This Hospital Survey on Patient Safety 1.0 (HSOPS ...

Feedback Report on Patient Safety Culture

Sample Medical Center

This Hospital Survey on Patient Safety™ 1.0 (HSOPS™) Feedback Report has been prepared specifically for:

Emergency Department

April 2021

REPORT DATE1/1/2021

SURVEY DETAILSDetails about the current survey

Survey Name: Hospital Survey on Patient Safety™ 1.0 (HSOPS™)

Survey Developer: Agency for Healthcare Research and Quality (AHRQ)

The AHRQ main Compare Database for this survey includes data from 320 Facilities and 191,997 Respondents

Compare Database: 2020 AHRQ HSOPS™ 1.0 subgroup Emergency Department

Administered by: Center for Patient Safety (CPS)

Organization: Sample Medical Center

Department: Emergency Department

Historical data included: YesHistorical data is mapped from: Emergency Department

Distribution Method: Online, hyperlink distributionSurvey period: 04/01/2021 to 04/30/2021

Response Rate: 98% (54 out of 55)

YOUR NEXT STEPS

Congratulations! You've taken a great step toward improving the culture of safety at your

organization! This report reveals cultural strengths and priorities as perceived by the staff that

responded during this survey period. Culture changes can take a long time to implement, but

measuring the culture is the first step. With the survey completed, it's time to get to work. Review

the results, develop goals that align with your strategic objectives, mission and vision, and

implement action plans that will best facilitate culture change in needed areas.

Commend your staff for participating in the survey (anonymously) and thank them for their valuable feedback. STEP 1

Preview your report. Skim through the pages, looking at available benchmarks, trends, scores, etc. No matter the score, or how you compare to others, higher scoring areas are strengths that can be used to mitigate the risks associated with weaker areas.

STEP 2

Set aside time to review the report in depth. Plan at least 30 minutes of interrupted time for digesting the information, or plan for an hour if you are new to using the survey. Your employees took valuable time to respond to the survey, and now is the time for you to commit to listening to their feedback. When reviewing the information, remember to keep other measures in mind. Consider turnover rate, employee engagement scores, employee safety metrics, and other data that can fully describe the unit or organization. Identify components you want to share with staff. Identify causal factors that may have contributed to the scores. Are the causal factors organization-wide, or specific to a certain area or team?

STEP 3

Share highlights of the results with employees and ask them for feedback and ideas to improve. STEP 4

What are your next steps? Will you develop an action plan? Consider engaging a team to work on improvement initiatives. STEP 5

CENTER FOR PATIENT SAFETY | HOSPITAL SURVEY ON PATIENT SAFETY 1.0 2

TABLE OF CONTENTSReport Components

GUIDANCE

RESOURCES

DID YOU KNOW

DASHBOARD

SAFETY GRADE & DEMOGRAPHICS

PRIORITY RANKINGS BY DIMENSION

RESULTS BY DIMENSION

PRIORITY RANKINGS BY QUESTION

PRIORITIES BY QUESTION (GRAPH)

RESULTS BY QUESTION

DETAILS BY QUESTION

COMMENTS

GUIDANCE

Consider starting at the back of the report, then work your way forward. Use the following as guidance:

While reviewing the report, look for the areas of lowest "positive score." These are areas in which staff responded mostly negative and will

require improvement planning. Also, while reviewing this report, look for the areas of highest "positive score." These are areas you will want

to celebrate. Moving scores closer to "100% positive" is always the goal.

Read the valuable feedback provided by your survey respondents. Look for themes and common concerns. Take note of any suggestions or other low-hanging fruit.

COMMENTS

Do you see some graphs with more red than others? Review the number of "neutral" responses which may lower your positive scores, but should not actually result in the question being considered negative.

DETAILS BY QUESTION

Did any questions improve over time? Any scores surprising? Any scores not surprising?RESULTS BY QUESTION

The lowest scoring questions are considered your "top priorities".PRIORITIES QUESTION

How do you score compared to others?RESULTS BY DIMENSION

Questions are rolled up into common themes, or dimensions. What trends are you seeing?PRIORITIES DIMENSION

Consider the demographic summary of those taking your survey. Were any areas represented more than others?DEMO-GRAPHICS

Use this as a snapshot to present to leaders, employees, or others as a high-level overview of your current culture's strengths and opportunities. Check out resources, made available based on your lowest scoring areas.

DASH-BOARD


RESOURCESResources and More Information

General Resourceshttps://forward.centerforpatientsafety.org/resources

Agency for Healthcare Research and Quality

www.ahrq.gov

Center for Patient Safetywww.centerforpatientsafety.org

DID YOU KNOW?

CENTER FOR PATIENT SAFETY

www.centerforpatientsafety.org

573.636.1014

If you have questions about this report, please contact the Center for Patient Safety.

Incomplete and Ineligible Survey DeterminationEach survey is examined for completeness and validity prior to inclusion in the final data set. Surveys are excluded if submitted blank, submitted with only background demographic questions answered, or submitted with less than 20% of the questions answered. Additionally, surveys are excluded when a respondent gives the exact same answer for all the questions in the survey (i.e. all 5's). Because the survey includes negatively worded items, respondents should use both the positive and negative ends of the response scales to provide consistent answers. If every answer is the same, the respondent did not give the survey his or her full attention and the responses are probably not valid.

Response Rate CalculationFinal response rates provided in the report are calculated following the removal of incomplete and ineligible surveys (see above) and only if original population sizes are received from organization.

Anonymity vs. IdentifiersThis survey was taken with complete anonymity. The Center for Patient Safety administered this survey and captured all responses directly from facility staff. The facility and its administrators do not have direct access to any of the individual respondent information. There were no individual respondent identification numbers or identifiers captured or associated with this survey. IP address is the only information captured by the Center for Patient Safety, however, this information is never released to the facility. Respondents were not asked to provide their name on the survey. Without tracking mechanisms, there is a small risk that an individual may have completed and returned more than one survey. The Center makes every effort to validate responses and reduce duplications or multiple entries by one individual. It is worth noting that the length of the survey, as well as reverse-worded questions, are deterrents to submitting more than one survey.

Validating and Cleaning the DataSurveys are coded automatically during the electronic submission process to reduce data entry errors. Manual data scrubbing is conducted before reports are prepared.

Frequencies of ResponsesThe two lowest response categories are combined (e.g. Strongly Disagree/Disagree or Never/Rarely) and the two highest response categories are combined (e.g. Strongly Agree/Agree or Most of the Time/Always) to make the results easier to view. "Neither" answers and missing responses are excluded from the overall percentage of positive/negative response. Negatively worded questions are reverse coded when calculating percent "positive."


DASHBOARDSAMPLE MEDICAL CENTER - EMERGENCY DEPARTMENTSurvey period: 04/01/2021 to 04/30/2021 2021 Responses: 54

2020 Responses: 45

2019 Responses: 40

2019 2020 ORG AHRQ AHRQ

% Pos. % Pos. % Pos. AHRQ %ile % Pos. 50th %ile 90th %ile

Average of All Twelve (12) Survey Dimensions 50.3% 73.1% 73.7% 75th 58.9% #N/A



Handoffs & Transitions 38.6% 34.8% 46.2% 25th 50.0%

Non-punitive Response to Error 32.1% 65.9% 48.2% 50th 39.0%

Staffing 41.4% 72.9% 62.4% 75th 45.0%

OPPORTUNITIES BY QUESTION 2019 2020 ORG AHRQ AHRQ

*Staff worry that mistakes they make are kept in their personnel file. 26.3% 46.7% 15.4% 10th 31.2% 30.0% 52.0%

Staff feel free to question the decisions or actions of those with more authority. 23.1% 55.6% 24.5% <10th 39.4% 45.0% 67.0%

*Problems often occur in the exchange of information across hospital units. 27.0% 31.8% 36.0% 25th 35.4% 46.0% 73.0%



Feedback & Communication About Error 49.6% 82.1% 89.2% 90th 63.0%

Supr/Mgr Expectations & Actions Promoting Patient Safety 66.7% 84.9% 87.4% 75th 77.0%

Management Support for Patient Safety 52.6% 83.3% 86.3% 90th 60.0%

STRENGTHS BY QUESTION 2019 2020 ORG AHRQ AHRQ

In this unit, we discuss ways to prevent errors from happening again. 65.8% 88.6% 96.0% 90th 86.2% 70.0% 90.0%

*My supv/mgr overlooks patient safety problems that happen over and over. 92.3% 95.6% 94.0% 90th 81.7% 77.0% 92.0%

Staff will freely speak up if they see something that may negatively affect patient

care.46.2% 77.8% 94.0% 90th 84.9% 74.0% 91.0%

2021OVERALL PERCENT POSITIVE (ALL DIMENSIONS)

2021

STRENGTHS BY DIMENSION

These are the dimensional areas (and specific questions) that staff have indicated as current strengths.

These are the dimensional areas (and specific questions) that staff have indicated as current weaknesses.

OPPORTUNITIES BY DIMENSION (TOP PRIORITIES)2021

2021

2021

46% 48%

62%

Handoffs & Transitions Non-punitive Response to Error Staffing

89% 87% 86%

Feedback & Communication About Error Supr/Mgr Expectations & Actions Promoting Patient Safety Management Support for Patient Safety


PATIENT SAFETY GRADE & DEMOGRAPHICSAS EVALUATED BY RESPONDENTS

PATIENT SAFETY RATING 2019 2020 ORG AHRQ AHRQ


Excellent 30.8% 68.9%

Very Good 17.9% 11.1%

Acceptable 48.7% 17.8% 9.8%

Poor 2.6% 2.2% 2.0%

Failing 0.0% 0.0% 0.0%

DEMOGRAPHICS

2021 Respondents: 51



2021 Respondents: 53 2021 Respondents: 52

2021 Respondents: 50 2021 Respondents: 52

* *

Percent of respondents giving various patient safety ratings.

92.0%75th 65.0%

2021

85.7%88.2%

0.0%

2.0%

9.8%

17.6%

70.6%

16%

37%

10%

10%

8%

20%

<1 year

1-5 years

6-10 years

11-15 years

16-20 years

>20 years

Years worked in this hospital13%

0%

0%

2%

4%

0%

4%

0%

0%

11%

0%

21%

8%

38%

Registered Nurse

Physician Assistant/Nurse Practitioner

LVN/LPN

Patient Care Asst/Hospital Aide/CarePartner

Attending/Staff Physician

Resident physician/Physician in training

Pharmacist

Dietician

Unit Assistant/Clerk/Secretary

Respiratory Therapist

Physical, Occupational, or SpeechTherapist

Technician (e.g., EKG, Lab, Radiology)

Administration/Management

Other

POSITION

58%

6%

4%

32%

0%

0%

No reports

1 to 2 reports

3 to 5 reports

6 to 10 reports

11 to 20 reports

21 reports or more

Event reports completed in the past 12 months

16%

37%

14%

10%

8%

16%

<1 year

1-5 years

6-10 years

11-15 years

16-20 years

>20 years

Years worked in current hospital work area/unit

2%

42%

54%

0%

2%

0%

<20 hours

20-39 hours

40-59 hours

60-79 hours

80-99 hours

>99 hours

Hours per week worked in this hospital

8%

19%

23%

15%

6%

29%

<1 year

1-5 years

6-10 years

11-15 years

16-20 years

>20 years

Years worked in current speciality or profession

69.8%

30.2%

YES, I typically have direct interaction orcontact with patients.

NO, I typically do NOT have directinteraction or contact with patients.

Typically have direct interaction or contact with patients


PRIORITY RANKINGS FOR DIMENSIONSCURRENT RESULTS PRIORITIZED BY DIMENSION



1st Handoffs & Transitions 38.6% 34.8% 46.2% 25th 50% 11.3%

2nd Non-punitive Response to Error 32.1% 65.9% 48.2% 50th 39% -17.7%

3rd Staffing 41.4% 72.9% 62.4% 75th 45% -10.5%

4th Communication Openness 45.3% 72.6% 65.5% 50th 61% -7.1%

5th Teamwork Across Units 41.9% 70.5% 70.5% 75th 48% 0.1%

6th Teamwork Within Units 61.3% 76.5% 74.4% 25th 81% -2.1%

7th Org Learning-Continuous Improvement 61.7% 82.2% 83.3% 90th 66% 1.1%

8th Overall Perceptions of Patient Safety 47.9% 74.4% 85.1% 90th 55% 10.7%

9th Frequency of Events Reported 64.0% 76.9% 86.0% 90th 62% 9.1%

10th Management Support for Patient Safety 52.6% 83.3% 86.3% 90th 60% 2.9%

11thSupr/Mgr Expectations & Actions Promoting

Patient Safety66.7% 84.9% 87.4% 75th 77% 2.4%

12th Feedback & Communication About Error 49.6% 82.1% 89.2% 90th 63% 7.1%

Dimensions are ranked in order of top priority. The highest ranked dimensions are also the highest scoring (% Pos.). These areas are considered

the most successful and should be celebrated. Lowest ranked questions (lowest scoring % Pos.) are noted in red and should be addressed

through action planning. Shifts in priorities over time can be expected. Note that a Percent Change of +/- 5.0% (or more) is statistically

significant.

Areas in which dimensional positive scores are greater than 80% are considered to have a consensus of excellence. The number of positive

responses for these areas represent the breadth and strength of the patient safety culture. It also reflects staff awareness and consistency in

the methods and processes for ensuring safe and high quality patient care. Areas of more than 80% positive will be highlighted below.

PERCENT

CHANGE

2021DIMENSION

46

.2%

48

.2%

62

.4%

65

.5%

70

.5%

74

.4%

83

.3%

85

.1%

86

.0%

86

.3%

87

.4%

89

.2%

Han

do

ffs

& T

ran

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e R

esp

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Err

or St

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ng

Co

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Op

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ess

Team

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Team

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ith

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arn

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ent

Ove

rall

Per

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of

Pat

ien

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Freq

uen

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f Ev

ents

Rep

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Man

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Sup

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rtfo

r P

atie

nt

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Sup

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tati

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rom

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Pat

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Feed

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Ab

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ror


RESULTS BY DIMENSION-TABLECURRENT RESULTS COMPARED TO HISTORICAL

Re

spo

nse

s

Mis

sin

g

Ne

gati

ve

Ne

utr

al

Po

siti

ve

Re

spo

nse

s

Mis

sin

g

Ne

gati

ve

Ne

utr

al

Po

siti

ve

Re

spo

nse

s

Mis

sin

g

Ne

gati

ve

Ne

utr

al

Po

siti

ve

Trendline

Distribution:

Neg-Neu-Pos

6th Teamwork Within Units 40 0

31

.3%

7.5

%

61

.3%

45 0

10

.1%

13

.5%

76

.5%

53 1

7.1

%

18

.5%

74

.4%

11thSupr/Mgr Expectations & Actions Promoting Patient

Safety 39 1

14

.1%

19

.2%

66

.7%

45 0

6.1

%

9.0

%

84

.9%

50 5

5.5

%

7.1

%

87

.4%

7th Org Learning-Continuous Improvement 40 0

6.7

%

31

.7%

61

.7%

45 0

5.2

%

12

.6%

82

.2%

52 2

6.4

%

10

.3%

83

.3%

10th Management Support for Patient Safety 38 2

17

.5%

29

.8%

52

.6%

44 1

7.6

%

9.1

%

83

.3%

51 3

7.2

%

6.5

%

86

.3%

8th Overall Perceptions of Patient Safety 39 1

30

.3%

21

.8%

47

.9%

45 0

16

.7%

8.9

%

74

.4%

52 2

9.2

%

5.7

%

85

.1%

12th Feedback & Communication About Error 38 2

25

.2%

25

.1%

49

.6%

45 0

10

.4%

7.4

%

82

.1%

50 4

4.7

%

6.1

%

89

.2%

9th Frequency of Events Reported 37 3

6.3

%

29

.7%

64

.0%

45 0

3.7

%

19

.4%

76

.9%

50 4

4.0

%

10

.0%

86

.0%

4th Communication Openness 39 1

35

.9%

18

.8%

45

.3%

45 0

20

.0%

7.4

%

72

.6%

50 4

21

.7%

12

.8%

65

.5%

5th Teamwork Across Units 37 3

31

.8%

26

.4%

41

.9%

44 1

18

.8%

10

.8%

70

.5%

51 3

19

.6%

9.9

%

70

.5%

3rd Staffing 37 3

42

.1%

16

.5%

41

.4%

44 1

16

.9%

10

.2%

72

.9%

53 2

24

.7%

12

.9%

62

.4%

1st Handoffs & Transitions 35 5

16

.2%

45

.2%

38

.6%

43 2

30

.4%

34

.8%

34

.8%

50 4

21

.5%

32

.3%

46

.2%

2nd Non-punitive Response to Error 39 1

38

.2%

29

.7%

32

.1%

45 0

23

.0%

11

.1%

65

.9%

52 2

29

.4%

22

.4%

48

.2%

Positive scores closer to 100% are the desired outcome. Priority rankings are indicated before each dimension for the most recent survey

period. Dimensions that have significant increases over previous years should be assessed to identify the factors contributing to the success.

Dimensions that trend down from previous years should be evaluated for internal or external factors that may be impacting the location, unit,

or the entire organization.

Addressing more than one or two dimensions at a time can be overwhelming. Consider selecting dimensions that may have similar underlying

themes and can be addressed simultaneously. For example, the two dimensions, Feedback and Communication About Mistakes and

Organizational Learning, reflect how much the culture encourages reporting of errors in order to learn from mistakes. When selecting a

dimension(s) to build your improvement plan, consider the number of neutral responses within any dimension. Large numbers of neutral

responses can pull down the percent positive score. Neutral scores should still be addressed, but should not be considered negative indicators

of performance. Consider identifying why staff do not feel strongly one way or the other about the topic.

The number of high-scoring dimensions reflect the breadth of patient safety culture. A significant number of low-scoring dimensions may point

to inconsistent beliefs about the culture of the organization. Policies and processes regarding safe and high-quality patient care may not be

embedded in the organization.

20202019 2021

DIMENSION


PRIORITY RANKINGS FOR QUESTIONS, page 1 of 2CURRENT RESULTS COMPARED TO HISTORICAL


% Pos. % Pos. % Pos.AHRQ

%ile% Pos.

50th

%ile

90th

%ile

1stNon-punitive Response

to Error

*Staff worry that mistakes they make are kept in their

personnel file.26.3% 46.7% 15.4% 10th 31% 30% 52% -31.3%

2ndCommunication

Openness

Staff feel free to question the decisions or actions of those

with more authority.23.1% 55.6% 24.5% <10th 39% 45% 67% -31.1%

3rd Handoffs & Transitions*Problems often occur in the exchange of information across

hospital units.27.0% 31.8% 36.0% 25th 35% 46% 73% 4.2%

4th Handoffs & Transitions*Things "fall between the cracks" when transferring patients

from one unit to another.57.1% 43.9% 39.2% 25th 34% 43% 70% -4.7%

5th Handoffs & Transitions*Important patient care information is often lost during shift

changes.27.0% 20.5% 40.0% 10th 40% 59% 80% 19.5%

6th Teamwork Across Units*It is often unpleasant to work with staff from other hospital

units.35.1% 54.5% 45.1% 25th 56% 50% 79% -9.4%

7th Teamwork Within Units In this unit, people treat each other with respect. 50.0% 61.4% 47.2% <10th 76% 79% 100% -14.2%

8th Staffing*We work in "crisis mode" trying to do too much, too

quickly.35.9% 68.9% 50.0% 75th 45% 34% 67% -18.9%

9th Staffing We have enough staff to handle the workload. 32.5% 75.6% 50.9% 50th 45% 37% 70% -24.6%

10thNon-punitive Response

to Error

*When an event is reported, it feels like the person is being

written up, not the problem.20.0% 73.3% 55.8% 75th 51% 40% 62% -17.6%

11th Teamwork Within Units When one area in this unit gets really busy, others help out. 50.0% 62.2% 67.3% 25th 73% 70% 89% 5.1%

12th Teamwork Across Units *Hospital units do not coordinate well with each other. 32.4% 63.6% 68.6% 90th 53% 34% 67% 5.0%

13th Handoffs & Transitions *Shift changes are problematic for patients in this hospital. 43.2% 43.2% 69.4% 75th 51% 49% 75% 26.2%

14th Staffing*We use more agency/temporary staff than is best for

patient care.60.5% 73.3% 71.7% 50th 58% 63% 87% -1.6%

15thNon-punitive Response

to Error*Staff feel like their mistakes are held against them. 50.0% 77.8% 73.6% 90th 59% 44% 70% -4.2%

16thOrg Learning-Continuous

ImprovementMistakes have led to positive changes here. 42.5% 80.0% 75.0% 90th 69% 57% 73% -5.0%

17th Staffing*Staff in this unit work longer hours than is best for patient

care.36.7% 73.8% 76.9% 90th 51% 46% 68% 3.1%

18thCommunication

Openness

*Staff are afraid to ask questions when something does not

seem right.66.7% 84.4% 78.0% 75th 74% 64% 88% -6.4%

19th

Suprvsr/Manager

Expectations & Actions

Promoting Patient Safety

My supv/mgr says a good word when he/she sees a job done

according to established patient safety procedures.51.3% 77.8% 82.0% 50th 82% 76% 95% 4.2%

2021

Questions are ranked in order of top priority. The highest ranked questions are also the highest scoring (% Pos.). These areas are considered the

most successful and should be celebrated. Lowest ranked questions (lowest scoring % Pos.) are noted in red and should be addressed through

action planning. Shifts in priorities over time can be expected. Note that a Percent Change of +/- 5.0% (or more) is statistically significant.

Areas in which dimensional positive scores are greater than 80% are considered to have a consensus of excellence. The number of positive

responses for these areas represent the breadth and strength of the patient safety culture. It reflects staff awareness and consistency in the

methods and processes for ensuring safe and high-quality patient care. Areas of more than 80% positive will be highlighted below. *Question is

reverse-worded.

QUESTIONPERCENT

CHANGEDIMENSION



% Pos. % Pos. % Pos.AHRQ

%ile% Pos.

50th

%ile

90th

%ile

2021QUESTION

PERCENT

CHANGEDIMENSION

20thMgmt Support for

Patient Safety

*Hospital mgmt seems interested in patient safety only after

an adverse event happens.36.8% 75.0% 82.4% 90th 58% 46% 70% 7.4%

21stOverall Perceptions of

Patient Safety*We have patient safety problems in this unit. 39.5% 80.0% 82.7% 90th 71% 50% 77% 2.7%

22ndFeedback & Commun.

About Error

We are given feedback about changes put into place based

on event reports.41.0% 77.8% 83.7% 90th 66% 56% 78% 5.9%

23rdFrequency of Events

Reported

When a mistake is made, but is caught and corrected before

affecting the patient, how often is this reported?43.2% 68.9% 84.0% 90th 73% 56% 76% 15.1%

24th Teamwork Across UnitsHospital units work well together to provide the best care

for patients.64.9% 90.9% 84.0% 75th 74% 59% 88% -6.9%

25th Teamwork Across UnitsThere is good cooperation among hospital units that need to

work together.35.1% 72.7% 84.3% 90th 67% 47% 79% 11.6%

26thOverall Perceptions of

Patient Safety

Our procedures and systems are good at preventing errors

from happening.75.0% 86.7% 84.9% 75th 81% 67% 87% -1.8%

27th

Suprvsr/Manager



*Whenever pressure builds up, my supv/mgr wants us to

work faster, even if it means taking shortcuts.51.3% 80.0% 85.4% 50th 79% 75% 95% 5.4%

28thFrequency of Events

Reported

When a mistake is made, but has no potential to harm the

patient, how often is this reported?73.0% 80.0% 86.0% 90th 73% 58% 76% 6.0%

29thOverall Perceptions of

Patient Safety

*It is just by chance that more serious mistakes don't

happen around here.35.0% 71.1% 86.3% 90th 67% 51% 77% 15.2%


Patient Safety

Hospital mgmt provides a work climate that promotes

patient safety.73.7% 90.9% 86.3% 75th 81% 71% 92% -4.6%

31stOverall Perceptions of

Patient SafetyPatient safety is never sacrificed to get more work done. 42.1% 60.0% 86.5% 90th 67% 50% 74% 26.5%

32ndOrg Learning-Continuous

Improvement

After we make changes to improve patient safety, we

evaluate their effectiveness.67.5% 82.2% 86.5% 90th 73% 63% 83% 4.3%

33rdFrequency of Events

Reported

When a mistake is made that could harm the patient, but

does not, how often is this reported?75.7% 81.8% 88.0% 75th 80% 71% 89% 6.2%

34th

Suprvsr/Manager



My supv/mgr seriously considers staff suggestions for

improving patient safety.71.8% 86.4% 88.0% 75th 83% 77% 96% 1.6%

35thFeedback & Commun.

About ErrorWe are informed about errors that happen in this unit. 42.1% 80.0% 88.0% 90th 80% 64% 79% 8.0%

36thOrg Learning-Continuous

ImprovementWe are actively doing things to improve patient safety. 75.0% 84.4% 88.5% 75th 83% 77% 93% 4.0%


Patient Safety

The actions of hospital mgmt show that patient safety is a

top priority.47.4% 84.1% 90.2% 90th 77% 64% 88% 6.1%

38th Teamwork Within UnitsWhen a lot of work needs to be done quickly, we work

together as a team to get the work done.72.5% 88.9% 90.6% 50th 92% 88% 100% 1.7%

39th Teamwork Within Units People support one another in this unit. 72.5% 93.3% 92.5% 50th 89% 87% 100% -0.9%

40thCommunication

Openness

Staff will freely speak up if they see something that may

negatively affect patient care.46.2% 77.8% 94.0% 90th 85% 74% 91% 16.2%

41st

Suprvsr/Manager



*My supv/mgr overlooks patient safety problems that

happen over and over.92.3% 95.6% 94.0% 90th 82% 77% 92% -1.6%

42ndFeedback & Commun.

About Error

In this unit, we discuss ways to prevent errors from

happening again.65.8% 88.6% 96.0% 90th 86% 70% 90% 7.4%


RESULTS BY QUESTION-GRAPHCURRENT RESULTS GRAPHED IN ORDER OF PRIORITY

52

%

67

%

73

%

70

%

80

%

79

%

10

0%

67

%

70

%

62

%

89

%

67

%

75

%

87

%

70

%

73

%

68

%

88

%

95

%

70

%

77

%

78

%

76

%

88

%

79

%

87

%

95

%

76

%

77

%

92

%

74

%

83

%

89

%

96

%

79

%

93

%

88

%

10

0%

10

0%

91

%

92

%

90

%

30

%

45

%

46

%

43

%

59

%

50

%

79

%

34

%

37

%

40

%

70

%

34

%

49

%

63

%

44

%

57

%

46

%

64

%

76

%

46

%

50

%

56

%5

6%

59

%

47

%

67

%

75

%

58

%

51

%

71

%

50

%

63

%

71

%

77

%

64

%

77

%

64

%

88

%

87

%

74

%

77

%

70

%

15.4%

24.5%

36.0%

39.2%

40.0%

45.1%

47.2%

50.0%

50.9%

55.8%

67.3%

68.6%

69.4%

71.7%

73.6%

75.0%

76.9%

78.0%

82.0%

82.4%

82.7%

83.7%

84.0%

84.0%

84.3%

84.9%

85.4%

86.0%

86.3%

86.3%

86.5%

86.5%

88.0%

88.0%

88.0%

88.5%

90.2%

90.6%

92.5%

94.0%

94.0%

96.0%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

*Staff worry that mistakes they make are kept in their personnel file.

Staff feel free to question the decisions or actions of those with more authority.

*Problems often occur in the exchange of information across hospital units.

*Things "fall between the cracks" when transferring patients from one unit to…

*Important patient care information is often lost during shift changes.

*It is often unpleasant to work with staff from other hospital units.

In this unit, people treat each other with respect.

*We work in "crisis mode" trying to do too much, too quickly.

We have enough staff to handle the workload.

*When an event is reported, it feels like the person is being written up, not the…

When one area in this unit gets really busy, others help out.

*Hospital units do not coordinate well with each other.

*Shift changes are problematic for patients in this hospital.

*We use more agency/temporary staff than is best for patient care.

*Staff feel like their mistakes are held against them.

Mistakes have led to positive changes here.

*Staff in this unit work longer hours than is best for patient care.

*Staff are afraid to ask questions when something does not seem right.

My supv/mgr says a good word when he/she sees a job done according to…

*Hospital mgmt seems interested in patient safety only after an adverse event…

*We have patient safety problems in this unit.

We are given feedback about changes put into place based on event reports.

When a mistake is made, but is caught and corrected before affecting the patient,…

Hospital units work well together to provide the best care for patients.

There is good cooperation among hospital units that need to work together.

Our procedures and systems are good at preventing errors from happening.

*Whenever pressure builds up, my supv/mgr wants us to work faster, even if it…

When a mistake is made, but has no potential to harm the patient, how often is…

*It is just by chance that more serious mistakes don't happen around here.

Hospital mgmt provides a work climate that promotes patient safety.

Patient safety is never sacrificed to get more work done.

After we make changes to improve patient safety, we evaluate their effectiveness.

When a mistake is made that could harm the patient, but does not, how often is…

My supv/mgr seriously considers staff suggestions for improving patient safety.

We are informed about errors that happen in this unit.

We are actively doing things to improve patient safety.

The actions of hospital mgmt show that patient safety is a top priority.

When a lot of work needs to be done quickly, we work together as a team to get…

People support one another in this unit.

Staff will freely speak up if they see something that may negatively affect patient…

*My supv/mgr overlooks patient safety problems that happen over and over.

In this unit, we discuss ways to prevent errors from happening again.

AHRQ 50th %ile AHRQ 90th %ile ORG Emergency Department


RESULTS BY QUESTION-TABLE, page 1 of 2CURRENT RESULTS BY QUESTION

Res

po

nse

s

Mis

sin

g

Neg

ativ

e

Neu

tral

Po

siti

ve

Res

po

nse

s

Mis

sin

g

Neg

ativ

e

Neu

tral

Po

siti

ve

Res

po

nse

s

Mis

sin

g

Neg

ativ

e

Neu

tral

Po

siti

ve

Trendline

39th People support one another in this unit. 40 0

27

.5%

0.0

%

72

.5%

45 0

6.7

%

0.0

%

93

.3%

53 1

3.8

%

3.8

%

92

.5%

38thWhen a lot of work needs to be done quickly, we work together as

a team to get the work done.

40 0

25

.0%

2.5

%

72

.5%

45 0

6.7

%

4.4

%

88

.9%

53 1

5.7

%

3.8

%

90

.6%

7th In this unit, people treat each other with respect. 40 0

45

.0%

5.0

%

50

.0%

44 1

15

.9%

22

.7%

61

.4%

53 1

9.4

%

43

.4%

47

.2%

11th When one area in this unit gets really busy, others help out. 40 0

27

.5%

22

.5%

50

.0%

45 0

11

.1%

26

.7%

62

.2%

52 2

9.6

%

23

.1%

67

.3%

19thMy supv/mgr says a good word when he/she sees a job done

according to established patient safety procedures.

39 1

25

.6%

23

.1%

51

.3%

45 0

11

.1%

11

.1%

77

.8%

50 4

12

.0%

6.0

%

82

.0%

34thMy supv/mgr seriously considers staff suggestions for improving

patient safety.

39 1

2.6

%

25

.6%

71

.8%

44 1

2.3

%

11

.4%

86

.4%

50 4

8.0

%

4.0

%

88

.0%

27th*Whenever pressure builds up, my supv/mgr wants us to work

faster, even if it means taking shortcuts.3

9 1

23

.1%

25

.6%

51

.3%

45 0

8.9

%

11

.1%

80

.0%

48 6

0.0

%

14

.6%

85

.4%

41st*My supv/mgr overlooks patient safety problems that happen

over and over.

39 1

5.1

%

2.6

%

92

.3%

45 0

2.2

%

2.2

%

95

.6%

50 4

2.0

%

4.0

%

94

.0%

36th We are actively doing things to improve patient safety. 40 0

0.0

%

25

.0%

75

.0%

45 0

4.4

%

11

.1%

84

.4%

52 2

3.8

%

7.7

%

88

.5%

16th Mistakes have led to positive changes here. 40 0

20

.0%

37

.5%

42

.5%

45 0

8.9

%

11

.1%

80

.0%

52 2

9.6

%

15

.4%

75

.0%

32ndAfter we make changes to improve patient safety, we evaluate

their effectiveness.

40 0

0.0

%

32

.5%

67

.5%

45 0

2.2

%

15

.6%

82

.2%

52 2

5.8

%

7.7

%

86

.5%

30thHospital mgmt provides a work climate that promotes patient

safety.

38 2

23

.7%

2.6

%

73

.7%

44 1

6.8

%

2.3

%

90

.9%

51 3

7.8

%

5.9

%

86

.3%

37thThe actions of hospital mgmt show that patient safety is a top

priority.

38 2

0.0

%

52

.6%

47

.4%

44 1

2.3

%

13

.6%

84

.1%

51 3

2.0

%

7.8

%

90

.2%

20th*Hospital mgmt seems interested in patient safety only after an

adverse event happens.

38 2

28

.9%

34

.2%

36

.8%

44 1

13

.6%

11

.4%

75

.0%

51 3

11

.8%

5.9

%

82

.4%

29th*It is just by chance that more serious mistakes don't happen

around here.

40 0

25

.0%

40

.0%

35

.0%

45 0

17

.8%

11

.1%

71

.1%

51 3

11

.8%

2.0

%

86

.3%

31st Patient safety is never sacrificed to get more work done. 38 2

50

.0%

7.9

%

42

.1%

45 0

33

.3%

6.7

%

60

.0%

52 2

9.6

%

3.8

%

86

.5%

21st *We have patient safety problems in this unit. 38 2

26

.3%

34

.2%

39

.5%

45 0

8.9

%

11

.1%

80

.0%

52 2

7.7

%

9.6

%

82

.7%

26thOur procedures and systems are good at preventing errors from

happening.

40 0

20

.0%

5.0

%

75

.0%

45 0

6.7

%

6.7

%

86

.7%

53 1

7.5

%

7.5

%

84

.9%

22ndWe are given feedback about changes put into place based on

event reports.

39 1

23

.1%

35

.9%

41

.0%

45 0

13

.3%

8.9

%

77

.8%

49 5

8.2

%

8.2

%

83

.7%

35th We are informed about errors that happen in this unit. 38 2

23

.7%

34

.2%

42

.1%

45 0

8.9

%

11

.1%

80

.0%

50 4

6.0

%

6.0

%

88

.0%

42ndIn this unit, we discuss ways to prevent errors from happening

again.

38 2

28

.9%

5.3

%

65

.8%

44 1

9.1

%

2.3

%

88

.6%

50 4

0.0

%

4.0

%

96

.0%

Team

wo

rk W

ith

in U

nit

sSu

pr/

Mgr

Exp

ecta

tio

ns

& A

ctio

ns

Pro

mo

tin

g P

atie

nt

Safe

ty

Org

Lea

rnin

g-C

on

tin

uo

us

Imp

rove

men

t

Man

agem

ent

Sup

po

rt f

or

Pat

ien

t Sa

fety

Ove

rall

Per

cep

tio

ns

of

Pat

ien

t Sa

fety

Feed

bac

k &

Co

mm

un

icat

ion

Ab

ou

t Er

ror

2020Positive scores closer to 100% are the desired outcome. Priority rankings

are indicated before each question for the most recent survey period.

*Question is reverse-worded

2019 2021


RESULTS BY QUESTION-TABLE, page 2 of 2CURRENT RESULTS BY QUESTION

Res

po

nse

s

Mis

sin

g

Neg

ativ

e

Neu

tral

Po

siti

ve

Res

po

nse

s

Mis

sin

g

Neg

ativ

e

Neu

tral

Po

siti

ve

Res

po

nse

s

Mis

sin

g

Neg

ativ

e

Neu

tral

Po

siti

ve

Trendline

23rdWhen a mistake is made, but is caught and corrected before affecting the

patient, how often is this reported? 37 3

10

.8%

45

.9%

43

.2%

45 0

4.4

%

26

.7%

68

.9%

50 4

6.0

%

10

.0%

84

.0%

28thWhen a mistake is made, but has no potential to harm the patient, how

often is this reported? 37 3

5.4

%

21

.6%

73

.0%

45 0

4.4

%

15

.6%

80

.0%

50 4

2.0

%

12

.0%

86

.0%

33rdWhen a mistake is made that could harm the patient, but does not, how

often is this reported? 37 3

2.7

%

21

.6%

75

.7%

44 1

2.3

%

15

.9%

81

.8%

50 4

4.0

%

8.0

%

88

.0%

40thStaff will freely speak up if they see something that may negatively affect

patient care. 39 1

43

.6%

10

.3%

46

.2%

45 0

17

.8%

4.4

%

77

.8%

50 4

4.0

%

2.0

%

94

.0%

2ndStaff feel free to question the decisions or actions of those with more

authority. 39 1

61

.5%

15

.4%

23

.1%

45 0

42

.2%

2.2

%

55

.6%

49 5

53

.1%

22

.4%

24

.5%

18th *Staff are afraid to ask questions when something does not seem right. 39 1

2.6

%

30

.8%

66

.7%

45 0

0.0

%

15

.6%

84

.4%

50 4

8.0

%

14

.0%

78

.0%

12th *Hospital units do not coordinate well with each other. 37 3

56

.8%

10

.8%

32

.4%

44 1

31

.8%

4.5

%

63

.6%

51 3

19

.6%

11

.8%

68

.6%

25th There is good cooperation among hospital units that need to work together. 37 3

32

.4%

32

.4%

35

.1%

44 1

13

.6%

13

.6%

72

.7%

51 3

9.8

%

5.9

%

84

.3%

6th *It is often unpleasant to work with staff from other hospital units. 37 3

32

.4%

32

.4%

35

.1%

44 1

29

.5%

15

.9%

54

.5%

51 3

43

.1%

11

.8%

45

.1%

24th Hospital units work well together to provide the best care for patients. 37 3

5.4

%

29

.7%

64

.9%

44 1

0.0

%

9.1

%

90

.9%

50 4

6.0

%

10

.0%

84

.0%

9th We have enough staff to handle the workload. 40 0

60

.0%

7.5

%

32

.5%

45 0

22

.2%

2.2

%

75

.6%

53 1

43

.4%

5.7

%

50

.9%

17th *Staff in this unit work longer hours than is best for patient care. 30

10

46

.7%

16

.7%

36

.7%

42 3

16

.7%

9.5

%

73

.8%

52 2

15

.4%

7.7

%

76

.9%

14th *We use more agency/temporary staff than is best for patient care. 38 2

5.3

%

34

.2%

60

.5%

45 0

6.7

%

20

.0%

73

.3%

53 1

11

.3%

17

.0%

71

.7%

8th *We work in "crisis mode" trying to do too much, too quickly. 39 1

56

.4%

7.7

%

35

.9%

45 0

22

.2%

8.9

%

68

.9%

52 2

28

.8%

21

.2%

50

.0%

4th*Things "fall between the cracks" when transferring patients from one unit

to another. 28

12

10

.7%

32

.1%

57

.1%

41 4

17

.1%

39

.0%

43

.9%

51 3

9.8

%

51

.0%

39

.2%

5th *Important patient care information is often lost during shift changes. 37 3

10

.8%

62

.2%

27

.0%

44 1

47

.7%

31

.8%

20

.5%

50 4

50

.0%

10

.0%

40

.0%

3rd *Problems often occur in the exchange of information across hospital units. 37 3

8.1

%

64

.9%

27

.0%

44 1

11

.4%

56

.8%

31

.8%

50 4

12

.0%

52

.0%

36

.0%

13th *Shift changes are problematic for patients in this hospital. 37 3

35

.1%

21

.6%

43

.2%

44 1

45

.5%

11

.4%

43

.2%

49 5

14

.3%

16

.3%

69

.4%

15th *Staff feel like their mistakes are held against them. 40 0

35

.0%

15

.0%

50

.0%

45 0

17

.8%

4.4

%

77

.8%

53 1

17

.0%

9.4

%

73

.6%

10th*When an event is reported, it feels like the person is being written up, not

the problem. 40 0

40

.0%

40

.0%

20

.0%

45 0

11

.1%

15

.6%

73

.3%

52 2

19

.2%

25

.0%

55

.8%

1st *Staff worry that mistakes they make are kept in their personnel file. 38 2

39

.5%

34

.2%

26

.3%

45 0

40

.0%

13

.3%

46

.7%

52 2

51

.9%

32

.7%

15

.4%

No

n-p

un

itiv

e R

esp

on

se t

o

Erro

r

Freq

uen

cy o

f Ev

ents

Rep

ort

edC

om

mu

nic

atio

n O

pen

nes

sTe

amw

ork

Acr

oss

Un

its

Staf

fin

gH

and

off

s &

Tra

nsi

tio

ns

Positive scores closer to 100% are the desired outcome. Priority rankings

are indicated before each question for the most recent survey period.


2019 2020 2021


DETAILS BY QUESTION, page 1 of 2CURRENT SURVEY DETAILS BY QUESTION

Res

po

nse

s

Mis

sin

g Strongly

Disagree/

Never

Disagree/

Rarely

Neither/

Sometimes

Agree/

Most of

the time

Strongly

Agree/

Always Distribution:

Neg-Neu-Pos

39th People support one another in this unit. 53 1 1.9% 1.9% 3.8% 26.4% 66.0%

38thWhen a lot of work needs to be done quickly, we work

together as a team to get the work done.

53 1 0.0% 5.7% 3.8% 22.6% 67.9%

7th In this unit, people treat each other with respect. 53 1 0.0% 9.4% 43.4% 17.0% 30.2%

11th When one area in this unit gets really busy, others help out. 52 2 1.9% 7.7% 23.1% 55.8% 11.5%

19thMy supv/mgr says a good word when he/she sees a job done

according to established patient safety procedures.

50 4 2.0% 10.0% 6.0% 52.0% 30.0%

34thMy supv/mgr seriously considers staff suggestions for

improving patient safety.

50 4 4.0% 4.0% 4.0% 24.0% 64.0%

27th*Whenever pressure builds up, my supv/mgr wants us to

work faster, even if it means taking shortcuts.

48 6 68.8% 16.7% 14.6% 0.0% 0.0%

41st*My supv/mgr overlooks patient safety problems that happen

over and over.

50 4 68.0% 26.0% 4.0% 0.0% 2.0%

36th We are actively doing things to improve patient safety. 52 2 1.9% 1.9% 7.7% 23.1% 65.4%

16th Mistakes have led to positive changes here. 52 2 3.8% 5.8% 15.4% 23.1% 51.9%

32ndAfter we make changes to improve patient safety, we

evaluate their effectiveness.

52 2 0.0% 5.8% 7.7% 25.0% 61.5%

30thHospital mgmt provides a work climate that promotes patient

safety.

51 3 2.0% 5.9% 5.9% 23.5% 62.7%

37thThe actions of hospital mgmt show that patient safety is a top

priority.

51 3 0.0% 2.0% 7.8% 21.6% 68.6%

20th*Hospital mgmt seems interested in patient safety only after

an adverse event happens.

51 3 43.1% 39.2% 5.9% 9.8% 2.0%

29th*It is just by chance that more serious mistakes don't happen

around here.

51 3 47.1% 39.2% 2.0% 9.8% 2.0%

31st Patient safety is never sacrificed to get more work done. 52 2 3.8% 5.8% 3.8% 23.1% 63.5%

21st *We have patient safety problems in this unit. 52 2 48.1% 34.6% 9.6% 5.8% 1.9%

26thOur procedures and systems are good at preventing errors

from happening.

53 1 0.0% 7.5% 7.5% 20.8% 64.2%

22ndWe are given feedback about changes put into place based on

event reports.

49 5 0.0% 8.2% 8.2% 53.1% 30.6%

35th We are informed about errors that happen in this unit. 50 4 4.0% 2.0% 6.0% 56.0% 32.0%

42ndIn this unit, we discuss ways to prevent errors from happening

again.

50 4 0.0% 0.0% 4.0% 16.0% 80.0%

2021Shaded blocks indicate the desired response to each question. Shaded

blocks are added together for "percent positive". Priority rankings are

indicated before each question for the most recent survey period.


Team

wo

rk W

ith

in U

nit

sSu

pr/

Mgr

Exp

ecta

tio

ns

& A

ctio

ns

Pro

mo

tin

g P

atie

nt

Safe

ty

Org

Lea

rnin

g-C

on

tin

uo

us

Imp

rove

men

t

Man

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DETAILS BY QUESTION, page 2 of 2CURRENT SURVEY DETAILS BY QUESTION

Res

po

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s

Mis

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g Strongly

Disagree/

Never

Disagree/

Rarely

Neither/

Sometimes

Agree/

Most of

the time

Strongly

Agree/

Always Distribution

Neg-Neu-Pos

23rdWhen a mistake is made, but is caught and corrected before

affecting the patient, how often is this reported?

50 4 0.0% 6.0% 10.0% 48.0% 36.0%

28thWhen a mistake is made, but has no potential to harm the

patient, how often is this reported?

50 4 0.0% 2.0% 12.0% 10.0% 76.0%

33rdWhen a mistake is made that could harm the patient, but

does not, how often is this reported?

50 4 0.0% 4.0% 8.0% 8.0% 80.0%

40thStaff will freely speak up if they see something that may

negatively affect patient care.

50 4 0.0% 4.0% 2.0% 16.0% 78.0%

2ndStaff feel free to question the decisions or actions of those

with more authority.

49 5 6.1% 46.9% 22.4% 10.2% 14.3%

18th*Staff are afraid to ask questions when something does not

seem right.

50 4 38.0% 40.0% 14.0% 4.0% 4.0%

12th *Hospital units do not coordinate well with each other. 51 3 39.2% 29.4% 11.8% 17.6% 2.0%

25thThere is good cooperation among hospital units that need to

work together.

51 3 3.9% 5.9% 5.9% 31.4% 52.9%

6th*It is often unpleasant to work with staff from other hospital

units.

51 3 5.9% 39.2% 11.8% 5.9% 37.3%

24thHospital units work well together to provide the best care for

patients.

50 4 0.0% 6.0% 10.0% 38.0% 46.0%

9th We have enough staff to handle the workload. 53 1 13.2% 30.2% 5.7% 39.6% 11.3%

17th*Staff in this unit work longer hours than is best for patient

care.

52 2 42.3% 34.6% 7.7% 11.5% 3.8%

14th*We use more agency/temporary staff than is best for patient

care.

53 1 49.1% 22.6% 17.0% 9.4% 1.9%

8th *We work in "crisis mode" trying to do too much, too quickly. 52 2 42.3% 7.7% 21.2% 17.3% 11.5%

4th*Things "fall between the cracks" when transferring patients

from one unit to another.

51 3 2.0% 37.3% 51.0% 7.8% 2.0%

5th*Important patient care information is often lost during shift

changes.

50 4 6.0% 34.0% 10.0% 12.0% 38.0%

3rd*Problems often occur in the exchange of information across

hospital units.

50 4 4.0% 32.0% 52.0% 12.0% 0.0%

13th *Shift changes are problematic for patients in this hospital. 49 5 4.1% 65.3% 16.3% 8.2% 6.1%

15th *Staff feel like their mistakes are held against them. 53 1 41.5% 32.1% 9.4% 15.1% 1.9%

10th*When an event is reported, it feels like the person is being

written up, not the problem.

52 2 11.5% 44.2% 25.0% 11.5% 7.7%

1st*Staff worry that mistakes they make are kept in their

personnel file.

52 2 5.8% 9.6% 32.7% 48.1% 3.8%

2021

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Shaded blocks indicate the desired response to each question. Shaded

blocks are added together for "percent positive". Priority rankings are

indicated before each question for the most recent survey period.



CURRENT COMMENTSCURRENT SURVEY RESULTS

● Sample Medical Center takes patient safety very seriously.

● SMC could do better at prioritizing patient safety during patient transfers.

● My team at Sample works well together.


Date post:	07-Dec-2021
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