1. Building and Measuring Safety Culture: Getting Started & Planning Your Survey Process August 21 & 23, 2012

2. Polling Question
Has your organization conducted a safety culture survey in the past 12 months?
Yes No
Do not know

3. Polling Question If yes, what survey instrument was used?
Safety Attitude Questionnaire (SAQ)
Hospital Survey on Patient Safety (HSOPS)
Other survey or measurement tool
Do not know

4. Learning Objectives Define safety culture
Describe why safety culture is important for improvement efforts
Identify best practices for measuring safety culture
Define the role and responsibilities of the survey coordinator
Identify characteristics of successful surveys and action items

5. A Brief overview of Safety Culture
Part I
A Brief overview of Safety Culture

6. The Armstrong Institute Model to Improve Care

7. Culture provides the context for team success
What is Safety Culture?
Perceived priority of safety relative to other goals
Culture is the compass team members use to guide their behaviors, attitudes, & perceptions on the job
What will I get praised for?
What will I get reprimanded for?
What is the “right” thing to do?
Culture provides the context for team success
Learned, shared, tacit assumptions among members of a meaningful social group
Lens through which “reality” is viewed
Colors perceptions of what is and what should be
Continuously evolving
--Balance positive and negative…highlight “right”
Image source: Marysia Tomaszewska, August 8, 2012, used under a Creative Commons License

8. What Are the Core Aspects of Safety Culture…
-The notion of “bad” culture or “good” culture is somewhat of a myth.
-As a multidimensional construct, there are several different things that contribute to culture…therefore, it is not that the entire culture is necessarily bad or good, rather that particular components may be areas of strength or may have room for improvement
-When going through culture survey results then it is important to identify dimensions that are strong as well as those that need improvement in order to identify and leverage strengths to improve areas that need work.
Schein, 2007

9. Why Safety Culture Matters
Safety culture is related to outcomes
Patient outcomes
Patient care experience
Infection rates, sepsis
Postop. hemorrhage, respiratory failure, accidental puncture/laceration
Treatment errors
Clinician outcomes
Incident reporting, burnout, turnover
Huang et al., 2010; Mardon et al., 2010; MacDavitt et al., 2007; Singer et al., 2009; Sorra et al., 2012; Weaver, 2011.

10. Why Safety Culture Matters
Safety culture influences the effectiveness of other safety and quality interventions
Can enhance or inhibit effects of other interventions
Safety culture can change through intervention
Best evidence so far for culture interventions that use multiple components
Haynes et al., 2011; Morello et al., 2012; Van Nord et al., 2010; Weaver et al., in press

11. Measuring Safety Culture
Part II
Measuring Safety Culture

12. CUSP & Safety Culture
Safety Culture is typically measured “Pre-CUSP” (before interventions begin):
Provides a baseline to diagnose barriers and facilitators that can impact improvement efforts
Then can be measured months following start of improvement efforts
Use reliable and valid survey instrument
Hospital Survey on Patient Safety (HSOPS)
CUSP is the intervention that you will use to help you improve culture results

13. What is the Hospital Survey on Patient Safety (HSOPS)?
Part of a suite of survey tools (SOPS) for hospitals, medical offices, nursing homes
Sponsored by: Agency for Healthcare Research & Quality
Developed by Westat, public release in 2004
The HSOPS App: An online survey tool
Developed by the Armstrong Institute, in partnership with CeCity
Allows participants to complete the survey online and survey coordinators to access detailed reports of results
Participants are asked to choose 1 to 5 for each question:
1 Strongly Disagree 2 Disagree 3 Neither Agree nor Disagree 4 Agree 5Strongly Agree
1 Never 2 Rarely 3 Sometimes 4 Most of the time 5 Always

14. HSOPS Questions & Composite Scores
(“Dimensions”)
No. of Questions
Example Question
1. Supervisor/manager expectations & actions promoting patient safety 4
B1. My supervisor/manager seriously considers staff suggestions for improving patient safety.
2. Organizational learning-continuous improvement 3
A9. Mistakes have led to positive changes here
3. Teamwork within unit
A1. People support one another in this unit.
4. Communication openness
C4. Staff feel free to question the decisions or actions of those with more authority.
5. Feedback & communication about error
C1. We are given feedback about changes put into place based on event reports.
Nonpunitive response to error
A8. Staff feel like their mistakes are held against them. (negatively worded)
Staffing
A2. We have enough staff to handle the workload.
Hospital management support for patient safety
F8. The actions of hospital management show that patient safety is a top priority.
Teamwork across hospital units
F4.There is good cooperation among hospital units that need to work together.
Hospital handoffs & transitions
F5.Important patient care information is often lost during shift changes. (negatively worded)

15. HSOPS Questions & Composite Scores (cont’d)
4 Outcome Variables
No. of Questions
Example Question
1. Overall perceptions of safety 4
A15. Patient safety is never sacrificed to get more work done.
2. Frequency of event reporting 3
D1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?
3. Patient safety grade (of hospital unit) 1
E1. Please give your work area/unit in this hospital an overall grade on patient safety.
4. Number of events reported in the last 12 months
G1. In the past 12 months, how many event reports have you filled out and submitted?
6 Background questions

16. Scoring guidelines created by AHRQ
HSOPS Scoring
Scoring guidelines created by AHRQ
Scores represent the % of positive responses
% who gave a score of 4 or 5

17. Overview of the Survey Administration Process
Part III
Overview of the Survey Administration Process

18. Effective surveys… Are confidential and anonymous
No way to link responses with address or other individual information
Results reported at unit-level
Critical that the survey coordinator, project team, and leadership focus on survey as a tool for learning and improvement
Have a clear reason and motivation to complete them
Must be clear to staff why you are asking them to complete this survey, what will happen with results, and what will be done based on their input
Are publically supported by both formal and informal unit leaders
If leaders and colleagues view the survey as important and worthy of their time, frontline staff will be more motivated to contribute their input

19. Two Options for HSOPS Option 1 Option 2
Collect fresh HSOPS data from participating work areas
Use online HSOPS App to survey work area team members
Upload previously collected HSOPS data from participating work areas
Upload excel file to online HSOPS App

20. What are the key tasks for planning our survey?
Phase
Task
Prep (~3 wks)
wk1
wk2
wk3
wk4
wk5
wk6
wk7
wk8 wk 9
Planning stage
Logistical tasks
Who will administer?
Who will be surveyed?
Publicize! Motivate participation.
Create a debriefing plan
Alert participants
Provide pre-notification (post, , meetings)
Upload unit data
Log-on and enter unit background info
Start!
Upload participant addresses or previously collected data
Track
Monitor response rates (target >60%)
Remind
1st reminder
Remind again
Final reminder
End the survey
Close the survey
Collect data
Download results report
Execute
Debrief & plan improvements

21. Who are key personnel in the HSOPS process?

22. Survey Coordinators: Key Responsibilities
Help to coordinate the survey administration process,
Learn how to use the online survey database (via training webinars and conference calls)
Help survey participants with the survey process,
Enter data about the work areas participating in the survey into the online survey database,
Monitor the survey response rate using the online survey database,
Work with hospital and work area leadership to distribute survey materials and information,
Communicate with other HSOPS Coordinators in the project

23. Online HSOPS Application (“HSOPS App”)

24. Developing HSOPS Survey List
Determine whom to survey
Clinical staff only?
Non-clinical support staff (e.g., environmental services)?
Compile unit list
address
Hospital area/unit
Staffing category (e.g., physician, nurse, technician, administrative support)
Make sure your list is up to date, check for:
Staff on administrative or extended sick leave,
Staff who appear in more than one staffing category or hospital area/unit,
Staff who have moved to another hospital area/unit,
Staff who no longer work at the hospital, and
Other changes that may affect the accuracy of your list addresses

25. Pre-Notification Materials to Inform Unit Clinicians and Staff of HSOPS
Why the hospital is conducting the survey and how staff responses will be used,
Which hospital staff were selected to be surveyed (e.g., all staff, nursing staff, all clinical staff, a random sample of staff, etc.),
How much time is needed to complete the survey, Confidentiality or anonymity assurances,
Suggested reply timeframe and how to return completed surveys,
Incentives for which units will be eligible, if they respond (Optional), and
Contact information for the main hospital point-of-contact.
Sorra & Nieva, 2004

26. Why should we aim for a response rate of 60% or higher?
Number of respondents who completed the online survey divided by the total number of unit members who were invited to complete the survey
Safety culture reflects the shared perceptions among unit members
Response rate of 60% is minimum necessary for a relatively representative sample
Important for validity and reliability of results

27. Thinking ahead: Creating a Debriefing Plan for your Survey Results
Debriefing is…
A semi-structured conversation among frontline clinicians and staff that is usually led by a designated facilitator
Purpose…
Encourage open communication, transparency, and interactive discussion about the survey results across all levels
To engage clinicians and staff in generating and implementing their ideas about how to create an effective safety culture in their work area

28. Some points to cover in your debriefing plan

29. We are here to support & guide: HSOPS Calls
Getting Started & Planning the Process
Intro to measurement, basics of survey administration
The online HSOPS process
A more detailed, technical call for survey coordinators that will walk through the details of how to use the online survey app
Interpreting HSOPS data and debriefing
Once data are collected and survey coordinators have download their results, another call will be held to walk through how to read reports, debriefing staff ,and interpret results

30. What if we have other surveys going on?
It is common for hospitals to use several different surveys to elicit input from clinicians and staff
Efforts to measure safety culture can be aligned with other surveys
E.g., JHM measures both safety culture and employee engagement annually
Some tips:
Try to not have more than 1 survey going on at the same time if possible (Lack of time and survey fatigue can negatively impact results)
Consider similar trends observed across surveys
You can debrief results of similar surveys at the same time if similar trends or common themes are observed in results

31. Some Additional Tips for Effective Surveys
Communicate to all staff on the unit the importance of their valuable input
Check response rates periodically and send reminders at different times throughout the survey administration process: before the survey is administered and a few times during the survey administration process
Send periodic reminders through various communication channels, such as s, announcements, during staff meetings, etc.
Create a debriefing plan for sharing results with clinicians and staff
Don’t be afraid to reach out for assistance when in doubt

32. Action Items:
Identify a survey coordinator for participating work areas
…Or coordinators if your team desires more than one coordinator
Send collated list of survey coordinators to your coordinating entity (HEN, Hospital association, or affinity group leader)
If collecting new data or uploading previously collected data
Coordinating entity to compile and send to JHU
Determine whom to survey and sample size
…Or locate previously collected data file
If collecting fresh HSOPS data.:
Compile unit list
Create informational materials to publicize the survey (posters, flyers, newsletters, meeting agenda items)
Send pre-notification letter, post pre-notification information, or hold pre-notification meeting
Create draft debriefing plan

33. Questions?
Reminder…
You can access all slides, call recordings, and project tools at the following website:

34. On-boarding Call Evaluation
We want to ensure that the on-boarding calls
provide useful and pertinent information for the
SUSP teams. For this reason we request that
you complete a brief evaluation following each
call. The evaluation may be found at the
following link:

35. References
Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Dziekan G, Herbosa T, Kibatala PL, Lapitan MC, Merry AF, Reznick RK, Taylor B, Vats A, Gawande AA; Safe Surgery Saves Lives Study Group. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf Jan;20(1):102-7.
Huang DT, Clermont G, Kong L, Weissfeld LA, Sexton JB, Rowan KM, Angus DC. Intensive care unit safety culture and outcomes: a US multicenter study. Int J Qual Health Care Jun;22(3):
MacDavitt K, Chou SS, Stone PW. Organizational climate and health care outcomes. Jt Comm J Qual Patient Saf Nov;33(11 Suppl):45-56.
Mardon RE, Khanna K, Sorra J, Dyer N, Famolaro T. Exploring relationships between hospital patient safety culture and adverse events. J Patient Saf Dec;6(4):
Morello RT, Lowthian JA, Barker AL, McGinnes R, Dunt D, Brand C. Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Qual Saf Jul 31. [Epub ahead of print]
Schein E. Organizational culture and leadership, 4th edition. San Francisco, CA: Jossey-Bass

36. References
Singer SJ, Falwell A, Gaba DM, Meterko M, Rosen A, Hartmann CW, Baker L. Identifying organizational cultures that promote patient safety. Health Care Manage Rev Oct-Dec;34(4):
Sorra J, Khanna K, Dyer N, Mardon R, Famolaro T. Exploring Relationships Between Patient Safety Culture and Patients' Assessments of Hospital Care. J Patient Saf Jul 10. [Epub ahead of print].
Sorra JS, Nieva VF. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No ). AHRQ Publication No Rockville, MD: Agency for Healthcare Research and Quality. September 2004.
van Noord I, de Bruijne MC, Twisk JW. The relationship between patient safety culture and the implementation of organizational patient safety defences at emergency departments.. Int J Qual Health Care Jun;22(3):162-9.
Weaver SJ. A configural approach to patient safety climate: The relationship between climate profile characteristics and patient safety. Doctoral dissertation. University of Central Florida
Weaver, S. J., Dy, S., Lubomski, L., & Wilson, R. Promoting a culture of safety. In R.M. Watcher, P.G. Shekelle, P. Pronovost (Eds.). Making healthcare safer: A critical analysis of the evidence of patient safety practices (AHRQ report # TBD). Rockville, MD. In press.