Hospital Survey on Patient Safety: 2007 Database Report

Summary

In response to requests from hospitals interested in comparing their results against those from other hospitals on the Hospital Survey on Patient Safety Culture, the Agency for Healthcare Research and Quality (AHRQ) established the Hospital Survey on Patient Safety Culture Comparative Database. In spring and summer 2006, U.S. hospitals that administered the AHRQ patient safety culture survey voluntarily submitted their data for inclusion in this new database. The 2007 database consists of data from 382 participating hospitals and 108,621 hospital staff respondents who completed the survey. This report was developed as a tool for:

• Comparison. To allow hospitals to compare their patient safety culture survey results against other hospitals.
• Assessment and learning. To provide data to hospitals to facilitate internal assessment and learning in the patient safety improvement process.
• Supplemental information. To provide supplemental information to help hospitals identify their strengths and areas with potential for improvement in patient safety culture.

Development of the Survey

The Hospital Survey on Patient Safety Culture was pilot tested, revised, and then released in November 2004. It is designed to assess hospital staff opinions about patient safety issues, medical error, and event reporting; it includes 42 items that measure 12 areas or composites of patient safety culture:

1. Communication openness.
2. Feedback and communication about error.
3. Frequency of events reported.
4. Handoffs and transitions.
5. Management support for patient safety.
6. Nonpunitive response to error.
7. Organizational learning/continuous improvement.
8. Overall perceptions of patient safety.
9. Staffing.
10. Supervisor/manager expectations and actions promoting safety.
11. Teamwork across units.
12. Teamwork within units.

Survey Administration Statistics

• The average hospital response rate was 56 percent, with an average of 284 completed surveys per hospital.
• Most hospitals (56 percent) administered paper surveys, which resulted in higher response rates (62 percent response) than Web (43 percent response) or mixed-mode surveys (53 percent response).
• Most hospitals (79 percent) administered the survey to all staff or a sample of all staff from all hospital departments.

Characteristics of Participating Hospitals

• Overall, the characteristics of the 382 database hospitals are fairly consistent with the distribution of U.S. hospitals registered with the American Hospital Association (AHA).
• Participating hospitals represent a range of bed sizes (numbers of patient beds) and geographic regions.
• Most hospitals are nonteaching (76 percent) and nongovernment owned (voluntary/nonprofit or proprietary/investor-owned) (72 percent).

Characteristics of Respondents

• There are 108,621 hospital staff respondents from 382 hospitals.
• Over one-third of respondents (34 percent) selected "Other" as their work area, followed by "Surgery" (10 percent), "Many different hospital units/No specific unit" (9 percent), and "Medicine" (9 percent).
• Over one-third of respondents (36 percent) selected "Registered Nurse" or "Licensed Vocational Nurse/Licensed Practical Nurse (LVN/LPN)" as their staff position, followed by "Other" (23 percent), and "Technician (e.g., EKG, Lab, Radiology)" (11 percent).
• Most respondents (76 percent) indicated they had direct interaction with patients.

Areas of Strength for Most Hospitals

Teamwork within units. This score—the extent to which staff support one another, treat each other with respect, and work together as a team—was the patient safety culture composite with the highest average percent positive response (78 percent), indicating this is an area of strength for most hospitals. The survey item with the highest average percent positive response (85 percent) was: "When a lot of work needs to be done quickly, we work together as a team to get the work done."

Patient safety grade. On average, the majority of respondents within hospitals (70 percent) gave their work area or unit a grade of either "A-Excellent" (22 percent) or "B-Very Good" (48 percent) on patient safety. However, there was a wide range of response in patient safety grades, from at least one hospital where none of the respondents (0 percent) provided their unit with a patient safety grade of "A-Excellent," to a hospital where 63 percent did.

Areas with Potential for Improvement for Most Hospitals

Nonpunitive response to error. This score—the extent to which staff feel that their mistakes and event reports are not held against them and that mistakes are not kept in their personnel file—was the patient safety culture composite with the lowest average percent positive response (43 percent), indicating this is an area with potential for improvement for most hospitals. The survey item with the lowest average percent positive response (35 percent) was: "Staff worry that mistakes they make are kept in their personnel file," (an average of only 35 percent strongly disagreed or disagreed with this item).

Number of events reported. On average, the majority of respondents within hospitals (53 percent) reported no events in their hospital over the past 12 months. It is likely that this percentage represents underreporting of events, and was identified as an area for improvement for most hospitals because potential patient safety problems may not be recognized or identified, and therefore may not be addressed. However, there was a wide range of response in the number of events reported, from a hospital where 96 percent of respondents had not reported a single event over the past 12 months, to a hospital where only 5 percent had not reported an event.

Results by Hospital Characteristics

Results on the survey's patient safety culture composites and items by hospital characteristics (bed size, teaching status, ownership and control, region) are highlighted. A 5 percent difference in percent positive scores was used as a rule of thumb to identify meaningful differences in scores.

Bed Size

• Smaller hospitals (49 beds or fewer) had the highest average positive response on all 12 patient safety culture composites.
• The largest difference across hospitals by bed size was on Handoffs & Transitions where the smallest hospitals (6-24 beds) scored 20 percent higher than the largest hospitals (400+ beds—56 percent positive compared to 36 percent positive).

Teaching Status, and Ownership and Control

• The largest difference across hospitals based on teaching status was on Teamwork Across Units, where nonteaching hospitals were 5 percent more positive than teaching hospitals (58 percent positive compared to 53 percent positive).
• Government-owned hospitals were more positive than nongovernment owned hospitals on Staffing (6 percent more positive), Handoffs & Transitions (6 percent more positive), and Teamwork Across Units (5 percent more positive).

Region*

• East South Central, West North Central, and West South Central hospitals scored highest across the 12 patient safety culture composites; Mid-Atlantic/New England, East North Central, and Pacific hospitals scored lowest.
• The largest difference by region was on Staffing where West North Central hospitals were 15 percent more positive than Mid Atlantic/New England hospitals (61 percent positive compared to 46 percent positive).

Patient Safety Grade

• Large hospitals (400+ beds) and hospitals in the Mountain region scored lowest on the percent of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very good" (64 percent for 400+ beds and 60 percent for the Mountain region).

Number of Events Reported

• Hospitals in the Pacific region had the highest percent of respondents who reported one or more events in the past year (54 percent); the lowest percent of respondents reporting events was 42 percent in the East South Central and West South Central regions.

*Note: States are categorized into AHA-defined regions as follows:

Results by Respondent Characteristics

Results on the survey's patient safety culture composites and items by respondent characteristics (work area/unit, staff position, interaction with patients) are highlighted. A 5 percent difference in percent positive scores was used as a rule of thumb to identify meaningful differences in scores.

Respondent Work Area/Unit

• Respondents in Rehabilitation had the highest average positive response on 9 of the 12 patient safety culture composites.
• The largest differences (23 percent) by work area/unit were on Overall Perceptions of Patient Safety (Rehabilitation was 76 percent positive; Medicine was 53 percent positive) and Nonpunitive Response to Error (Rehabilitation was 59 percent positive; Emergency was 36 percent positive).

Respondent Staff Position

• Respondents in Administration/Management had the highest average positive response on 11 of the 12 patient safety culture composites.
• The largest difference (27 percent) by staff position was on Nonpunitive Response to Error; Administration/Management was 60 percent positive and Patient Care Assistants Aides/Care Partners were 33 percent positive.

Respondent Interaction With Patients

• Respondents with direct patient interaction were 8 percent more positive on Handoffs & Transitions compared to those without direct patient interaction (46 percent positive compared to 38 percent positive).
• Respondents without direct patient interaction were 7 percent more positive about Management Support for Patient Safety than those with direct patient interaction (75 percent positive compared with 68 percent positive).

Patient Safety Grade

• Rehabilitation had the highest percent of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very good" (81 percent); Medicine had the lowest percent (58 percent).
• Administration/Management had the highest percent of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very good" (79 percent); Registered Nurse/LVN/LPN had the lowest percent (64 percent).

Number of Events Reported

• ICU (any type) had the highest percent of respondents reporting one or more events in the past year (69 percent); the lowest percent reporting events was Anesthesiology (41 percent).
• Pharmacists had the highest percent of respondents reporting one or more events in the past year (76 percent); the lowest percent reporting events were Unit Assistants/Clerks/ Secretaries (21 percent).
• More respondents with direct patient interaction reported one or more events in the past year (52 percent) compared to those without direct patient interaction (32 percent).

Action Planning for Improvement

The delivery of survey results is not the end point in the survey process, it is just the beginning. It is often the case that the perceived failure of surveys to create lasting change is actually due to faulty or nonexistent action planning or survey followup. Seven steps of action planning are provided to give hospitals guidance on next steps to take to turn their survey results into actual patient safety culture improvement.

1. Understand your survey results.
2. Communicate and discuss the survey results.
3. Develop focused action plans.
4. Communicate action plans and deliverables.
5. Implement action plans.
6. Track progress and evaluate impact.
7. Share what works.

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