percentage of response identified patient safety as an important issue in health care of the country today.
BREH is one of the larger sized hospitals in Istanbul/Turkey with a total of 498 beds capacity.
The association between the patient four safety indicators (needle sticks, cut wounds, wound dressing allergy, and infections due to contamination) and events reported about indicators in questions were analyzed.
Events report data were obtained. Statistical analysis was performed to assess whether each of the four safety indicators measures. Agreement between the measures of events was assessed based on contingency table analysis using Chi-square tests and/or Fisher’s exact tests, depending on the number and the rate of cases with adverse events.
Survey Instruments
The survey instrument consisted of 4 major scales with 12 subscales that were rated on a five-point Likert Scale (ranging from 1 for strongly disagree to 5 for strongly agree). Major scales were needle sticks, cut wounds, wound dressing allergy, infections. Socio-demographics questions were included the age and years of experience.
Structural validity of each major safety dimension relationship of “Patient Safety Knowledge of Health Staff Scale” was shown with a correlation between 0.41 and 0.68. Internal consistency reliability for all items was high (α = 0.80). The Spearman-Brown coefficient was 0.81.
The factor loading of each item was above 0.40 and the structure of the survey scale was considered appropriate. Factor loadings were between 0.42 and 0.83.
Ethical approval was obtained from BREH ethics committee together with written consents from participating physicians and nurses before proceeding with the study.
Results
The mean age of healthcare personnel was 36 ± 8.3. While 104 (40.94%) of them were working in the Department of Internal Medicine, 110 (43.30%) were working in the Department of Surgery, and 40 (15.74%) were working in the intensive care/emergency/operation room.
Of the participants, the length of time worked varied, with 59 staff (23.22%) having worked for five years or less, and 195 staff (76.77%) having professional experience of 10 years or longer.
Major Scales: Mean patient safety knowledge questionnaire scores for needle sticks, cut wounds, dressing allergy, infections indicators were 47.13(11.8); 39.04(14.5); 38.02(10.5); 39.72(9.7), respectively. There are statistically significant differences between physician and nurse knowledge questionnaire scores for patient

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safety (see Table 1).
Table 1
The Results of the “Patient Safety Knowledge” Scale Mean Are Shown


Physician
Nurse
Total scale scores
P
Needle sticks
46.11 ± 11.2
47.12 ± 10.1
47.13 ± 11.8
t = 9.23; * p = 0.003
Cut wound
38.46 ± 10.1
39.11 ± 11.3
39.04 ± 14.5
t = 7.46; * p = 0.007
Dressing allergy,
37.65 ± 9.4
37.44 ± 10.7
37.02 ± 10.5
t = 1.53; p = 0.456
Infections indicators
39.91 ± 7.6
41.12 ± 8.7
39.72 ± 9.7
t = 8.78; * p = 0.003
Total scale scores
45.81 ± 9.3
47.45 ± 10.4
46.12 ± 12.5
t = 6.27; * p = 0.001
Notes. * : Mean of 4 Scale; Source: Done by authors using SPSS.
As part of routine hospital and clinical activities at BREH, nurses, physicians report patient safety events including medical errors and “near-misses” (errors caught before they reach the patient) to a nurse that is responsible to keep the patient safety report.
Table 2
Patient Safety Indicators of Events Reported Mean and SD (During Three Months)

Needle sticks Cut wound Dressing allergy Infections indicators Total


Events reported
Percent
12 ± 1.5
26.06
7 ± 0.6
15.21
8 ± 1.1
17.39
19 ± 1.3
41.34
46 ± 2.1
100

Note. Souce: Done by authors using SPSS.
Infections and needle sticks are the most reported disease during three months process as indicated in the Table 2. Significant statistical differences were also found between the frequency of events reported by nurses compare with physician and patient safety indicators scale points (t = 5.96; p < 0.05).





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764                           HEALTHCARE RISK MANAGEMENT AND PATIENT SAFETY
The Figure 1 shows that the reporting frequency for events decreased over time (p = 0.002) during three months at 2011 in the short term and in this hospital. Four indicators used in patient care were improved during these periods.
Table 3
Patient Safety Knowledgeof Four Major Scales Mean in Internal, Surgical, Intensive Care, Emergency and
Operating Room Are Shown in the Table
Intensive
Internal medicine Surgery
                                Emergency             Operation room        P
care
Needle sticks              12 ± 1.5                13 ± 1.1      14 ± 0.9          15 ± 0.7                 13 ± 0.9                     t = 11.02; *p = 0.001
Cut wound                  7 ± 0.6                  8 ± 0.9        8 ± 0.7            9 ± 0.6                   8 ± 0.8                       t = 15.10; *p = 0.002
Dressing allergy         8 ± 1.1                  9 ± 0.7        10 ± 1             6 ± 0.2                   6 ± 0.6                       t = 8.02; *p = 0.05
Infections indicators   16 ± 1.3                20 ± 0.80    18 ± 1             22 ± 0.1                 18 ± 0.7                     t = 1.08; *p = 0.001
Total scale scores        16 ± 2.2                17 ± 1.0      16 ± 1             18 ± 0.3                 17 ± 0.9                     t = 8.34; *p = 0.015
Notes. * : 4 major scale mean; Source: Done by authors using SPSS.
Table 3 Shows that the significant statistical differences were also found between the frequency of events reported according to department (internal medicine, surgery, intensive care, emergency, operation room) and patient safety indicators (F = 8.34; p < 0.05). According to Table 3, mean score of relevant patient safety indicator are statistically found to be high in the emergency room (18 ± 0.3; t = 8.34; *p = 0.015).
Discussion
Comparison of physicians and nurses for patient safety indicator using data from frequency of events indicated that nurses patient safety knowledge mean score are statistically significant than physicians in needle sticks, cut wounds, and infections indicators. While nurses are more used to participate in patient safety culture, physician are not yet. This finding suggests that changes need to be made in the organizational culture of hospitals like to involve nurses in the development and implementation of changes in healthcare safety work for establishing care protocols, improving communication and effective measurement of progress and feedback.
Physicians and nurses must cooperate in improving patient safety by the use of evidence-based medicine (Santacruz-Varela, Torres, & Dolci, 2010; Becher & Chassin, 2002).
But, there is no statistically significant difference in dressing allergy indicator. It could be because of other three indicators which make harm to both patient and health staff, but dressing allery is only a complaint of patient. The main reason of nurse and physician awareness of patient safety indicator is that the evaluation and management of risks for patient safety in the hospital of the country are still trying to develop (Firth-Cozens, 2001). There is the limited methodological survey. Absence of trained teams to evaluate and manage health risks with a scientific and systemic approach is an other important problem.
Findings from statistical analyses suggest that, nurses reported 67% of all events while physicians reported 35%. This result is probably due to a number of reasons based on lack of awareness of patient safety indicators.
Physicians do not view medical error as an important health problem even though they reported personal experiences with medical errors that had serious consequences (Reason, 2000).
Physicians and nurses are qualified and well prepared in the science and art of medicine, but they have not got necessary skills and knowledges to improve patient safety during their education or training.

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There are different levels of systematic safety approach proposed by Donabedian in the hospitals and health care system like human, hospital, and clinical (Donabedian, 1978). In this study, hospital safety indicators are not used. Human and clinical safety indicators were interpreted. Chronic patients who often use health care services are vulnerable of the patient safety indicators more often than others. Firstly, because of their own pathology; and secondly, because of health personnel who may unintentionally cause harm to them.
Step by step patient safety indicators reestablishing in every hospital and primary health care setting called family practice center in Turkey. Still, there are lots of jobs to be done. But, to the extent that progress is made in the risk reduction using patient safety approaches in the Turkish hospital, it is possible to achieve further progress in patient safety.
The study also suggests that changes need to be made in the organizational culture of hospital environments. For effective patient safety culture physicians and nursesmust collaborate in promoting a change in the system from the current “culture of blame” to a “culture of safety” (Larson, 2000). The collaboration and problem-solving ability is needed among nurse and physician. Evidence-based medicineand quality of care also are important components of patient safety (Scherer & Fitzpatrick, 2008; Saint et al., 2012).
Patient safety and risk management are careful examinations of health care systems either in hospital or community care. They are useful for identifying factors and facilitating decisions of which precautions should be taken for safer provision of health care (Donabedian, 1980, 1982, 1985, 1988).
Hospitals like other organisation are mostly harmed by the actions of personnel or unsafe conditions (Al Awa et al., 2011). For example, emergency room patient safety indicators are found to be high according to the other part of the hospitals. This is because this part of the hospital is open to all kind of infection than any other part of it. Because all hospital staff is in a hurry in this part of the hospital, needle sticks and cut wound are higher than any other part.
These harms were shown as a result of complications like infections which result as a extended hospital stays for patients and their relatives. Finally, Turkish health care system need people who seek risk management in the health care as a professional job for very near challenges of the future. Implementing risk management and patient safety culture will facilitate the policy evaluation and cost-benefit analysis in the hospital.
A new study to find indicators levels of risk management in patient safety around specific problems such as patient identification and falls in hospitalize will help the study of risk management in the Turkish hospitals.
Limitation
The research sample was comprised of staff from only one hospital. It is possible that the apparent level of patient safety knowledge varies by the adverse event identification method used in the hospital.
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