By Carolyn M. Clancy, MD

Increasing emphasis on patient safety has led healthcare experts to discover that most patient safety errors are due to issues with systems rather than "bad" individuals, and that some systems are more prone to errors than others. In an attempt to prevent and reduce medical errors, the healthcare industry has begun to focus on developing predictive measures of safety, particularly the measurable components of a safety culture such as management and leadership behavior, effective team functioning, communication, and employee perceptions of safety.

The AHRQ Hospital Survey on Patient Safety Culture
As part of our goal to support a culture of patient safety and quality improvement in the U.S. healthcare system, the Agency for Healthcare Research and Quality (AHRQ) sponsored the development of a patient safety culture assessment tool¹ for hospitals called the Hospital Survey on Patient Safety Culture that was pilot tested, revised, and released in November 2004. AHRQ is also in the process of sponsoring similar assessment tools to be developed for nursing homes and ambulatory outpatient medical offices. Beyond diagnosing the current status of the safety culture in an organization, the surveys can also be used to:

• Raise awareness about patient safety issues
  
  
• Evaluate specific patient safety interventions or programs
  
  
• Fulfill directives or regulatory requirements
  
  
• Conduct internal and external benchmarking
  
  
• Track changes over time

We are aware that there are other organizational culture and patient safety surveys available; however, there are several advantages of the AHRQ survey. First of all, it is free and is accompanied by technical support tools such as the Survey User's Guide and a template to display survey results. In addition, it was designed to be administered to all types of hospital staff, including clinical and non-clinical staff. Also, it can be used to assess individual hospital units or departments or can be administered hospital-wide.

The survey development process was rigorous, based on a review of existing research and other culture surveys. It is also comprehensive and specific, as it measures staff perceptions of patient safety in their work area/unit as well as perceptions about patient safety in the hospital as a whole. The following 12 areas of patient safety are included:

1. Overall perception of safety
   
   
2. Frequency of event reporting
   
   
3. Supervisor/manager expectations and actions promoting patient safety
   
   
4. Organizational learning — continuous improvement
   
   
5. Teamwork within units
   
   
6. Communication and openness
   
   
7. Feedback and commu-nication about error
   
   
8. Non-punitive response to error
   
   
9. Staffing
   
   
10. Hospital management support for patient safety
    
    
11. Teamwork across hospital units
    
    
12. Hospital handoffs and transitions

Two additional questions ask about:

• the patient safety "grade" the respondent would assign to their work area/unit, and
  
  
• the number of events the respondent has reported in the last 12 months.

The New AHRQ Patient Safety Culture Comparative Database
We have now taken the next step and have established the Hospital Survey on Patient Safety Culture Comparative Database. In spring and summer 2006, hospitals that administered the AHRQ hospital 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. The database reports result in tables offering two perspectives — hospital characteristics such as bed size, teaching status, and geographic region; and respondent characteristics such as work area/unit, staff position, and interaction with patients.

Analysis of the data reveals areas of strength for the hospitals that participated as well as areas with potential for improvement. "Teamwork within units" was the patient safety culture composite with the highest scoring average, at 78%. In addition, the majority of respondents gave their work area a grade of either excellent or very good on patient safety. However, the lowest positive response was given by respondents in the area of non-punitive response to error, and under-reporting of events 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.

Participating hospitals represent a range of bed sizes and geographic regions. Most hospitals are non-teaching (76%) and non-government owned (72%). These characteristics are consistent with the distribution of hospitals in the U.S. that are registered with the American Hospital Association. Most respondents (76%) indicated that they had direct interaction with patients. Over one-third of the respondents reported that they were either registered nurses or licensed practical nurses.

Another advantage of using the AHRQ Hospital Survey on Patient Safety Culture is that hospitals that contribute data to the database may compare their hospital's patient safety culture survey results to those of other participating hospitals to help in establishing, improving, and maintaining a culture of patient safety in their institutions.

Highly reliable healthcare systems are characterized as having an organizational commitment to safety, by maintaining a culture that embraces continuous learning and willingness to change. Higher employee satisfaction and more positive perceptions of the organization improve corporate performance. AHRQ is committed to helping all healthcare providers in the U.S. to strengthen their organizational culture and foster a climate that supports patient safety and improved healthcare quality. We are confident that the AHRQ Hospital Survey on Patient Safety Culture can help health institutions to learn and improve their culture even as demands and resources continue to be a challenge.

References

Agency for Healthcare Research and Quality. (2007, April). Patient safety culture surveys. Rockville, MD: Author. Available at http://www.ahrq.gov/qual/hospculture/

1 Survey instruments, user's guides, reports, technical assistance briefings, and other tools mentioned are available on the AHRQ Web site at http://www.ahrq.gov/qual/hospculture/.