For the well-insured, obtaining health care in the United States is like dining in a sumptuous restaurant that has menus without prices. A price-free menu encourages diners to ignore cost when making their selections. Similarly, well-insured patients usually don't know the prices of medical services at the time they receive them. Even for common procedures, few hospitals list their charges, much less the accompanying professional fees and the out-of-pocket costs; these are only revealed weeks or months later, when the explanation of benefits statement arrives. Without prices, motivated patients cannot "shop around" for lower-cost providers of care—and even patients who knew the price could not easily learn whether the care represents good value.

Objective: To assess variation in safety climate across VA hospitals nationally.

Study Setting: Data were collected from employees at 30 VA hospitals over a 6-month period using the Patient Safety Climate in Healthcare Organizations survey.

Study Design: We sampled 100 percent of senior managers and physicians and a random 10 percent of other employees. At 10 randomly selected hospitals, we sampled an additional 100 percent of employees working in units with intrinsically higher hazards (high-hazard units [HHUs]).

Data Collection: Data were collected using an anonymous survey design.

Principal Findings: We received 4,547 responses (49 percent response rate). The percent problematic response-lower percent reflecting higher levels of patient safety climate-ranged from 12.0-23.7 percent across hospitals (mean=17.5 percent). Differences in safety climate emerged by management level, clinician status, and workgroup. Supervisors and front-line staff reported lower levels of safety climate than senior managers; clinician responses reflected lower levels of safety climate than those of nonclinicians; and responses of employees in HHUs reflected lower levels of safety climate than those of workers in other areas.

Conclusions: This is the first systematic study of patient safety climate in VA hospitals. Findings indicate an overall positive safety climate across the VA, but there is room for improvement.