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Is Patient Safety Culture Improving? Repeating Organizational Assessment at 18-24 Months


Coleen SmithBy Coleen Smith, MBA, RN
Director of High Reliability Initiatives
Joint Commission Center for Transforming Healthcare

This is the next in a series of posts examining the 11 tenets of safety culture discussed in our Sentinel Event Alert 57 and accompanying infographic. It examines the how organizational assessments of safety culture should be repeated every 18 to 24 months to review progress and sustain improvement.  

In previous blog posts, we examined tenets of safety culture focused on measuring safety culture performance, validating those results and using assessment information to guide unit-based quality and safety improvement initiatives. 

As we’ve discussed in this series, 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. 

At what interval should an organization re-evaluate its culture?

Readministration Intervals

Historically, organizations performed these re-evaluations every three years. More recently, hospitals that have readministered the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS) more than once have done so every 20 months. While AHRQ doesn’t provide a set recommendation for readministration intervals, it cautions against administering surveys less than 6 months apart. 

Another tool in use, the Safety Attitudes Questionnaire (SAQ), does not provide a recommendation of readministration intervals.

To determine a reasonable readministration interval, organizations should identify answers to this key question:

  • After the last organizational assessment of patient safety culture, what actions were taken in response to identified areas of opportunity?

If the organization progressed on unit-based action plans for local areas of opportunity, then aiming for a shorter readministration interval, such as 18 months, is realistic.

On the other hand, if efforts to improve were less formalized or expectations were not established, then a longer readministration interval would be more appropriate. 

Match Improvement Timeline 

Staff and leaders become frustrated when improvement is not evident when surveys are readministered.

To maximize organizational response rate, enough staff need to respond for the organization to be reasonably confident that strengths and opportunities were accurately identified. Many larger organizations elect to use a sample of the total number of staff, while hospitals and other health care settings will send the survey to everyone (the entire population) if the total of staff and physicians number 500 or less. Either approach is appropriate, depending on organization size.  

To ensure a high response rate (that at least 50 percent of recipients respond to the survey), there are several steps you can take:

  1. Communicate, communicate, communicate!  Publicity is important and can include a message from leadership, clear statements about the importance of the survey and how the information will be used to improve patient safety culture, assurance of individual anonymity or confidentially (depending on whether you use individual identifiers), and information for the point of contact.

  2. Calculate response rates on a routine basis. At least once a week, calculate the response rate: Divide the number of returned surveys (numerator) by the number of staff who received the survey (denominator).

  3. Send out the survey a second time about two weeks after the initial distribution. If response rates are still too low after this step, consider adding a week to the data collection period or sending out a reminder notice to staff.

Finally, focus on the survey feedback and close the loop with staff. This will help ensure high response rates in future surveys and show staff their feedback was taken seriously. There are a few approaches to consider:

  1. Identify a common area of opportunity across the organization and create a multi-disciplinary team that demonstrates a cross-section of the organization to develop actions. Build in accountability by scheduling regular progress reports to leadership, including the governing body.

  2. Alternatively, have each unit or area develop an action plan specific to its area(s) of opportunity. Maintain accountability by scheduling routine progress reports to leadership, with identified timelines and milestones.

In either case, the important part is that staff see the feedback being used to help improve patient safety culture. Acknowledging areas of staff concern will gain employees’ trust that you are doing something with their feedback. 

It is even more powerful if you connect the areas of concern with the actions that are being taken and with results of follow-up surveys. For example, you can highlight that changes to the event-reporting system were the result of feedback showing that more than 60 percent of employees did not submit more than one event report in the previous year. It was discovered that this was due in part to the difficulty of using the system.

In summary, it is important to determine a reasonable interval for readministration, gain a high response rate, and demonstrate the linkage between the survey results and improvement actions. 

Coleen Smith, MBA, RN, is the Director of High Reliability Initiatives for the Joint Commission Center for Transforming Healthcare. Smith joined The Joint Commission in 2004 and the Center in 2011. Prior to her current role, she was Project Lead and Robust Process Improvement® Black Belt in the Center, where she led or co-led strategic projects on “Reducing Colorectal Surgical Site Infections”, “Preventing Avoidable Heart Failure Hospitalizations and Safety Culture”. In her prior work at The Joint Commission,  Smith held the position of Patient Safety Specialist in the Office of Quality and Patient Safety, Sentinel Event Unit.