Chapter 1. Introduction

The safety of resident care is critical to the quality of care in nursing homes. As nursing homes continually strive to improve, there is growing recognition of the importance of establishing a culture of safety. Achieving such a culture requires an understanding of the values, beliefs, and norms about what is important in the organization and what attitudes and behaviors related to resident safety are expected and appropriate. A definition of safety culture applicable to all health care settings, including nursing homes, is provided below.

Safety Culture Definition The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures. Study Group on Human Factors. Organising for safety: Third report of the ACSNI (Advisory Committee on the Safety of Nuclear Installations). Sudbury, UK: HSE Books; 1993.

Development of the Nursing Home Survey on Patient Safety Culture

Purpose

In November 2004, the Agency for Healthcare Research and Quality (AHRQ) made available to the public the Hospital Survey on Patient Safety Culture (HSOPS). The hospital survey has been well received and administered in hundreds of hospitals. In response to nursing homes interested in a survey that focuses on safety culture in their organizations, AHRQ sponsored the development of the Nursing Home Survey on Patient Safety Culture. The new survey is designed specifically for nursing home staff and asks for their opinions about the culture of patient safety in the nursing home. The survey can be used:

• As a diagnostic tool to assess the status of patient safety culture in a nursing home.
• As an intervention to raise staff awareness about patient safety issues.
• As a mechanism to evaluate the impact of patient safety improvement initiatives.
• As a way to track changes in patient safety culture over time.

Survey Development and Pilot Test

To develop the nursing home safety culture survey, researchers reviewed the literature on resident safety in nursing homes, health care quality, medical errors, error reporting, safety climate and culture, and organizational climate and culture. In addition, they reviewed many existing nursing home surveys. None of those surveys, however, focused specifically on staff opinions about resident safety issues. The researchers then consulted more than two dozen experts in the field of nursing home safety for help in identifying key topics and issues. On the basis of all those activities, the researchers identified a potential list of dimensions to include in the survey and sought input from long-term care experts to help identify key dimensions.

Researchers then developed draft survey items to measure the key dimensions. The survey draft was iteratively pretested with nursing home staff to ensure that the items were easy to understand and answer and were relevant to resident safety in nursing homes. The pretest findings were used to revise the survey for a larger pilot test. The Flesch-Kincaid score for the pilot test instrument was below a 7th-grade reading level.

The pilot test version of the Nursing Home Survey on Patient Safety Culture was administered in late 2007 to more than 5,000 staff working in 40 nursing homes across the United States. Participating nursing homes varied by bed size, geographic region, urbanicity, and ownership.

At the end of data collection, more than 3,700 surveys were received. Analysts examined item statistics and the reliability of the safety culture dimensions. Exploratory and confirmatory factor analyses were conducted to examine the factor structure of the survey. Based on these analyses, the survey was revised so that the final items and dimensions in the Nursing Home Survey on Patient Safety Culture have sound psychometric properties.

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Defining a "Nursing Home"

The survey was designed to measure resident safety culture in a nursing home facility or in a special contained area of a facility (e.g., a hospital) that includes only licensed nursing home beds, so it is important to understand the type of nursing home facility that the survey was designed for.

• It was not designed for use in assisted living facilities, community care facilities, or independent living facilities.
• If a nursing home is located on a large campus or facility that has a mix of nursing home and other long-term care programs (such as independent living, assisted living, and rehabilitation services), survey only the facilities or areas with nursing home beds. Exclude staff who work only in areas with independent living, assisted living, or rehabilitation beds.

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Identifying Who Should Complete the Survey

The survey was designed to be administered to all employees in your nursing home, ranging from nursing home administrators, physicians (M.D. or D.O.), physician assistants, and nursing staff to housekeeping, maintenance, and security staff. However, because you want to survey staff with the knowledge and ability to answer the survey questions, we recommend that you consider defining eligible staff members for the survey as follows:

• Staff members, including agency and contract staff, who routinely work in the nursing home. You want to make sure staff have enough experience with your nursing home policies and day-to-day activities to be able to accurately answer the survey questions.
• Staff members who can read and understand the English language.
• New staff who have worked in your nursing home long enough, in your best judgment, to be able to provide informed answers to the survey questions.
• Physicians and other providers, such as physician assistants and nurse practitioners, who may work as full-time employees in the nursing home or who may visit and provide health care to one or more residents. Because it is important to obtain the perceptions of these caregivers, we recommend including physicians and providers who may spend only a few hours a week in the nursing home, particularly if they have done so regularly for several months or more. Use your best judgment to decide which physicians and other providers are familiar enough with the nursing home to provide knowledgeable answers to the survey questions.

If any of your staff or providers work in more than one nursing home, instruct them to answer the survey questions only about the nursing home where they receive the survey. Also, if they work in multiple areas of a campus or facility that has a mix of nursing home and other long-term care programs, instruct them to think only about the nursing home facility or unit when answering the survey questions. The survey was not designed for assisted living or independent living facilities or areas.

Selecting a Sample

If your nursing home has a large number of staff or if your budget is limited, you may wish to survey only a subset or sample of staff rather than surveying a census of all your nursing home staff. In Appendix A, we provide guidelines on how to select a sample.

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Safety Culture Dimensions Measured in the Survey

The Nursing Home Survey on Patient Safety Culture emphasizes resident safety issues. It includes 42 survey items measuring 12 dimensions. Nine of the 12 survey dimensions are similar to those appearing in the Hospital Survey on Patient Safety Culture (HSOPS), although the items included in the dimensions are different. Three HSOPS dimensions were dropped from the nursing home survey: Frequency of event reporting, Teamwork across units, and Teamwork within units. Three new dimensions were added: Compliance With Procedures, Training and Skills, and Teamwork. The list of dimensions in the nursing home survey includes:

1. Teamwork (4 items)
2. Staffing (4 items)
3. Compliance With Procedures (3 items)
4. Training and Skills (3 items)
5. Nonpunitive Response to Mistakes (4 items)
6. Handoffs (4 items)
7. Feedback and Communication About Incidents (4 items)
8. Communication Openness (3 items)
9. Supervisor Expectations and Actions Promoting Resident Safety (3 items)
10. Overall Perceptions of Resident Safety (3 items)
11. Management Support for Resident Safety (3 items)
12. Organizational Learning (4 items)

In addition, the nursing home survey includes 7 background demographic questions and two overall rating questions:

1. Would they tell friends that this is a safe nursing home for their family (1 item)
2. How would they rate this nursing home on resident safety (1 item)

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Modifying or Customizing the Survey

The survey was developed to be general enough for use in most nursing homes. You may find that the survey uses terms that are different from those used in your nursing home. It is also possible that your nursing home's management would like to ask additional questions about resident safety and care. Anticipating the need for some modification or customization of the survey, we have included the survey form as a modifiable electronic file on the AHRQ Web site (www.ahrq.gov/qual/hospculture). We recommend making changes to the survey only when they are absolutely necessary, however, because any changes may affect the reliability and validity of the survey and make comparisons with other nursing homes difficult. We provide the following suggestions regarding modifications to the survey.

Modifying Background Items

The survey includes background questions about the respondent's tenure in the organization, work hours, and staff category. You may wish to tailor the response options for these background questions to reflect your nursing home's hours of operation and staff positions.

Adding or Removing Items

Adding items. If your nursing home decides to add items to the survey, we recommend that you add these items just before the Background Information section, which is the last section in the survey.

Removing items. Although the survey takes about 10 to 15 minutes to complete, you may want to administer a shorter survey with fewer items. The best way to shorten the survey is to refer to Part Two of this document to see the safety culture dimensions assessed in the survey. Delete certain dimensions that your nursing home is not interested in assessing (that means deleting all the items in those dimensions). In this way, your nursing home's results on the remaining safety culture dimensions can still be compared with the results of other nursing homes using the survey. We do not recommend selectively removing items within the various dimensions.

Surveying Nursing Homes With a New Model of Care A new movement in nursing home care, designed to enhance nursing home residents' choice and autonomy in an atmosphere of "home," is currently being implemented in a small number of nursing homes around the country. In this alternative model of care, residents may live in "neighborhood" clusters or communities staffed by a permanent team of clinical and nonclinical workers. One aim of this resident-centered model is that staff get to know residents as individuals and can thus better meet their needs. When administering the Nursing Home Survey on Patient Safety Culture in nursing homes with this arrangement, instruct staff to answer the survey questions in the context of the entire nursing home, not just their particular neighborhood or area. Presumably, the unique culture in these nursing homes is consistent throughout the organization. To capture information about where a respondent works, the specific name of each neighborhood cluster can be added to the response options for item 7 in the background information section of the survey. This information will enable survey feedback results to be provided to each cluster or neighborhood.

Web-Based Data Collection

We strongly recommend using paper-based survey data collection to make sure you obtain the highest possible response rate in your nursing home. Because nursing home staff's access to E-mail and the internet, as well as staff computer skills, may be very limited, it is best to administer the survey on paper only. In addition, recent research and evidence shows that, generally, Web-based surveys have lower response rates than paper surveys (Groves, 2002; Shih and Fan, 2008). Despite the probability of lower response rates, your nursing home or health care system may decide to use a Web-based survey to collect the data because you have done so successfully in the past on other staff surveys. Web-based surveys have a wide range of design features and can involve different data collection procedures, so please read Appendix B, "Conducting a Web-Based Survey," for guidelines on how to adapt the Nursing Home Survey on Patient Safety Culture to this method of data collection.

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Contents of This Survey User's Guide

The survey, this user guide, and the survey dimension descriptions are available on the AHRQ Web site (www.ahrq.gov/qual/hospculture). They are designed to provide nursing homes with the basic knowledge and tools needed to conduct a safety culture assessment, along with ideas for using the data. This guide provides a general overview of the issues and major decisions involved in conducting a survey and reporting the results. Part One of the guide presents information about data collection and how to organize and plan your survey project and includes the following chapters:

Chapter 2—Getting Started. Chapter 2 provides information on planning the project, outlines major decisions and tasks in a task timeline, and discusses hiring a vendor and forming a project team.

Chapter 3—Determining Your Data Collection Methods. Chapter 3 outlines decisions about how surveys will be distributed and returned and discusses the importance of establishing a point of contact within the nursing home.

Chapter 4—Establishing Data Collection Procedures. Chapter 4 describes techniques for publicizing and promoting the survey, recommends data collection steps, discusses the importance of protecting confidentiality, and describes the content and assembly of survey materials.

Chapter 5—Preparing and Analyzing Data and Producing Reports. Chapter 5 discusses the steps needed to prepare the data and analyze the responses and provides suggestions for producing summary feedback reports.

Part Two of the guide includes the nursing home survey form, followed by an overview of the survey items, grouped according to the safety culture dimensions they are intended to measure and the reliability statistics from the pilot data. A sample page from the Microsoft PowerPoint® Survey Feedback Template (part of the toolkit downloadable from the AHRQ Web site) that can be used to summarize the survey results is also provided.

Appendix A provides guidelines for designing and selecting a sample of staff in nursing homes. Appendix B provides guidelines for administering a Web-based survey, and Appendix C includes a sample data collection protocol for nursing homes to use during survey administration.

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