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Use Insight Gained From Safety Culture Surveys to Make Improvements


Smith_C_09-13By Coleen Smith,
Director, High Reliability Initiatives
Joint Commission Center for Transforming Healthcare

This is the sixth in a series of posts examining the 11 tenets of safety culture discussed in our Sentinel Event Alert and accompanying infographic.  In this post, we examine the sixth tenet: Determine an organizational baseline measure on safety culture performance using a validated tool.

Joint Commission-accredited hospitals must regularly evaluate their safety culture using valid and reliable tools, according to Standard LD.03.01.01, Element of Performance 1. How they choose to meet this performance standard is up to them. For many hospitals, it’s an ongoing challenge to accurately assess safety culture without burdening employees with another survey.

Two survey tools designed to help meet this accreditation requirement and mentioned in the Sentinel Event Alert are the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS) and the Safety Attitudes Questionnaire (SAQ). Another more recently developed tool is called SCORE, an integrated survey of safety, communication, organizational reliability, resilience/burnout, and engagement.

The HSOPS measures hospital performance on 12 dimensions of 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. non-punitive response to error
  7. organizational learning (continuous improvement)
  8. overall perceptions of safety
  9. staffing
  10. supervisor/manager expectations and actions promoting safety
  11. teamwork across units
  12. teamwork within units.

Introduced in 2004, the HSOPS has been used by hundreds of hospitals. The most recent HSOSP database report (2016) presents safety culture data compiled from 680 U.S. hospitals comparing its safety culture results. The 2016 report also includes a chapter on trending that presents results showing changes over time for the 326 hospitals that administered the survey and submitted data more than once. Participating in the database is voluntary; therefore, more hospitals than what are included in the report may be using the survey.

The SAQ was developed by the University of Texas and was the subject of a 2006 study. The SAQ measures six culture domains: 

  1. teamwork climate
  2. safety climate
  3. perceptions of management
  4. job satisfaction
  5. working conditions
  6. stress recognition. 

The SAQ also enables users to compare themselves with other organizations.

A 2012 study compared the HSOPS and the SAQ, finding them both reliable and advising prospective users to consider survey length, content, sensitivity to change, and the ability to benchmark when selecting one of these surveys.

Introduced in 2014 by a partnership of Safe & Reliable Healthcare, LLC, and the Duke Patient Safety Center, SCORE creates detailed unit-level indicators and provides in-depth and actionable insights into organizational clinical and operational performance and risk, according to the Safe and Reliable Health care website. SCORE touts itself as an advance over its predecessors in the safety culture survey space.

Survey Fatigue
When surveying staff, hospitals sometimes struggle with “survey fatigue,” since team members may be asked to complete questionnaires on various topics in addition to safety culture. High participation rates means more reliable data, and hospitals must strike a balance between choosing a tool that gains in-depth information but is not intimidating or difficult to complete.

No matter what survey tool is used, it’s not enough only to survey, from a high reliability standpoint. Hospitals must use the information gained to make visible improvements. Otherwise, they will continue to receive subpar participation from team members on surveys. Team members will say, "I complete this survey every year, and I don't see that you've done anything with the information that I've given you.” Hospitals must view the feedback gained from team members as opportunities to make improvements all the way down to the unit level because culture varies by unit.

Goal Setting 
Drs. Mark Chassin, president of The Joint Commission and Jerod Loeb, Ph.D, late executive vice president, Division of Healthcare Quality Evaluation, wrote about this dynamic in their influential 2013 Milbank Quarterly article on high-reliability health care. “Today, many hospitals regularly use one of several available staff surveys to assess their safety culture. Few, however, analyze the meaning of the survey data, evaluate where each area of the hospital is falling short, and undertake specific, focused interventions to remedy those shortcomings. As hospitals make more progress toward high reliability, they will include safety culture metrics as part of their strategic planning programs, set goals for improving on those metrics, and report on those metrics to their boards, just as they report on metrics related to financial performance or patient satisfaction.”