Introduction

Patient safety is a critical component of health care quality. As health care organizations continually strive to improve, there is a growing recognition of the importance of establishing a culture of safety. Achieving a culture of safety requires an understanding of the values, beliefs, and norms about what is important in an organization and what attitudes and behaviors related to patient safety are expected and appropriate. A definition of safety culture 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. Source: Organising for Safety: Third Report of the ACSNI (Advisory Committee on the Safety of Nuclear Installations) Study Group on Human Factors. Health and Safety Commission (of Great Britain). Sudbury, England: HSE Books, 1993.

Development of the Hospital Survey on Patient Safety Culture

Recognizing the need for a measurement tool to assess the culture of patient safety in health care organizations, the Medical Errors Workgroup of the Quality Interagency Coordination Task Force (QuIC) sponsored the development of a hospital survey focusing on patient safety culture. Funded by the Agency for Healthcare Research and Quality (AHRQ), the Hospital Survey on Patient Safety Culture was developed by a private research organization under contract with AHRQ.

To develop this survey, the researchers conducted a review of the literature pertaining to safety, accidents, medical error, error reporting, safety climate and culture, and organizational climate and culture. In addition, the researchers reviewed existing published and unpublished safety culture surveys and conducted in-person and telephone interviews with hospital staff. The survey was pretested with hospital staff to ensure the items were easily understood and relevant to patient safety in a hospital setting. Finally, the survey was pilot tested with more than 1,400 hospital employees from 21 hospitals across the United States. The pilot data were analyzed, examining item statistics and the reliability and validity of the safety culture scales, as well as the factor structure of the survey through exploratory and confirmatory factor analyses. Based on the analysis of the pilot data, the survey was revised by retaining only the best items and scales. The resulting Hospital Survey on Patient Safety Culture has sound psychometric properties for the included items and scales.

The survey and its accompanying toolkit materials are designed to provide hospital officials with the basic knowledge and tools needed to conduct a safety culture assessment, along with ideas for using the data. Part One of the Hospital Survey presents issues inherent to the data collection process and the overall project organization. Part Two includes the Survey Form, followed by a separate overview of the included items, grouped according to the safety culture dimensions they are intended to measure and the reliability findings derived from the pilot data. A sample page from the Survey Feedback Report also is provided. Appendix A summarizes the development of the pilot survey. Appendix B is a journal article on the uses of safety culture assessments and their place in the clinical treatment environment.

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Who Should Complete the Survey

The Hospital Survey on Patient Safety Culture examines patient safety culture from a hospital staff perspective. The survey can be completed by all types of hospital staff—from housekeeping and security to nurses and physicians. The survey is best suited for the following, however:

• Hospital staff who have direct contact or interaction with patients (clinical staff, such as nurses, or nonclinical staff, such as unit clerks).
• Hospital staff who may not have direct contact or interaction with patients but whose work directly affects patient care (staff in units such as pharmacy, laboratory/pathology).
• Hospital-employed physicians who spend most of their work hours in the hospital (emergency department physicians, hospitalists, pathologists).
• Hospital supervisors, managers, and administrators.

Note that some physicians have privileges at hospitals but are not hospital employees and may spend the majority of their work time in nonhospital, outpatient settings. Consequently, these types of physicians may not be fully aware of the safety culture of the hospital and generally should not be asked to complete the survey. Careful consideration should be used in deciding which physicians to include or exclude from taking the survey.

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Safety Culture Dimensions Measured in the Survey

The survey places an emphasis on patient safety issues and on error and event reporting. The survey measures seven unit-level aspects of safety culture:

• Supervisor/Manager Expectations & Actions Promoting Safety (4 items).
• Organizational Learning—Continuous Improvement (3 items).
• Teamwork Within Units (4 items).
• Communication Openness (3 items).
• Feedback and Communication About Error (3 items).
• Nonpunitive Response to Error (3 items).
• Staffing (4 items).

In addition, the survey measures three hospital-level aspects of safety culture:

• Hospital Management Support for Patient Safety (3 items).
• Teamwork Across Hospital Units (4 items).
• Hospital Handoffs and Transitions (4 items).

Finally, four outcome variables are included:

• Overall Perceptions of Safety (4 items).
• Frequency of Event Reporting (3 items).
• Patient Safety Grade (of the Hospital Unit) (1 item).
• Number of Events Reported (1 item).

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Modifying or Customizing the Survey

The survey was developed to be general enough for use in most hospitals. You may find, however, that the survey uses terms that are different from those used in your hospital, or that your hospital's management would like to ask hospital staff additional questions about patient safety. Anticipating the need for some modification or customization of the survey, the survey form and feedback report templates are available as modifiable electronic files at the AHRQ Web site (www.ahrq.gov/qual/hospculture/).

Here are some suggestions regarding modifications to the survey:

• Modifying background items. The survey begins with a background question about the respondent's primary work area or unit. The survey ends with some additional background questions about such topics as staff position, tenure in the organization, and work hours. Your hospital may wish to modify the responses to these background questions so they are tailored to reflect the names of your hospital's work units, staff position titles, and the like.
• Use of the term "unit." The survey places most of its emphasis on safety culture at the unit level, because staff will be most familiar with safety culture at this level. There also is a section that pertains to safety culture across the hospital as a whole. If you work in a smaller hospital that does not have differentiated units with multiple staff members in each unit, you may want to consider modifying some of the instructions and/or items in the survey from a focus on the "unit" to a focus on the hospital as a whole. The term "unit" also may be replaced by an equivalent term, such as "department," if it suits your hospital (just be sure to make this replacement everywhere it applies in the survey).
• Adding items. If your hospital would like to add additional items to the survey, we recommend adding these items toward the end of the survey (after "Section G: Number of Events Reported").
• Making the survey shorter or removing items. Although the survey takes only about 10 to 15 minutes to complete, your hospital may want to administer a shorter survey with fewer items. Part Two of the Hospital Survey on Patient Safety Culture includes an overview of the safety culture dimensions assessed in the survey and the reliability figures for each dimension. Delete the dimensions that your hospital is not interested in assessing (be sure to delete all of the items associated with those dimensions). In this way, your hospital's results on the remaining safety culture dimensions still can be compared to other hospitals that use the survey.
• Adapting the survey for Web-based data collection. We recommend using a paper-based survey data collection methodology to make sure you obtain the highest possible response rates. Despite the probability of lower response rates, however, your hospital may decide that it is more feasible and logistically advantageous to do data collection with a Web-based survey. Web-based surveys have a wide range of design features and can involve different data collection procedures, so please be sure to read Conducting a Web-based Survey for guidelines on how to adapt the Hospital Survey for this type of data collection.

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Contents of this Survey User's Guide

This Survey User's Guide is designed to assist you in conducting your own hospital survey on patient safety. This guide provides a general overview of the issues and major decisions involved in conducting a survey and reporting the results. The guide includes the following sections:

• Getting Started 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.
• Selecting a Sample describes the process of selecting a suitable sample group from your staff.
• Determining Your Data Collection Methods outlines decisions about how surveys will be sent and returned and discusses the importance of establishing points-of-contact within the hospital.
• Establishing Data Collection Procedures suggests techniques for maximizing your response rate, discusses the importance of protecting confidentiality, and outlines survey materials to be assembled.
• Conducting a Web-based Survey presents the pros and cons of using a Web-based survey approach to data collection and outlines special considerations that must be taken into account.
• Preparing and Analyzing Data, and Producing Reports discusses the steps needed to prepare the data and analyze the responses and provides suggestions for producing feedback reports.

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