A first step is to select a survey instrument that is valid and reliable—that is, it measures what it intends to measure and produces similar results upon repeat administrations.
Several safety culture assessment tools are available; including proprietary instruments, such as the Pascal Metrics’ Safety Attitudes Questionnaire (SAQ), and those in the public domain, such as the AHRQ Surveys of Patient Safety. Each can be adapted to a variety of health care settings, including medical offices and nursing homes. Each has strengths and can provide an excellent starting point for implementing a culture of safety.
Before choosing a survey, consider several factors:
- Is the survey free or is there a charge?
- Generally speaking, survey tools that cost money upfront provide the analytics you need, while the “free” surveys may wind up costing more in terms of your internal resources to analyze the data. It is unwise to make a decision based solely on upfront costs.
- How are the responses tabulated and analyzed?
- The most useful data for organizations is at the unit level, by domain and by question. Because most hospitals exhibit great variability within their own organization, it is useful for units to be assessed in relation to other units in the same organization, as well as to a standard (e.g., less than 60 percent positive response rate is a “danger zone.”). Finally, it is most useful also to know the trajectory for each unit: Have its scores increased or decreased in each domain since the last survey?
- Can the survey be administered electronically or only on paper?
- Some surveys are offered on paper alone while others are offered as a choice of paper or electronic. The paper form of the survey may allow for better control of administration, thereby maintaining a higher response rate. The electronic form of the survey may be administered by email or web link and can afford more flexibility for frontline staff in terms of convenience of completion.
After selecting a survey tool, you must decide who will be surveyed and how often. It’s best to survey all of your clinical work units, but if that’s not possible, follow these best-practice guidelines suggested by the National Quality Forum:
- Survey a census of units or service areas that in aggregate deliver care to more than 50 percent of the patients receiving care
- Measure service lines or units where there is a high patient safety risk
- Survey a valid sample to allow unit-level analysis and facilitate improvement
Many hospitals begin with their critical care and high-risk areas, such as intensive care units, emergency departments, their labs and/or their pharmacies.
Once you have determined the areas to survey, you must develop a team to collect information and ensure a minimum response rate across each area of your institution. Generally, a 60 percent response rate is required to ensure valid results.
Best practice is to measure culture of safety on an organization-wide basis every 12 months to 18 months. Normally it takes about four weeks to distribute and collect the survey.
Your level of preparation before the survey will have a large impact on the usefulness of the results to drive improvement. Success demands an organizational commitment to measuring your safety culture, as well as an organized approach to staffing this endeavor.
Organizations will need to invest time and resources to:
1. Name a Project Lead with strong project management and leadership skills and knowledge of the organization’s clinical and nonclinical structure.
- Negotiate/oversee contract development and approval
- Develop a strategy for survey administration and results dissemination
- Communicate strategy to organizational leadership and facility coordinator
- Provide/arrange training to project leads
- Oversee accomplishment of key milestones
2. Identify a facility coordinator (for each facility being measured) who has strong project management skills, is trusted by staff and has a passion for improving patient safety and culture.
- Serve as a facility resource for culture assessment issues and education
- Communicate plan and importance of culture assessment throughout the facility
- Recruit unit coordinators in quantity appropriate for the facility
- Identify clinical areas to be surveyed
- Coordinate the collection and entry of the number of target participants
- Coordinate assignment of physicians, social work, pharmacy or other non-unit based personnel to clinical areas as appropriate
- Distribute surveys to clinical areas
- Coordinate the return of surveys to the administrator at the end of the survey period (if paper survey is used)
- Manage user access to the analytical platform for the facility
- Coordinate the dissemination of results
- Oversee the completion of debriefings
3. Identify a unit coordinator for each work unit
- Serves as unit resource on culture assessment
- Develop a communication plan
- Collect target participant numbers (total number of active staff on the unit who work a minimum number of hours on that work unit) and information
- Develop a comprehensive plan to distribute and collect the surveys
- Ensure anonymity
- At the direction of the project lead, enter target figures into the platform
- Encourage participation and organize promotions, such as staff lunches
- Organize and participate in debriefing sessions after results have been analyzed
4. Develop a communication plan. You may want to use our Culture Assessment FAQ tool.
5. Develop a comprehensive plan to distribute and collect the surveys.
It is important for staff to respond anonymously. In order to improve participation, managers may offer incentives such as a pizza party, candy bars, etc. Normally a four-week period of time is required for the dissemination and collection of the survey.
Measurement of the culture of safety by itself is not enough. The results must be fed back to the organization to stimulate discussions about areas of weakness and solutions for improvement. Because culture resides at the local level, it’s important to discuss the results by departments, units and roles. Focusing on group-level data depersonalizes the discussion and fosters actionable ideas for improvement in the context of the local realities of care delivery.
More than simply a measuring stick, feedback to respondents at the work-unit level can actually be the first step in improving culture. Hopkins safety researchers have developed a "Culture Check-Up” tool that provides a structure for reviewing the results with frontline caregivers (not managers) to identify specific areas of concern and obtain insights and recommendations on how to address the issues. Selecting one or two items from SAQ results helps to focus the discussion on specific areas for improvement.