Attachment A-2 -- Part I 2009 HSOPS Database Report

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Collection of Information for AHRQ's Hospital Survey on Patient Safety Culture Comparative Database

Attachment A-2 -- Part I 2009 HSOPS Database Report

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ATTACHMENT A-2

The authors of this report are responsible for its content. Statements in the report should not be
construed as endorsement by the Agency for Healthcare Research and Quality or the U.S.
Department of Health and Human Services.

Hospital Survey on Patient Safety Culture:
2009 Comparative Database Report

Prepared for:
Agency for Healthcare Research and Quality (AHRQ)
U.S. Department of Health and Human Services (HHS)
540 Gaither Road
Rockville, MD 20850
http://www.ahrq.gov
Contract No. HHSA 290200710024C
Managed and prepared by:
Westat, Rockville, MD
Joann Sorra, Ph.D.
Theresa Famolaro, M.P.S.
Naomi Dyer, Ph.D.
Dawn Nelson
Kabir Khanna, M.A.
AHRQ Publication No. XX-XXXX
January 2009

This document is in the public domain and may be used and reprinted without permission except
those copyrighted materials noted for which further reproduction is prohibited without specific
permission of copyright holders.
Suggested Citation:
Sorra J, Famolaro T, Dyer N, Nelson D, Khanna K. Hospital Survey on Patient Safety Culture
2009 Comparative Database Report. (Prepared by Westat, Rockville, MD, under Contract No.
HHSA 290200710024C). AHRQ Publication No. XX-XXXX. Rockville, MD: Agency for
Healthcare Research and Quality. January 2009.

No investigators have any affiliations or financial involvement (e.g., employment,
consultancies, honoraria, stock options, expert testimony, grants or patents received or
pending, or royalties) that conflict with material presented in this report.

Table of Contents
Page
Executive Summary ....................................................................................................................1
Purpose and Use of This Report ................................................................................................11

2009 Comparative Database Report
Chapter 1. Introduction.............................................................................................................15
Development of the Survey. ....................................................................................15
The 2009 Comparative Database and Report…..….….. ..........................................16
Chapter 2. Survey Administration Statistics..............................................................................19
Chapter 3. Characteristics of Participating Hospitals ................................................................23
Bed Size .................................................................................................................23
Teaching Status.......................................................................................................24
Ownership and Control ...........................................................................................24
Geographic Region. ................................................................................................25
Chapter 4. Characteristics of Respondents................................................................................27
Work Area/Unit ......................................................................................................27
Staff Position ..........................................................................................................28
Interaction with Patients..........................................................................................29
Chapter 5. Overall Results…. ...................................................................................................31
Calculation of Percent Positive Scores ....................................................................32
Overall Results: Composite and Item-level Charts ..................................................33
Chapter 6. Comparing Your Results .........................................................................................41
Description of Comparative Statistics.. ...................................................................41
Composite and Item-level Comparative Tables .......................................................44
Appendixes A & B: Overall Results by Hospital and Respondent Characteristics....51
Chapter 7. Trending: Comparing Results Over Time….. ..........................................................55
Characteristics of the 204 Trending Hospitals .........................................................56
Description of Trending Statistics ...........................................................................57
Composite and Item-level Trending Results…. .......................................................58
Pie Charts of Trending Results….….. .....................................................................67
Additional Trending Analyses.................................................................................71
Appendixes C & D: Trending Results by Hospital and Respondent Characteristics .77
Chapter 8. What’s Next? Action Planning for Improvement…. ................................................81
Seven Steps of Action Planning. .............................................................................81
References….............................................................................................................................85
Notes: Description of Data Cleaning and Calculations...............................................................87

List of Tables
Table 1-1.
Table 2-1.
Table 2-2.
Table 2-3.
Table 2-4.
Table 2-5.
Table 3-1.

Page
Patient Safety Culture Composites and Definitions..................................................15
Overall Statistics for the 2009 Database Participating Hospitals ..............................20
Summary Statistics for 2009 Database Participating Hospitals.................................20
Survey Administration Statistics..............................................................................20
Average Hospital Response Rate by Mode ..............................................................21
Types of Staff or Work Areas/Units Surveyed .........................................................21
Distribution of Database Hospitals and Respondents by Bed Size............................24
iii

Table 3-2.
Table 3-3.
Table 3-4.
Table 4-1.
Table 4-2.
Table 4-3.
Table 6-1.
Table 6-2.
Table 6-3.
Table 6-4.
Table 6-5.

Distribution of Database Hospitals and Respondents by Teaching Status................24
Distribution of Database Hospitals and Respondents by Ownership and Control.....24
Distribution of Database Hospitals and Respondents by Geographic Region...........25
Distribution of Database Respondents by Work Area/Unit .....................................28
Distribution of Database Respondents by Staff Position..........................................29
Distribution of Database Respondents by Interaction with Patients .........................29
Interpretation of Percentile Scores ..........................................................................43
Sample Percentile Statistics ....................................................................................44
Composite-level Comparative Results for the 2009 Database .................................45
Item-level Comparative Results for the 2009 Database ...........................................46
Average Distribution of Work Area/Unit Patient Safety Grades—2009 Database
Comparative Results ..........................................................................................50
Table 6-6. Average Distribution of Number of Events Reported in the Past 12 Months—2009
Database Comparative Results ...........................................................................50
Table 7-1. Summary Statistics for Previous and Most Recent Data Submissions from the 204
Trending Hospitals.............................................................................................56
Table 7-2. Distribution of 204 Trending Hospitals by Bed Size ...............................................57
Table 7-3. Distribution of 204 Trending Hospitals by Teaching Status ....................................57
Table 7-4. Distribution of 204 Trending Hospitals by Ownership and Control.........................57
Table 7-5a. Example of Trending Statistics ...............................................................................58
Table 7-5b. Example of Other Trending Statistics .....................................................................58
Table 7-6. Trending: Composite-level Results.........................................................................60
Table 7-7. Trending: Item-level Results ..................................................................................61
Table 7-8. Trending: Average Distribution of Work Area/Unit Patient Safety Grades .............65
Table 7-9. Trending: Average Distribution of Number of Events Reported in the Past 12
Months...............................................................................................................65
Table 7-10. Types of Patient Safety Actions Taken by the 2009 Trending Hospitals..................72
NOTES
Table 1.
Table 2.

Example of Computing Item and Composite Percent Positive Scores .....................88
Data Table for Example of How to Compute Percentiles ........................................89

List of Charts
Page
Chart 5-1. Composite-level Average Percent Positive Response―Across All 2009
Database Hospitals............................................................................................ 35
Chart 5-2. Item-level Average Percent Positive Response―Across All 2009 Database
Hospitals........................................................................................................... 36
Chart 5-3. Distribution of Work Area/Unit Patient Safety Grades―Averages Across All 2009
Database Hospitals............................................................................................ 40
Chart 5-4. Distribution of Numbers of Events Reported in the Past 12 Months―Averages
Across All 2009 Database Hospitals.................................................................. 40
Chart 7-1. Trending: Percentage of Hospitals that Increased, Decreased, or Did Not Change
by 5 Percent at Composite Level ....................................................................... 68
Chart 7-2. Trending: Percentage of Hospitals that Increased, Decreased, or Did Not Change
by 5 Percent on Work Area/Unit Patient Safety Grade....................................... 70
Chart 7-3. Trending: Percentage of Hospitals that Increased, Decreased, or Did Not Change
by 5 Percent on Number of Events Reported ..................................................... 70
Appendixes cited in this report are provided electronically at http://www.ahrq.gov/qual/hospculture/.
iv

Executive Summary
In response to requests from hospitals interested in comparing their results to other hospitals
on the Hospital Survey on Patient Safety Culture, the Agency for Healthcare Research and
Quality (AHRQ) established the Hospital Survey on Patient Safety Culture Comparative
Database. The first comparative database report was released in 2007 and was comprised of data
from 382 U.S. hospitals that administered the AHRQ patient safety culture survey to 108,621
hospital staff and voluntarily submitted their data for inclusion in this new database. The second
comparative database report was released in 2008 and was comprised of data from 519 hospitals
that administered the survey to 160,176 hospital staff.
The Hospital Survey on Patient Safety Culture 2009 Comparative Database Report is an
update of the 2008 report. The 2009 report includes more data, reporting results from a total of
622 hospitals and 196,462 hospital staff respondents. In addition, the 2009 report includes a
chapter on trending that presents results showing change over time for 204 hospitals that
administered the survey and submitted data more than once.
Because hospitals will not necessarily administer the hospital patient safety culture survey
every single year, but may administer it on an 18-month, 24-month, or other administration
cycle, the comparative database is a “rolling” benchmark that retains data from prior years when
a hospital does not have new data to submit, replaces older data with more recent data when it is
available, and adds new data from hospitals submitting for the first time. The comparative
database report will be produced yearly through at least 2012.
This comparative database report was developed as a tool for the following purposes:


Comparison—To allow hospitals to compare their patient safety culture survey results to
other hospitals.



Assessment and Learning—To provide data to hospitals to facilitate internal assessment
and learning in the patient safety improvement process.



Supplemental Information—To provide supplemental information to help hospitals
identify their strengths and areas with potential for improvement in patient safety culture.



Trending—To provide data that describe changes in patient safety culture over time.

Development of the Survey
The Hospital Survey on Patient Safety Culture was pilot tested, revised, and then released in
November 2004. It was designed to assess hospital staff opinions about patient safety issues,
medical error, and event reporting and includes 42 items that measure 12 areas or composites of
patient safety culture, including:
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. Nonpunitive response to error
7. Organizational learning–Continuous improvement
8. Overall perceptions of patient safety
9. Staffing
10. Supervisor/manager expectations and actions promoting safety
11. Teamwork across units
12. Teamwork within units
The survey also includes two questions that ask respondents to provide an overall grade on
patient safety for their work area/unit and to indicate the number of events they have reported
over the past 12 months.

2009 Database Hospitals
The hospitals in the 2009 database fall into three categories:


395 hospitals from the previous database report that are still included in the 2009 report;
of which
o 314 hospitals submitted data one time; and
o 81 hospitals submitted data twice, older data was replaced by data from their readministration data so the database reflects their most recent survey data.



227 hospitals that submitted data for the 2009 report; of which
o 104 hospitals submitted data for the first time; and
o 123 hospitals submitted data from a re-administration of the survey; older data
from these hospitals was replaced by data from their re-administration data so the
database reflects their most recent survey data.

Survey Administration Statistics


The average hospital response rate was 52 percent, with an average of 316 completed
surveys per hospital.



Most hospitals (44 percent) administered paper surveys, which resulted in higher
response rates (58 percent) compared to web (45 percent) or mixed mode surveys (52
percent).
2



Most hospitals (74 percent) administered the survey to all staff or a sample of all staff
from all hospital departments.

Characteristics of Participating Hospitals


Participating hospitals represent a range of bed sizes and geographic regions.



Most hospitals are non-teaching (69 percent) and non-government owned (voluntary/nonprofit or proprietary/investor owned) (78 percent).



Overall, the characteristics of the 622 database hospitals are fairly consistent with the
distribution of U.S. hospitals registered with the American Hospital Association (AHA).

Characteristics of Respondents


There are 196,462 hospital staff respondents from 622 hospitals.



One-third of respondents (33 percent) selected “Other” as their work area, followed by
“Surgery” (10 percent), “Medicine” (9 percent), and “Many different hospital units/No
specific unit” (8 percent).



Over one-third of respondents (36 percent) selected “Registered Nurse” or “Licensed
Vocational Nurse/Licensed Practical Nurse (LVN/LPN)” as their staff position, followed
by “Other” (22 percent), and “Technician (e.g., EKG, Lab, Radiology)” (10 percent).



Most respondents (77 percent) indicated they had direct interaction with patients.

Areas of Strength for Most Hospitals
Teamwork Within Units—The extent to which staff support one another, treat each other with
respect, and work together as a team was the patient safety culture composite with the highest
average percent positive response (79 percent), indicating this is an area of strength for most
hospitals. The survey item with the highest average percent positive response (86 percent) was:
“When a lot of work needs to be done quickly, we work together as a team to get the work
done.”
Patient Safety Grade—On average, the majority of respondents within hospitals (73 percent)
gave their work area or unit a grade of either “A-Excellent” (25 percent) or “B-Very Good” (48
percent) on patient safety. However, there was a wide range of response in patient safety grades,
from at least one hospital where none of the respondents (0 percent) provided their unit with a
patient safety grade of “A-Excellent,” to a hospital where 63 percent did.

Areas with Potential for Improvement for Most Hospitals
Nonpunitive Response to Error—The extent to which staff feel that their mistakes and event
reports are not held against them and that mistakes are not kept in their personnel file was one of
the two patient safety culture composites with the lowest average percent positive response (44
percent), indicating this is an area with potential for improvement for most hospitals. The survey

item with the lowest average percent positive response was: “Staff worry that mistakes they
make are kept in their personnel file” (an average of only 35 percent).
Handoffs & Transitions—The extent to which important patient care information is
transferred across hospital units and during shift changes was the other patient safety culture
composite with the lowest average percent positive response (44 percent), indicating this is also
an area with potential for improvement for most hospitals. The survey item with the lowest
average percent positive response was: “Things ‘fall between the cracks’ when transferring
patients from one unit to another” (an average of only 41 percent).
Number of Events Reported—On average, the majority of respondents within hospitals (52
percent) reported no events in their hospital over the past 12 months. It is likely that this
represents under-reporting of events and 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. However, there was a wide range of responses in the number of
events reported, from a hospital where 96 percent of respondents had not reported a single event
over the past 12 months, to a hospital where only 5 percent had not reported an event.

Overall Results by Hospital Characteristics
Results on the survey’s patient safety culture composites and items by hospital characteristics
(bed size, teaching status, ownership and control, geographic region) are highlighted. A 5 percent
difference in percent positive scores was used as a rule of thumb to identify meaningful
differences in scores.
Bed Size


Smaller hospitals (49 beds or fewer) had the highest average percent positive response on
all 12 patient safety culture composites.



The largest difference by bed size was on Handoffs & Transitions where the smallest
hospitals (6-24 beds) scored 22 percent higher than large hospitals (400-499 beds) (55
percent compared to 33 percent positive).



Large hospitals (400-499 beds) scored lowest on the percent of respondents who gave
their work area/unit a patient safety grade of “Excellent” or “Very good” (64 percent for
400-499 beds compared to 78 percent for 25-49 beds).



There were no noticeable differences on number of events reported based on bed size (all
differences were 3 percent or less).

Teaching Status, and Ownership and Control


Non-teaching hospitals had the highest average percent positive response on Teamwork
Across Units and Handoffs & Transitions.



Government-owned hospitals were more positive than non-government on Handoffs &
Transitions (6 percent more positive), and Staffing (5 percent more positive).



There were no noticeable differences on patient safety grade or number of events
reported based on teaching status or ownership and control (all differences were 3 percent
or less).
4

Geographic Region*


East South Central hospitals had the highest average percent positive response across the
12 patient safety culture composites; Pacific hospitals had the lowest.



The largest difference by region was on Staffing and Handoffs & Transitions where West
North Central hospitals were 10 percent more positive than Mid Atlantic/New England
hospitals (for Staffing) and Pacific hospitals (for Handoffs & Transitions).



West South Central hospitals scored highest on the percent of respondents who gave their
work area/unit a patient safety grade of “Excellent” or “Very good” (77 percent).



Pacific hospitals had the highest percent of respondents who reported one or more events
in the past year (53 percent); the lowest percent of respondents reporting events was in
the West South Central region (40 percent).

Overall Results by Respondent Characteristics
Results on the survey’s patient safety culture composites and items by respondent
characteristics (work area/unit, staff position, interaction with patients) are highlighted. A 5
percent difference in percent positive scores was used as a rule of thumb to identify meaningful
differences in scores.
Work Area/Unit


Respondents in Rehabilitation had the highest average percent positive response on 8 of
the 12 patient safety culture composites.



The largest difference by work area/unit was on Nonpunitive Response to Error (22
percent). On this composite, Rehabilitation was 59 percent positive and Emergency was
37 percent positive.



Rehabilitation had the highest percent of respondents who gave their work area/unit a
patient safety grade of “Excellent” or “Very good” (81 percent); Emergency and
Medicine had the lowest percent (62 percent).



ICU (any type) had the highest percent of respondents reporting one or more events in the
past year (66 percent); Anesthesiology had the lowest percent of respondents reporting
events (43 percent).

Staff Position


Respondents in Administration/Management had the highest average positive response on
11 of the 12 patient safety culture composites.

NOTE: States are categorized into AHA-defined regions as follows:
Mid Atlantic/New England: NY, NJ, PA, ME, NH, VT, MA, RI, CT
South Atlantic: DE, MD, DC, VA, WV, NC, SC, GA, FL
East North Central: OH, IN, IL, MI, WI
East South Central: KY, TN, AL, MS

West North Central: MN, IA, MO, ND, SD, NE, KS
West South Central: AR, LA, OK, TX
Mountain: MT, ID, WY, CO, NM, AZ, UT, NV
Pacific: WA, OR, CA, AK, HI



The largest difference (26 percent) by staff position was on Nonpunitive Response to
Error; Administration/Management was 62 percent positive and Patient Care Assistants
Aides/Care Partners were 36 percent positive.



Administration/Management had the highest percent of respondents who gave their work
area/unit a patient safety grade of “Excellent” or “Very good” (82 percent); Registered
Nurse/LVN/LPN had the lowest percent (66 percent).



Pharmacists had the highest percent of respondents reporting one or more events in the
past year (75 percent); Unit Assistants/Clerks/Secretaries had the lowest percent
reporting events (22 percent).

Interaction with Patients


Respondents with direct patient interaction were 7 percent more positive on Handoffs &
Transitions compared to those without direct patient interaction (45 percent compared to
38 percent positive).



Respondents without direct patient interaction were 7 percent more positive about
Management Support for Patient Safety than those with direct patient interaction (76
percent compared to 69 percent positive).



Respondents without direct patient interaction had the highest percent of respondents who
gave their work area/unit a patient safety grade of “Excellent” or “Very good” (77
percent) compared to those with direct patient interaction (72 percent).



More respondents with direct patient interaction reported one or more events in the past
year (53 percent) than respondents without direct patient interaction (32 percent).

Trending: Comparing Results Over Time
Results regarding changes over time on the patient safety culture composites and items for
the 204 hospitals (of the 622 total database hospitals) that administered the survey and submitted
data more than once are highlighted. When comparing results over time, a 5 percent difference in
percent positive scores between the previous and most recent survey administrations was used as
a rule of thumb to identify meaningful changes in scores over time.


For the 204 hospitals with trending data, the average length of time between previous and
most recent survey administrations was 16 months (range: 7 months to 35 months).



The average change in percent positive scores between administrations on the patient
safety culture composites was a slight increase of 2 percent (ranging from 1 to 3 percent
change).



37 percent of trending hospitals increased by 5 percent or more on Overall Perceptions of
Patient Safety.



22 percent of hospitals decreased in percent positive scores by 5 percent or more on
Organizational Learning–Continuous Improvement.



There were no noticeable differences on changes to the percent of respondents who gave
their work area/unit a patient safety grade of “A-Excellent” and “B-Very Good” (average
percent increased by 4 percent).



There were no noticeable differences on the number of events reported by respondents in
the last 12 months (the average percent of respondents reporting one or more events
increased by only 2 percent).

Additional Trending Analyses
Quantitative and qualitative data on changes in patient safety culture over time are
highlighted. Quantitative data includes questionnaire data on actions taken by the trending
hospitals to improve their patient safety culture, as well as correlational analyses of the actions
taken with changes to Hospital Survey on Patient Safety Culture (HSOPS) scores. Qualitative
data consists of findings from nine interviews conducted with trending hospital staff, who
provided potential explanations for increases and decreases in their hospitals’ HSOPS scores.

Trending Results by Hospital Characteristics
Results for the 204 trending hospitals regarding changes over time on the patient safety
culture composites and items by hospital characteristics are highlighted. When comparing results
over time, a 5 percent difference in percent positive scores between the previous and most recent
survey administrations was used as a rule of thumb to identify meaningful changes in scores over
time.
Trending: Bed Size


Hospitals with 100-299 beds had the largest increases in percent positive response over
time on 10 of the 12 patient safety culture composites (average increase across the 10
composites was 5 percent).



Hospitals with 200-299 beds had the greatest average change across the 12 patient
safety culture composites (average 5 percent change).



The largest increase over time was for medium-large hospitals (200-299 beds) on
Teamwork Within Units and Organizational Learning—Continuous Improvement, both
increasing 8 percent from the previous administration.



The largest decrease over time was for large hospitals (500 or more beds) on the
Overall Perceptions of Patient Safety, decreasing 6 percent from the previous
administration.



Small hospitals (6-24 beds) had the highest increase in percent of respondents who gave
their work area/unit a patient safety grade of “Excellent” or “Very good” (a 7 percent
increase, from 71 percent in the previous administration to 78 percent in the most recent
administration).



Small hospitals (6-24 beds) also had the highest increase in percent of respondents
reporting one or more events in the past year (a 6 percent increase, from 41 percent to
47 percent).

Trending: Teaching Status and Ownership and Control


There were no noticeable differences or changes across the patient safety culture
composites for teaching versus non-teaching hospitals or government-owned versus
non-government hospitals (all changes and differences were 4 percent or less).
7



Non-teaching hospitals had a greater increase than teaching hospitals in the percent of
respondents who gave their work area/unit a patient safety grade of “Excellent” or
“Very good” (a 5 percent increase, from 69 percent to 74 percent).



Government-owned hospitals had a greater increase than non-government hospitals in
the percent of respondents who gave their work area/unit a patient safety grade of
“Excellent” or “Very good” (a 6 percent increase, from 69 percent to 75 percent).



There were no noticeable differences or changes on the percent of respondents who
reported one or more events in the past year based on teaching status.



Government-owned hospitals had a greater increase than non-government hospitals in the
percent of respondents who reported one or more events in the past year (a 5 percent
increase, from 42 percent to 47 percent).

Trending Results by Respondent Characteristics
Results for the 204 trending hospitals regarding changes over time on the patient safety
culture composites and items by respondent characteristics are highlighted. When comparing
results over time, a 5 percent difference in percent positive scores between the previous and most
recent survey administrations was used as a rule of thumb to identify meaningful changes in
scores over time.
Trending: Work Area/Unit


Respondents in Psych/Mental Health had the greatest average change in percent positive
response across the 12 patient safety culture composites, with an average change of 5
percent.



Respondents in Obstetrics had the largest increases in positive response over time on 5 of
the 12 patient safety culture composites (average increase across the 5 composites was 6
percent).



Respondents in Anesthesiology had the largest decreases in positive response over time
on 4 of the 12 patient safety culture composites (average decrease across the 4
composites was 5 percent).



Medicine had the largest average percent of respondents who increased over time in
giving their work area/unit a patient safety grade of “Excellent” or “Very good” (an 8
percent increase from 56 to 64 percent), followed by ICU (7 percent increase), Surgery (6
percent increase), and Lab (5 percent increase).
Lab had the largest average percent of respondents who increased over time in their
reporting of one or more events in the past year (a 7 percent increase: from 48 to 55
percent) followed by Anesthesiology, Radiology, and Rehabilitation (all increasing by 5
percent); the largest decrease in percent reporting was in Obstetrics (a 6 percent decrease
from 58 to 52 percent).



Trending: Staff Position


Pharmacists had the largest increases in positive response over time on 4 of the 12
patient safety culture composites (average increase across the 4 composites was 6
percent).
8



Admin/Mgmt, RN/LVN/LPN, and Technicians had the largest average percent of
respondents who increased over time in giving their work area/unit a patient safety grade
of “Excellent” or “Very good” (5 percent increases).



There were no noticeable differences in the percent of respondents reporting one or more
events over time based on staff position (all changes over time were less than +/- 5
percent).

Trending: Interaction with Patients


There were no noticeable composite differences over time based on respondent
interaction with patients (all were increases over time of 4 percent or less).



There were no noticeable differences in the percent of respondents giving their work
unit/area a patient safety grade of “Excellent” or “Very good” or those reporting one or
more events over time based on respondent direct patient interaction.

Action Planning for Improvement
The delivery of survey results is not the end point in the survey process, it is just the
beginning. It is often the case that the perceived failure of surveys to create lasting change is
actually due to faulty or nonexistent action planning or survey follow-up. Seven steps of action
planning are provided to give hospitals guidance on next steps to take to turn their survey results
into actual patient safety culture improvement.
1. Understand your survey results
2. Communicate and discuss the survey results
3. Develop focused action plans
4. Communicate action plans and deliverables
5. Implement action plans
6. Track progress and evaluate impact
7. Share what works

Purpose and Use of This Report
In response to requests from hospitals interested in comparing their results to other hospitals
on the Hospital Survey on Patient Safety Culture, the Agency for Healthcare Research and
Quality (AHRQ) established the Hospital Survey on Patient Safety Culture Comparative
Database. The first comparative database report was released in 2007 and was comprised of data
from 382 U.S. hospitals that administered the AHRQ patient safety culture survey to 108,621
hospital staff and voluntarily submitted their data for inclusion in this new database. The second
comparative database report was released in 2008 and was comprised of data from 519 hospitals
that administered the survey to 160,176 hospital staff.
The Hospital Survey on Patient Safety Culture 2009 Comparative Database Report is an
update of the 2008 report. The 2009 report consists of data from a total of 622 hospitals and
196,462 hospital staff respondents who completed the survey. The hospitals in the 2009 report
fall into three categories:




Because hospitals will not necessarily administer the hospital patient safety culture survey
every single year, but may administer it on an 18-month, 24-month, or other administration
cycle, the comparative database is a “rolling” benchmark that retains data from prior years when
a hospital does not have new data to submit, replaces older data with more recent data when it is
available, and adds new data from hospitals submitting for the first time. The comparative
database report will be produced yearly through at least 2012.
This comparative database report was developed as a tool for the following purposes:


Comparison—To allow hospitals to compare their patient safety culture survey results to
other hospitals.



Assessment and Learning—To provide data to hospitals to facilitate internal assessment
and learning in the patient safety improvement process.



Supplemental Information—To provide supplemental information to help hospitals
identify their strengths and areas with potential for improvement in patient safety culture.



Trending—To provide data that describe changes in patient safety culture over time.
11

The report presents statistics (averages, standard deviations, minimum and maximum scores
and percentiles) on the patient safety culture areas or composites assessed in the survey as well
as the survey's items. In addition, the 2009 report includes a chapter on trending that describes
patient safety culture change over time for the 204 hospitals that submitted data from their
previous and most recent safety culture surveys.
Appendixes A and B present overall results by hospital characteristics (bed size, teaching
status, ownership and control, geographic region) and respondent characteristics (hospital work
area/unit, staff position, interaction with patients).

Appendix A—Results by Hospital Characteristics
 Bed size
 Teaching status
 Ownership and control
 Geographic region
Appendix B—Results by Respondent Characteristics
 Work area/unit
 Staff position
 Interaction with patients
Appendixes C and D show trends over time for the 204 hospitals that administered the survey
and submitted data more than once. Average percent positive scores from the most recent and
previous administrations are shown on the survey composites and items, broken down by
hospital characteristics (bed size, teaching status, ownership and control) and respondent
characteristics (hospital work area/unit, staff position, interaction with patients).

Appendix C—Trending Results by Hospital Characteristics
 Bed size
 Teaching status
 Ownership and control
Appendix D—Trending Results by Respondent Characteristics
 Work area/unit
 Staff position
 Interaction with patients
Note: Because there were fewer than 20 trending hospitals in several hospital geographic
region breakout categories, trending results are not shown by hospital geographic region to
ensure hospital confidentiality.

2009 Comparative Database Report

Chapter 1. Introduction
Patient safety is a critical component of healthcare quality. As healthcare organizations
continually strive to improve, there is a growing recognition of the importance of establishing a
culture of patient safety. Achieving a culture of patient safety requires an understanding of the
values, beliefs, and norms about what is important in an organization and what attitudes and
behaviors related to patient safety are supported, rewarded, and expected.

Development of the Survey
Recognizing the need for a measurement tool to assess the culture of patient safety in
healthcare organizations, the Medical Errors Workgroup of the Quality Interagency Coordination
Task Force (QuIC) sponsored the development of a hospital survey focusing on patient safety
culture. Funded by the Agency for Healthcare Research and Quality (AHRQ), the Hospital
Survey on Patient Safety Culture was developed under contract by Westat, a private research
organization. To develop this patient safety culture assessment tool, a review of research
pertaining to safety, patient safety, error and accidents, and error reporting was conducted, as
well as an examination of existing published and unpublished safety culture assessment tools. In
addition, hospital employees and administrators were interviewed to identify key patient safety
and error reporting issues.
The survey was pilot tested, revised, and then released by AHRQ in November 2004. It was
designed to assess hospital staff opinions about patient safety issues, medical error, and event
reporting and includes 42 items that measure 12 areas or composites of patient safety culture.
Each of the 12 patient safety culture composites is listed and defined in Table 1-1.
Table 1-1. Patient Safety Culture Composites and Definitions
Patient Safety Culture Composite
Definition: The extent to which….
1. Communication openness

2. Feedback & communication about error

3. Frequency of events reported

4. Handoffs & transitions
5. Management support for patient safety

6. Nonpunitive response to error

Staff freely speak up if they see something that may
negatively affect a patient, and feel free to question
those with more authority
Staff are informed about errors that happen, given
feedback about changes implemented, and discuss
ways to prevent errors
Mistakes of the following types are reported:
1) mistakes caught and corrected before affecting
the patient, 2) mistakes with no potential to harm the
patient, and 3) mistakes that could harm the patient,
but do not
Important patient care information is transferred
across hospital units and during shift changes
Hospital management provides a work climate that
promotes patient safety and shows that patient
safety is a top priority
Staff feel that their mistakes and event reports are
not held against them, and that mistakes are not kept
in their personnel file

Table 1-1. Patient Safety Culture Composites and Definitions, continued
Patient Safety Culture Composite
7. Organizational learning–Continuous
improvement
8. Overall perceptions of patient safety
9. Staffing

10. Supervisor/manager expectations and
actions promoting safety

11. Teamwork across units
12. Teamwork within units

Definition: The extent to which….
There is a learning culture in which mistakes lead to
positive changes and changes are evaluated for
effectiveness
Procedures and systems are good at preventing
errors and there is a lack of patient safety problems
There are enough staff to handle the workload and
work hours are appropriate to provide the best care
for patients
Supervisors/managers consider staff suggestions for
improving patient safety, praise staff for following
patient safety procedures, and do not overlook
patient safety problems
Hospital units cooperate and coordinate with one
another to provide the best care for patients
Staff support one another, treat each other with
respect, and work together as a team

The survey also includes two questions that ask respondents to provide an overall grade on
patient safety for their work area/unit and to indicate the number of events they have reported
over the past 12 months. In addition, respondents are asked to provide limited background
demographic information about themselves (their work area/unit, staff position, whether they
have direct interaction with patients, etc). The survey’s toolkit materials are available from the
AHRQ web site (www.ahrq.gov/qual/hospculture) and include the survey, survey items and
dimensions, Hospital Survey User’s guide, Hospital Survey Feedback Report Template,
information about acquiring the Microsoft Excel™ Data Entry and Analysis Tool, an article
about safety culture assessment, and a series of three national technical assistance conference
calls. The toolkit provides hospitals with the basic knowledge and tools needed to conduct a
patient safety culture assessment and ideas regarding how to use the data.

The 2009 Comparative Database and Report
Since its release, the Hospital Survey on Patient Safety Culture has been widely implemented
across the U.S. hospitals administering the survey have expressed interest in comparing their
survey results against other hospitals as an additional source of information to help them identify
areas of strength and areas for patient safety culture improvement. In response to these requests,
AHRQ funded the Hospital Survey on Patient Safety Culture Comparative Database to enable
hospitals to compare their most recent survey results against other hospitals and to examine
trends in patient safety culture over time. Hospitals interested in submitting to the database
should go to the AHRQ web site for more information (www.ahrq.gov/qual/hospculture).

What is new in the 2009 Comparative Database Report?
The Hospital Survey on Patient Safety Culture 2009 Comparative Database Report is an
update of the 2008 report, presenting the most current benchmarking data and trending data
available. The 2009 report contains 204 hospitals that submitted data to the comparative database
more than once, which provides substantially more data to analyze trends in patient safety
culture over time. On average, hospitals show small increases in the patient safety culture

composites and survey items over time. The average increase in composite scores across the 204
trending hospitals is 2 percent (ranging from 1 percent to 3 percent).
In addition to being an update of the 2008 report, the 2009 report contains several new types
of data not previously reported. Chapter 7 presents quantitative and qualitative data on changes
in patient safety culture over time. The quantitative data includes questionnaire data on actions
taken by the 2009 trending hospitals to improve their patient safety culture, as well as
correlational analyses of the actions taken with changes to Hospital Survey on Patient Safety
Culture (HSOPS) scores. The qualitative data consists of findings from nine interviews
conducted with trending hospital staff and suggest explanations for increases and decreases in
hospitals’ HSOPS scores.
Finally, there are now enough trending hospitals to present trending results by hospital
characteristics (bed size, teaching status, ownership and control), as well as respondent
characteristics (work area/unit, staff position, interaction with patients). These breakouts are
presented in Appendixes C and D.

Data Limitations
The survey results presented in this report represent the largest compilation of data from the
Hospital Survey on Patient Safety Culture currently available, and therefore provide a useful
reference for comparison. However, there are several limitations to these data that should be kept
in mind.
First, the hospitals that submitted data to the database are not a statistically selected sample
of all U.S. hospitals since only hospitals that administered the survey on their own and were
willing to submit their data for inclusion in the database are represented. However, the
characteristics of the database hospitals are fairly consistent with the distribution of U.S.
hospitals registered with the American Hospital Association (AHA) and are described further in
Chapter 3.
Second, hospitals that administered the survey were not required to undergo any training and
administered it in different ways. Some hospitals used a paper-only survey, others used webonly, and others used a combination of these two methods to collect the data. It is possible that
these different modes could lead to differences in survey responses; further research is needed to
determine if there are mode effects that affect the results. In addition, some hospitals conducted a
census, surveying all hospital staff, while others administered the survey to a sample of staff. In
cases in which a sample was drawn, no data were obtained to determine the methodology used to
draw the sample. Survey administration statistics that were obtained about the database hospitals,
such as survey administration modes and response rates, are provided in Chapter 2.
Finally, while the data submitted by hospitals have been cleaned for out-of-range values
(e.g., invalid response values due to data entry errors) and blank records (where responses to all
survey items were missing), as well as some logic checks, we have otherwise presented the data
as submitted. We have not made any additional attempts to verify or audit the accuracy of the
data submitted by the hospitals.

Chapter 2. Survey Administration Statistics
This chapter presents descriptive information on the 2009 database hospitals regarding how
they conducted survey administration.

Highlights


The 2009 database consists of data from 196,462 hospital staff respondents across
622 participating hospitals.



The average hospital response rate was 52 percent, with an average of 316
completed surveys per hospital.



Most hospitals (44 percent) administered paper surveys, which resulted in higher
response rates (58 percent) compared to web (45 percent) or mixed mode surveys
(52 percent).



Most hospitals (74 percent) administered the survey to all staff or a sample of all
staff from all hospital departments.

The 2009 database consists of survey data from 622 hospitals with a total of 196,462 hospital
staff respondents. Participating hospitals administered the Hospital Survey on Patient Safety
Culture to their hospital staff between October 2004 and July 2008 and voluntarily submitted
their data for inclusion in the database.
Because hospitals do not necessarily administer the hospital patient safety culture survey
every single year, but may administer it on an 18-month, 24-month, or other administration
cycle, the comparative database is a “rolling” benchmark. Data from prior years is retained in the
database when a hospital does not have new data to submit; older data is replaced with more
recent data when it is available; and new data is added from hospitals submitting for the first
time.
Overall statistics for the hospitals included in the 2009 database are shown in Table 2-1,
broken down according to when the data were submitted. The 2009 database includes 395
hospitals carried over from the 2008 report and new data submissions from 227 hospitals. Of the
395 hospital submissions carried over from the 2008 database, 314 hospitals submitted data only
once, and 81 hospitals submitted data more than once. Of the 227 new hospital submissions, 104
hospitals submitted data for the first time, and 123 hospitals submitted new data based on a readministration of the survey. Old data from hospitals that submitted more than once was replaced
by data from their re-administration so the database reflects their most recent survey data.

Table 2-1. Overall Statistics for the 2009 Database Participating Hospitals

Overall Statistic
Number of
hospitals
Number of
individual survey
respondents

Previous Submissions (H=395)
New Submissions (H=227)
(Included in prior database
(New data for the 2009 report)
reports)
First time
Resubmissions
First time
Resubmissions
Total
submissions
(Submitted more submissions
(Submitted more
2009
(Submitted once)
than once)
(Submitted once)
than once)
Database
314

104

123

622

94,825

9,717

32,096

59,824

196,462

For the 2009 database overall, an average of 316 completed surveys were submitted per
hospital (range: 11 to 3,908 surveys), and an average of 833 surveys were administered per
hospital (range: 15 to 11,269), with an average hospital response rate of 52 percent (range: 4 to
100 percent) (see Table 2-2).
Table 2-2. Summary Statistics for 2009 Database Participating Hospitals
Average Number of completed surveys per hospital (range: 11 to 3,908)

316

Average Number of surveys administered per hospital (range: 15 to 11,269)

833

Average hospital response rate (range: 4% to 100%)

52%

Most hospitals administered only paper surveys (44 percent), followed by web (33 percent)
and mixed mode administrations involving both paper and web surveys (23 percent) (see Table
2-3).
Table 2-3. Survey Administration Statistics
Survey
Administration Mode
Paper only
Web only
Both paper and web
TOTAL

2009 Database
Hospitals
Number
Percent
276
44%
206
33%
140
23%
622
100%

2009 Database
Respondents
Number
Percent
53,293
27%
78,184
40%
64,985
33%
196,462
100%

As shown in Table 2-4, paper survey administrations received a considerably higher average
response rate (58 percent) than web (45 percent) or mixed mode administrations (52 percent). It
is therefore still an overall recommendation that hospitals conduct the Hospital Survey on Patient
Safety Culture as a paper survey, but each hospital should take into consideration its own prior
experience with survey modes and response rates when determining which mode is best.
Table 2-4. Average Hospital Response Rate
by Mode
Survey
Administration Mode
Paper only
Web only
Both web and paper

Average Hospital
Response Rate
58%
45%
52%

Most hospitals (463 or 74 percent) administered the survey to a census of all hospital staff, or
a sample of staff, from all hospital work areas/units; fewer hospitals (105 or 17 percent)
administered the survey to a subset of selected staff or work areas/units; and 54 hospitals (9
percent) administered the survey to a subset of selected staff and selected work areas/units (see
Table 2-5). Twelve hospitals did not administer the entire survey; they excluded one or more of
the non-demographic survey items. Those 12 hospitals were excluded from composite
calculations if they omitted one or more of the items within a particular composite, but were
included in item-level calculations for those items they retained.
Table 2-5. Types of Staff or Work Areas/Units Surveyed
Types of Staff or Work
Areas/Units Surveyed
All staff, or a sample of all staff,
from all work areas/units
Selected staff only
Selected work areas/units only
Selected staff and selected work
areas/units
TOTAL

2009 Database
Hospitals
Number
Percent

2009 Database
Respondents
Number
Percent

463

74%

152,594

78%

79
26

13%
4%

16,741
4,851

9%
2%

22,276

11%

622

100%

196,462

100%

Chapter 3. Characteristics of Participating Hospitals
As background for understanding the survey results, this chapter presents information about
the distribution of database hospitals by bed size, teaching status, ownership and control, and
geographic region. Although the hospitals that voluntarily submitted data to the database do not
constitute a statistically selected sample, the characteristics of these hospitals are fairly consistent
with the distribution of U.S. hospitals registered with the American Hospital Association (AHA).
The characteristics of database hospitals by AHA-defined categories of bed size, teaching status,
ownership and control, and geographic region are presented in the following tables.1 Database
hospitals and survey respondents are described, as well as the distribution of U.S. AHAregistered hospitals included in the 2006 AHA Annual Survey of Hospitals.2

Highlights


Participating hospitals represent a range of bed sizes and geographic regions.



Most hospitals are non-teaching (69 percent) and non-government owned
(voluntary/non-profit or proprietary/investor owned) (78 percent).



Overall, the characteristics of the 622 database hospitals are fairly consistent with
the distribution of U.S. hospitals registered with the American Hospital
Association (AHA).

Bed Size
Table 3-1 shows the distribution of database hospitals and respondents by hospital bed size.
Overall, the distribution of database hospitals by bed size is similar to the distribution of AHAregistered U.S. hospitals. Similar to the AHA-registered U.S. hospitals, the largest group of
database hospitals (139 hospitals or 22 percent) fall in the bed size category of 25 to 49 beds.
The majority of the database hospitals (421 hospitals or 68 percent) have fewer than 200 beds,
which is similar to the percentage of AHA-registered U.S. hospitals (74 percent).
It is important to note that while smaller hospitals are more prevalent in the database, they
account for fewer respondents than larger hospitals. Hospitals with fewer than 200 beds account
for only 32 percent of all database respondents (61,434 respondents), whereas hospitals with 200
or more beds account for over twice as many respondents (135,028 respondents or 69 percent).

To ensure hospital confidentiality, a rule was established requiring at least 20 hospitals to be in a particular breakout category
before data would be displayed by that category. Therefore, some of the standard AHA categories have been combined. In
addition, column percent totals in the tables may not sum to exactly 100% due to rounding of decimals.

Data for AHA-registered hospitals were obtained from the 2006 AHA Annual Survey of Hospitals Database, © 2007 Health
Forum, LLC, an affiliate of the American Hospital Association. Hospitals not registered with the AHA were asked to provide
information on their hospital’s characteristics such as bed size, teaching status, etc.

Table 3-1. Distribution of Database Hospitals and Respondents by Bed Size
(Compared to AHA-registered U.S. Hospitals)

Bed Size
6-24 beds
25-49 beds
50-99 beds
100-199 beds
200-299 beds
300-399 beds
400-499 beds
500 or more beds
TOTAL

AHA-registered
U.S. Hospitals
Number Percent
607
10%
1,374
22%
1,329
21%
1,341
21%
704
11%
402
6%
205
3%
318
5%
6,280
100%

2009 Database
Hospitals
Number Percent
60
10%
139
22%
111
18%
111
18%
74
12%
55
9%
23
4%
49
8%
622
100%

2009 Database
Respondents
Number
Percent
3,703
2%
13,426
7%
15,766
8%
28,539
15%
31,990
16%
35,153
18%
14,636
7%
53,249
27%
196,462
100%

Teaching Status
As shown in Table 3-2, most database hospitals were non-teaching (69 percent), which
compares closely to the distribution of AHA-registered U.S. hospitals.
Table 3-2. Distribution of Database Hospitals and Respondents by Teaching Status
(Compared to AHA-registered U.S. Hospitals)
Teaching
Status
Teaching
Non-Teaching
TOTAL

AHA-registered
U.S. Hospitals
Number Percent
1,442
23%
4,838
77%
6,280
100%

2009 Database
Hospitals
Number Percent
190
31%
432
69%
622
100%

2009 Database
Respondents
Number Percent
94,772
48%
101,690
52%
196,462
100%

Ownership and Control
The distribution of database hospitals and respondents by government versus nongovernment ownership and control is shown in Table 3-3. Most database hospitals (78 percent)
are non-government owned and controlled (i.e., voluntary/non-profit or proprietary/investor
owned). The distribution of database hospitals closely matches the distribution of AHAregistered U.S. hospitals in terms of the percentages of government and non-government
hospitals.
Table 3-3. Distribution of Database Hospitals and Respondents by Ownership and Control
(Compared to AHA-registered U.S. Hospitals)

Ownership and Control
Government (federal or non-federal)
Non-Government (voluntary/nonprofit or proprietary/investor owned)
TOTAL

AHA-registered
U.S. Hospitals
Number Percent
1,645
26%

2009 Database
Hospitals
Number Percent
139
22%

2009 Database
Respondents
Number
Percent
20,837
11%

4,635

74%

483

78%

175,625

89%

6,280

100%

622

100%

196,462

100%

Geographic Region
Table 3-4 shows the distribution of database hospitals by AHA-defined geographic regions.
The largest percentages of database hospitals are from the East North Central region (27 percent)
followed by the South Atlantic and West North Central regions (17 percent each). The database
distribution under-represents Mid Atlantic/New England and West South Central hospitals, and
over-represents the East North Central and West North Central hospitals compared to the
distribution of AHA-registered U.S. hospitals.
Table 3-4. Distribution of Database Hospitals and Respondents by Geographic Region
(Compared to AHA-registered U.S. Hospitals)

Region
Mid Atlantic/New England
South Atlantic
East North Central
East South Central
West North Central
West South Central
Mountain
Pacific
TOTAL

AHA-registered U.S.
Hospitals
Number
Percent
878
14%
963
15%
905
14%
534
9%
794
13%
1,063
17%
484
8%
659
10%
6,280
100%

2009 Database
Hospitals
Number
Percent
37
6%
104
17%
165
27%
34
5%
104
17%
45
7%
58
9%
75
12%
622
100%

2009 Database
Respondents
Number
Percent
20,546
10%
36,825
19%
54,909
28%
8,978
5%
20,986
11%
13,242
7%
17,264
9%
23,712
12%
196,462
100%

West North Central: MN, IA, MO, ND, SD, NE, KS
West South Central: AR, LA, OK, TX
Mountain: MT, ID, WY, CO, NM, AZ, UT, NV
Pacific: WA, OR, CA, AK, HI

Chapter 4. Characteristics of Respondents
This chapter presents information describing the respondents within the participating
hospitals. The data presented here are based on respondents’ answers to survey questions that
asked them to indicate the hospital work area/unit where they spend most of their work time,
their staff position, and whether they typically have direct interaction with patients. In the tables
presented in this chapter, respondents from hospitals that omitted one of these questions, or those
who did not respond, are shown as missing in the tables and are excluded from total percentages.

Highlights


There are 196,462 hospital staff respondents from 622 hospitals.



One-third of respondents (33 percent) selected “Other” as their work area, followed
by “Surgery” (10 percent), “Medicine” (9 percent), and “Many different hospital
units/No specific unit” (8 percent).



Over one-third of respondents (36 percent) selected “Registered Nurse” or “Licensed
Vocational Nurse/Licensed Practical Nurse (LVN/LPN)” as their staff position,
followed by “Other” (22 percent), and “Technician (e.g., EKG, Lab, Radiology)”
(10 percent).



Most respondents (77 percent) indicated they had direct interaction with patients.

Work Area/Unit
One-third of respondents (33 percent) selected “Other” as their work area, followed by
“Surgery” (10 percent), “Medicine” (9 percent), and “Many different hospital units/No specific
unit” (8 percent) (see Table 4-1). Because the Hospital Survey on Patient Safety Culture uses
generic categories for hospital work areas and units, it appears that a large percentage of
respondents chose the “Other” response option that allowed them to specify the name of their
specific work area or unit. Participating hospitals were not asked to submit written or otherspecify responses for any questions so no data are available to further describe the respondents in
the “Other” work area category.

Table 4-1. Distribution of Database Respondents by Work Area/Unit
2009 Database
Respondents
Number Percent

Work Area/Unit
Other
Surgery
Medicine
Many different hospital units/No specific unit
Intensive care unit (any type)

60,617
17,393
17,143
14,428
12,040

33%
10%
9%
8%
7%

TOTAL
Missing: Did not answer or were not asked the question

10,528
9,703
9,273
8,088
7,429
5,226
4,534
4,298
1,184
181,884
14,578

6%
5%
5%
4%
4%
3%
2%
2%
1%
100%

Overall total

196,462

Radiology
Emergency
Laboratory
Obstetrics
Rehabilitation
Pharmacy
Pediatrics
Psychiatry/mental health
Anesthesiology

Staff Position
Over one-third of respondents (36 percent) selected “Registered Nurse” or “Licensed
Vocational Nurse/Licensed Practical Nurse (LVN/LPN)” as their staff position, followed by
“Other” (22 percent), and “Technician (e.g., EKG, Lab, Radiology)” (10 percent) (see Table 42). Similar to the work area/unit question, many respondents chose the “Other” response option
that allowed them to specify their specific staff position, but no data are available to further
describe the respondents in the “Other” staff position category.

Table 4-2. Distribution of Database Respondents by Staff Position
2009 Database
Respondents
Number Percent

Staff Position
Registered Nurse (RN) or Licensed Vocational Nurse (LVN)/
Licensed Practical Nurse (LPN)
Other
Technician (EKG, Lab, Radiology)
Administration/Management
Unit Assistant/Clerk/Secretary
Patient Care Asst/Hospital Aide/Care Partner
Therapists (Respiratory, Physical, Occupational or Speech)
Attending/Staff Physician, Resident Physician/ Physician in
Training, or Physician Assistant (PA)/Nurse Practitioner (NP)
Pharmacist
Dietician
TOTAL
Missing: Did not answer or were not asked the question
Overall total

66,261
40,839
19,230
13,750
11,914

36%
22%
10%
7%
6%

10,386
9,026

6%
5%

8,084
3,123
1,195
183,808
12,654
196,462

4%
2%
1%
100%

Interaction with Patients
The survey asked respondents whether they typically have direct interaction or contact with
patients. As shown in Table 4-3, most respondents (77 percent) indicated “yes,” they had direct
interaction with patients.
Table 4-3. Distribution of Database Respondents by Interaction with Patients

Interaction With Patients
YES, have direct patient interaction
NO, do NOT have direct patient interaction
TOTAL
Missing: Did not answer or were not asked the question
Overall total

2009 Database
Respondents
Number
Percent
143,052
77%
43,658
23%
186,710
100%
9,752
196,462

Chapter 5. Overall Results
As noted in Chapter 1, the Hospital Survey on Patient Safety Culture assesses hospital staff
opinions about patient safety issues, medical error, and event reporting and consists of 42 items
that measure 12 areas or composites of patient safety culture (plus two questions on patient
safety grade and number of events reported). This chapter presents the overall survey results for
the database, showing the average percent of positive response across the database hospitals on
each of the survey’s items and composites.

Highlights


Teamwork Within Units—the extent to which staff support one another, treat each
other with respect, and work together as a team was the patient safety culture
composite with the highest average percent positive response (79 percent), indicating
this is an area of strength for most hospitals.
 The survey item with the highest average percent positive response was:
“When a lot of work needs to be done quickly, we work together as a team to get
the work done”. An average of 86 percent strongly agreed or agreed with this item.



Nonpunitive Response to Error—the extent to which staff feel that their mistakes and
event reports are not held against them, and that mistakes are not kept in their
personnel file—was one of the two patient safety culture composites with the lowest
average percent positive response (44 percent), indicating this is an area with potential
for improvement for most hospitals.
 The survey item with the lowest average percent positive response was:
“Staff worry that mistakes they make are kept in their personnel file”. An average
of only 35 percent strongly disagreed or disagreed with this item.



Handoffs & Transitions—the extent to which important patient care information is
transferred across hospital units and during shift changes—was the other patient safety
culture composite with the lowest average percent positive response (44 percent),
indicating this is also an area with potential for improvement for most hospitals.
 The survey item with the lowest average percent positive response was:
“Things ‘fall between the cracks’ when transferring patients from one unit to
another”. An average of only 41 percent strongly disagreed or disagreed with this
item.



On average, the majority of respondents within hospitals (73 percent) gave their work
area or unit a grade of “A-Excellent” (25 percent) or “B-Very Good” (48 percent) on
patient safety; this was identified as an area of strength for most hospitals.



On average, the majority of respondents within hospitals (52 percent) reported no
events in their hospital over the past 12 months. It is likely that this represents underreporting of events and was identified as an area for improvement for most hospitals.

Reporting the average across hospitals ensures that each hospital receives an equal weight
that contributes to the overall average. Reporting the data at the hospital level in this way is
important because culture is considered to be a group or hospital characteristic and is not
considered to be a solely individual characteristic. An alternative method would be to report a
straight percent of positive responses across all respondents, but this method would give greater
weight to respondents from larger hospitals since there are almost twice as many respondents
from larger hospitals as those from smaller hospitals (as noted in Chapter 3).

Calculation of Percent Positive Scores
Most of the survey’s items ask respondents to answer using 5-point response categories in
terms of agreement (Strongly agree, Agree, Neither, Disagree, Strongly disagree) or frequency
(Always, Most of the time, Sometimes, Rarely, Never). Three of the 12 patient safety culture
composites use the frequency response option (Feedback and Communication About Error,
Communication Openness, and Frequency of Events Reported) while the other nine composites
use the agreement response option.

Item-level Percent Positive Response
Both positively worded items (such as “People support one another in this work area”) and
negatively worded items (such as “We have patient safety problems in this work area”) are
included in the survey. Calculating the percent positive response on an item is different for
positively and negatively worded items:


For positively worded items, percent positive response is the combined percentage of
respondents within a hospital who answered “Strongly agree” or “Agree,” or “Always” or
“Most of the time,” depending on the response categories used for the item.
For example, for the item “People support one another in this work area,” if 50 percent of
respondents within a hospital Strongly agree and 25 percent Agree, the item-level percent
positive response for that hospital would be 50% + 25%= 75% positive.



For negatively worded items, percent positive response is the combined percentage of
respondents within a hospital who answered “Strongly disagree” or “Disagree,” or
“Never” or “Rarely,” because a negative answer on a negatively worded item indicates a
positive response.
For example, for the item “We have patient safety problems in this work area,” if 60
percent of respondents within a hospital Strongly disagree and 20 percent Disagree, the
item-level percent positive response would be 80 percent positive (i.e., 80 percent of
respondents do not believe they have patient safety problems in their work area).

Composite-level Percent Positive Response
The survey’s 42 items measure 12 areas or composites of patient safety culture. Each of the
12 patient safety culture composites includes 3 or 4 survey items. Composite scores were
calculated for each hospital by averaging the percent positive response on the items within a
composite. For example, for a 3-item composite, if the item-level percent positive responses
were 50 percent, 55 percent, and 60 percent, the hospital’s composite-level percent positive
response would be the average of these three percentages or 55% positive.3

Overall Results: Composite and Item-level Charts
Composite-level Results
The composite-level results in Chart 5-1 show the average percent positive response for each
of the 12 patient safety culture composites, across all hospitals in the database. By displaying the
percent positive as an average across hospitals, each hospital’s composite score is weighted
equally. The patient safety culture composites are shown in order from the highest average
percent positive response to the lowest.
Teamwork Within Units—the extent to which staff support one another, treat each other with
respect, and work together as a team—was the patient safety culture composite with the highest
average percent positive response (79 percent), indicating this to be an area of strength across the
database hospitals (see Chart 5-1).
Nonpunitive Response to Error—the extent to which staff feel that event reports and their
own mistakes are not held against them, and that mistakes are not kept in their personnel file—
was one of the two patient safety culture composites with the lowest average percent positive
response (44 percent), indicating this is an area with potential for improvement across the
database hospitals (see Chart 5-1).
Handoffs & Transitions—the extent to which important patient care information is
transferred across hospital units and during shift changes—was the other patient safety culture
composite with the lowest average percent positive response (44 percent), indicating this is also
an area with potential for improvement for most hospitals (see Chart 5-1).

Item-level Results
The item-level results in Chart 5-2 (over 4 pages) show the average percent positive response
for each of the 42 survey items. The survey items are grouped by the patient safety culture
composite they are intended to measure. Within each composite, the items are presented in the
order in which they appear in the survey. The survey item with the highest average percent
positive response (86 percent) was from the patient safety culture composite Teamwork Within
3

Note that this method for calculating composite scores is slightly different than the method described in the September 2004
Survey User’s Guide that is part of the original survey toolkit materials on the AHRQ web site. The guide advises computing
composites by calculating the overall percent positive across all the items within a composite. The updated recommendation
included in this report is to compute item percent positive scores first, and then average the item percent positive scores to obtain
the composite score, which gives equal weight to each item in a composite. The Survey User’s Guide will eventually be updated
to reflect this slight change in methodology.

Units: “When a lot of work needs to be done quickly, we work together as a team to get the work
done.” The survey item with the lowest average percent positive response (35 percent) was from
the patient safety culture composite Nonpunitive Response to Error: “Staff worry that mistakes
they make are kept in their personnel file,” (that is, an average of only 35 percent of respondents
in each hospital Strongly disagreed or Disagreed with this negatively worded item).
Results from the item that asked respondents to give their hospital work area/unit an overall
grade on patient safety are shown in Chart 5-3. The chart shows the average percent of
respondents within each hospital providing grades from “A-Excellent” to “E-Failing.” On
average across hospitals, most respondents were positive with 73 percent giving their work area
or unit a patient safety grade of “A-Excellent” (25 percent) or “B-Very Good” (48 percent). Very
few (5 percent) gave their work area/unit a “Poor” (4 percent) or “Failing” (1 percent) grade.
Results from the item that asked respondents to indicate the number of events they had
reported over the past 12 months are shown in Chart 5-4. The chart shows the average percent of
respondents within each hospital who indicated they reported “No event reports” up to “21 or
more event reports.” On average across hospitals, the majority of respondents (52 percent)
reported no events in their hospital over the past 12 months. It is likely that this represents underreporting and 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.

Chart 5-1. Composite-level Average Percent Positive Response—Across All 2009 Database Hospitals
Patient Safety Culture Composites

Average % Positive Response

1. Teamwork Within Units

79%

Supervisor/Manager Expectations & Actions
Promoting Patient Safety

Organizational Learning--Continuous
Improvement

71%

Management Support for
Patient Safety

70%

75%

5. Overall Perceptions of Patient Safety

64%

6. Feedback & Communication About Error

63%

7. Communication Openness

62%

60%

8. Frequency of Events Reported

57%

9. Teamwork Across Units

55%

10. Staffing

11. Handoffs & Transitions

44%

12. Nonpunitive Response to Error

44%

20%

40%

60%

80%

100%

Chart 5-2. Item-level Average Percent Positive Response—Across All 2009 Database Hospitals
(Page 1 of 4)
Item

Survey Items By Composite

Survey Item Average % Positive Response

1. Teamwork Within Units
A1

1. People support one another in this unit.

85%

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

86%

3. In this unit, people treat each other with
respect.

A11

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

78%
68%

2. Supervisor/Manager Expectations &
Actions Promoting Patient Safety
B1

1. My supervisor/manager says a good word
when he/she sees a job done according to
established patient safety procedures.

2. My supervisor/manager seriously considers
staff suggestions for improving patient safety.

B3R

3. Whenever pressure builds up, my
supervisor/manager wants us to work faster,
even if it means taking shortcuts.

B4R

4. My supervisor/manager overlooks patient
safety problems that happen over and over.

72%

76%

74%

77%

3. Organizational Learning—Continuous
Improvement
A6

1. We are actively doing things to improve
patient safety.

2. Mistakes have led to positive changes here.

A13

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

82%
63%
68%

20%

40%

60%

80%

100%

Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive
response is based on those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response
category used for the item).

Chart 5-2. Item-level Average Percent Positive Response—Across All 2009 Database Hospitals
(Page 2 of 4)
Item

Survey Items By Composite

Survey Item Average % Positive Response

4. Management Support for Patient Safety
F1

F9R

1. Hospital management provides a work
climate that promotes patient safety.

80%

2. The actions of hospital management show
that patient safety is a top priority.
3. Hospital management seems interested in
patient safety only after an adverse event
happens.

72%
59%

5. Overall Perceptions of Patient Safety
A10R

1. It is just by chance that more serious
mistakes don’t happen around here.

A15

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

A17R

3. We have patient safety problems in this unit.

A18

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

60%
64%
62%
70%

6. Feedback and Communication About Error
C1

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

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

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

53%
64%
70%

20%

40%

60%

80%

100%

Chart 5-2. Item-level Average Percent Positive Response—Across All 2009 Database Hospitals
(Page 3 of 4)
Item

Survey Items By Composite

Survey Item Average % Positive Response

7. Communication Openness
C2

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

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

C6R

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

76%
47%
63%

8. Frequency of Events Reported
D1

1. When a mistake is made, but is caught and
corrected before affecting the patient, how
often is this reported?

2. When a mistake is made, but has no
potential to harm the patient, how often is this
reported?

3. When a mistake is made that could harm the
patient, but does not, how often is this
reported?

52%

56%

73%

9. Teamwork Across Units
F2R

1. Hospital units do not coordinate well with
each other.

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

58%

F6R

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

58%

F10

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

45%

67%
0%

20%

40%

60%

80%

100%

Chart 5-2. Item-level Average Percent Positive Response—Across All 2009 Database Hospitals
(Page 4 of 4)
Item

Survey Items By Composite

Survey Item Average % Positive Response

10. Staffing
A2

1. We have enough staff to handle the
workload.

A5R

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

A7R

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

A14R

4. We work in “crisis mode” trying to do too
much, too quickly.

54%
52%
65%
49%

11. Handoffs & Transitions
F3R

1. Things “fall between the cracks” when
transferring patients from one unit to another.

F5R

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

F7R

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

F11R

4. Shift changes are problematic for patients in
this hospital.

41%
49%
42%
45%

12. Nonpunitive Response to Error
A8R

1. Staff feel like their mistakes are held against
them.

A12R

2. When an event is reported, it feels like the
person is being written up, not the problem.

A16R

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

51%
45%
35%
0%

20%

40%

60%

80%

100%

Chart 5-3. Distribution of Work Area/Unit Patient Safety Grades—
Averages Across All 2009 Database Hospitals
100%
80%
60%

48%

40%

25%

23%

20%

4%
0%

A
Excellent

B
C
Very Good Acceptable

D
Poor

E
Failing

Chart 5-4. Distribution of Numbers of Events Reported in the Past 12 Months—
Averages Across All 2009 Database Hospitals

100%
80%
60%

52%

40%

28%

20%

13%
4%

6 to 10

11 to 20

0%
None

1 to 2

3 to 5

21 or
more

Chapter 6. Comparing Your Results
To compare your hospital’s survey results to the results from the database hospitals, you will
need to calculate your hospital’s percent positive response on the survey’s 42 items and 12
composites (plus the two questions on patient safety grade and number of events reported). Refer
to Chapter 5 and the Notes section at the end of this report for a description of how to calculate
these percent positive scores. You will then be able to compare your hospital’s results against the
database averages, and examine the percentile scores to place your hospital’s results relative to
the distribution of database hospitals.
When comparing your hospital’s results against results from the database, keep in mind that
the database only provides relative comparisons. Even though your hospital’s survey results may
be better than the database statistics, you may still believe there is room for improvement in a
particular area within your hospital in an absolute sense. As you will notice from the database
results, there are some patient safety composites that even the highest-scoring hospitals could
improve upon. Therefore, the comparative data provided in this report should be used to
supplement your hospital’s own efforts toward identifying areas of strength and areas on which
to focus patient safety culture improvement efforts.

Highlights


When examining differences in percent positive scores across hospitals, there was
considerable variability in the range of scores comparing the lowest and highestscoring hospitals.
 As an indicator of this variability in scores, the average difference between the
percent positive scores of the lowest and highest-scoring hospitals was 60
percent across the 12 patient safety composites, and 71 percent across the 42
survey items.



There was a wide range of response in patient safety grades, from at least one
hospital where none of the respondents (0 percent) provided their unit with a
patient safety grade of “A-Excellent,” to a hospital where 63 percent did.



There was also a wide range of response in the number of events reported, from
a hospital where 96 percent of respondents had not reported a single event over
the past 12 months, to a hospital where only 5 percent had not reported an event.

Description of Comparative Statistics
In addition to the average percent positive scores presented in the charts in the previous
chapter (Chapter 5), a number of additional statistics are provided in this report to facilitate
comparisons against the database hospitals. A description of each statistic shown in the
comparative results tables in this chapter is provided next.

Average Percent Positive and Standard Deviation
The average percent positive scores for each of the 12 patient safety culture composites and
for the survey’s 42 items (plus the two questions on patient safety grade and number of events
reported) are provided in the comparative results tables in this chapter (these statistics were also
displayed in the previous chapter in Charts 5-1 to 5-4). These average percent positive scores
were calculated by averaging composite-level percent positive scores across all hospitals in the
database, as well as averaging item-level percent positive scores across hospitals. Since the
percent positive is displayed as an overall average, scores from each hospital are weighted
equally in their contribution to the calculation of the average.4
In addition, the standard deviation (s.d.), a measure of the spread or variability of hospital
scores around the average, is also displayed. The standard deviation tells you the extent to which
hospitals’ scores differ from the average:


If scores from all hospitals were exactly the same, then the average would represent all
their scores perfectly and the standard deviation would be zero.



If scores from all hospitals were very close to the average, then the standard deviation
would be small, and close to zero.



If scores from many hospitals were very different from the average, then the standard
deviation would be a large number.

When the distribution of hospital scores follows a normal, bell-shaped curve (where most of
the scores fall in the middle of the distribution, with fewer scores at the lower and higher ends of
the distribution), the average, plus or minus the standard deviation, will include about 68 percent
of all hospital scores. For example, if an average percent positive score across the database
hospitals was 70 percent with a standard deviation of 10 percent (and scores were normally
distributed), then about 68 percent of all the database hospitals would have scores between 60
and 80 percent.
Statistically “significant” differences between scores. You may be interested in
determining the statistical significance of differences between your scores and the averages in
the database, or between scores in various breakout categories (differences in scores by hospital
bed size, teaching status, etc). Statistical significance is greatly influenced by samples size, so as
the number of observations in comparison groups gets larger, small differences in scores will end
up being statistically significant. While a 1 percent difference between percent positive scores
might be “statistically” significant (that is, not due to chance), the difference is not likely to be
meaningful or “practically” significant. Keep in mind that statistically significant differences are
not always important, and non-significant differences are not always trivial. Therefore, we
recommend the following guideline:


Use a 5 percent difference as a rule of thumb when comparing your hospital’s
results to the database averages. Your hospital’s percent positive score should be at
least 5 percent higher than the database average to be considered “better,” and should be

As noted in Chapter 5, an alternative method would be to report a straight percent of positive response across all respondents,
but this method would give greater weight to respondents from larger hospitals since they account for almost twice as many
responses as those from smaller hospitals.

at least 5 percent lower to be considered “lower” than the database average. A 5 percent
difference is likely to be statistically significant for most hospitals given the number of
responses per hospital, and is also a meaningful difference to consider.

Minimum and Maximum Scores
The minimum (lowest) and maximum (highest) percent positive scores are presented for each
composite and item. These scores provide information about the range of percent positive scores
obtained by hospitals in the database and are actual scores from the lowest and highest-scoring
hospitals. When comparing against the minimum and maximum scores, keep in mind that these
scores may represent hospitals that are extreme outliers (indicated by large differences between
the minimum and the 10th percentile score, or between the 90th percentile score and the
maximum).

Percentiles
The 10th, 25th, 50th (or median), 75th and 90th percentile scores are displayed for the survey
composites and items. Percentiles provide information about the distribution of hospital scores.
To calculate percentile scores, all hospital percent positive scores were ranked in order from low
to high. A specific percentile score shows the percent of hospitals that scored at or below a
particular score. For example, the 50th percentile, or median, is the percent positive score where
50 percent of the hospitals scored the same or lower, and 50 percent of the hospitals scored
higher. When the distribution of hospital scores follows a normal, bell-shaped curve (where most
of the scores fall in the middle of the distribution with fewer scores at the lower and higher ends
of the distribution), the 50th percentile, or median, will be very similar to the average score.
Interpret the percentile scores as shown in Table 6-1.
Table 6-1. Interpretation of Percentile Scores

Percentile Score
10 percentile

Interpretation

This score represents the lowest scoring
hospitals

25th percentile
This score represents lower-scoring hospitals

50th percentile (or median)
This score represents the middle of the
distribution of hospitals

75th percentile
This score represents higher-scoring hospitals

90th percentile
This score represents the highest scoring
hospitals

10% of the hospitals scored the same or lower
90% of the hospitals scored higher
25% of the hospitals scored the same or lower
75% of the hospitals scored higher
50% of the hospitals scored the same or lower
50% of the hospitals scored higher
75% of the hospitals scored the same or lower
25% of the hospitals scored higher
90% of the hospitals scored the same or lower
10% of the hospitals scored higher

To compare against the database percentiles, compare your hospital’s percent positive scores
against the percentile scores for each composite and item. Look for the highest percentile where
your hospital’s score is higher than that percentile.

For example: On survey item 1 in Table 6-2, the 75th percentile score is 49 percent positive,
and the 90th percentile score is 62 percent positive.
Table 6-2. Sample Percentile Statistics

Survey Item % Positive Response

Survey Item

Min

10th
%ile

Item 1

10%

25th
%ile

Median/
50th
%ile

75th
%ile

90th
%ile

Max

25%

35%

49%

62%

96%

If your hospital’s score is 55%, your score falls here:
If your hospital’s score is 65%, your score falls here:



If your hospital’s score is 55 percent positive, it falls above the 75th percentile (but below
the 90th), meaning that your hospital scored higher than at least 75 percent of the
hospitals in the database.



If your hospital’s score is 65 percent positive, it falls above the 90th percentile, meaning
your hospital scored higher than at least 90 percent of the hospitals in the database.

Composite and Item-level Comparative Tables
Table 6-3 presents comparative statistics (average percent positive and standard deviation,
minimum and maximum scores, and percentiles) for each of the 12 patient safety culture
composites. The patient safety culture composites are shown in order from the highest average
percent positive response to the lowest.
Table 6-4 presents comparative statistics for each of the 42 survey items. The survey items
are grouped by the patient safety culture composite they are intended to measure, and within
each composite the items are presented in the order in which they appear in the survey.
The comparative results in Tables 6-3 and 6-4 show considerable variability in the range of
hospital scores (lowest to highest) across the 12 patient safety culture composites. There was a
60 percent average difference between the percent positive scores of the lowest and highest
hospitals for the composites, and a 71 percent average difference for the items. The standard
deviation around the average percent positive scores ranged from 6.17 percent to 11.77 percent
on the composites, and ranged from 5.81 percent to 13.92 percent on the items.
Patient safety grades shown in Table 6-5 had a wide range of response, from at least one
hospital where none of the respondents (0 percent) provided their unit with a patient safety grade
of “A-Excellent,” to a hospital where 63 percent did.
Number of events reported also had a wide range of response as shown in Table 6-6, from a
hospital where 96 percent of respondents had not reported a single event over the past 12
months, to a hospital where only 5 percent had not reported an event.
44

Table 6-3. Composite-level Comparative Results for the 2009 Database
Composite % Positive Response

Patient Safety Culture Composites

#
Hospitals

Average
%
Positive

s.d.

Min

10th
%ile

25th
%ile

Median/
50th
%ile

75th
%ile

90th
%ile

Max

Teamwork Within Units

621

79%

6.17%

52%

72%

76%

80%

83%

87%

97%

Supervisor/Manager Expectations &
Actions Promoting Patient Safety

622

75%

6.74%

47%

66%

70%

75%

79%

83%

95%

Organizational Learning-Continuous
Improvement

621

71%

7.64%

39%

61%

66%

71%

76%

80%

94%

Management Support for Patient
Safety

620

70%

10.15%

37%

57%

64%

71%

78%

84%

97%

Overall Perceptions of Patient Safety

621

64%

9.36%

27%

52%

58%

64%

70%

77%

89%

Feedback & Communication About
Error

618

63%

8.63%

32%

52%

57%

62%

68%

74%

90%

Communication Openness

619

62%

6.94%

40%

54%

58%

61%

66%

70%

98%

Frequency of Events Reported

617

60%

7.97%

33%

50%

55%

60%

66%

71%

84%

Teamwork Across Units

621

57%

11.00%

14%

44%

49%

56%

65%

72%

91%

10.

Staffing

620

55%

10.28%

25%

42%

48%

54%

62%

69%

87%

11.

Handoffs & Transitions

622

44%

11.77%

19%

30%

36%

42%

51%

61%

93%

12.

Nonpunitive Response to Error

621

44%

8.68%

14%

34%

38%

43%

49%

55%

82%

Table 6-4. Item-level Comparative Results for the 2009 Database (Page 1 of 4)
Survey Item % Positive Response

Item

Survey Items By Composite

Teamwork Within Units

1. People support one another in this unit.

2. When a lot of work needs to be done
quickly, we work together as a team to get the
work done.
3. In this unit, people treat each other with
respect.

Average
%
Positive

s.d.

H = 621
N = 192,527

85%

H = 621
N = 192,455

# Hospitals &
# Respondents

Min

10th
%ile

25th
%ile

Median/
50th
%ile

75th
%ile

90th
%ile

Max

6.40%

45%

77%

82%

86%

89%

93%

100%

86%

5.81%

62%

79%

82%

86%

90%

93%

100%

78%

7.93%

31%

68%

73%

78%

83%

87%

100%

68%

8.42%

26%

58%

63%

68%

73%

79%

97%

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

H = 621
N = 192,280
H = 621
N = 189,110

Supervisor/Manager Expectations &
Actions Promoting Patient Safety
1. My supv/mgr says a good word when
he/she sees a job done according to
established patient safety procedures.

H = 622
N = 189,567

72%

8.21%

41%

61%

67%

72%

78%

81%

95%

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

H = 622
N = 189,149

76%

7.86%

41%

66%

71%

76%

82%

86%

100%

3. Whenever pressure builds up, my supv/mgr
B3R wants us to work faster, even if it means
taking shortcuts.

H = 622
N = 189,526

74%

8.55%

43%

64%

68%

74%

80%

85%

100%

H = 622
N = 187,842

77%

7.05%

52%

68%

72%

77%

81%

86%

100%

H = 621
N = 190,239

82%

7.77%

19%

73%

77%

82%

87%

91%

100%

A4
A11

2.
B1
B2

B4R
3.
A6

4. My supv/mgr overlooks patient safety
problems that happen over and over.
Organizational Learning— Continuous
Improvement
1. We are actively doing things to improve
patient safety.

2. Mistakes have led to positive changes here.

H = 622
N = 191,118

63%

8.58%

33%

53%

57%

63%

68%

74%

100%

A13

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

H = 622
N = 188,202

68%

9.76%

12%

56%

61%

68%

74%

79%

94%

Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).

Table 6-4. Item-level Comparative Results for the 2009 Database (Page 2 of 4)
Survey Item % Positive Response
Average
%
Positive

s.d.

Min

10th
%ile

25th
%ile

Median/
50th
%ile

75th
%ile

90th
%ile

Max

Survey Items By Composite

# Hospitals &
# Respondents

Management Support for Patient Safety
1. Hospital mgmt provides a work climate that
promotes patient safety.

H = 622
N = 188,278

80%

9.75%

30%

67%

73%

80%

87%

91%

100%

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

H = 620
N = 184,677

72%

10.49%

36%

58%

65%

72%

79%

85%

100%

F9R

3. Hospital mgmt seems interested in patient
safety only after an adverse event happens.

H = 622
N = 184,071

59%

12.01%

15%

45%

51%

59%

67%

76%

93%

H = 622
N = 190,591

60%

11.00%

18%

47%

53%

60%

68%

74%

85%

Item
4.
F1

Overall Perceptions of Patient Safety
1. It is just by chance that more serious
A10R
mistakes don’t happen around here.
A15

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

H = 621
N = 187,492

64%

10.63%

27%

51%

57%

63%

71%

78%

100%

A17R

3. We have patient safety problems in this
unit.

H = 622
N = 188,306

62%

11.67%

22%

48%

55%

62%

69%

77%

92%

A18

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

H = 622
N = 190,749

70%

9.00%

35%

59%

64%

70%

76%

81%

100%

Feedback and Communication About Error
1. We are given feedback about changes put
into place based on event reports.

H = 620
N = 181,755

53%

10.41%

18%

40%

47%

54%

60%

65%

90%

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

H = 620
N = 182,755

64%

9.64%

35%

53%

58%

63%

70%

77%

93%

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

H = 618
N = 183,922

70%

8.93%

33%

59%

65%

70%

76%

82%

100%

6.
C1

Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).

Table 6-4. Item-level Comparative Results for the 2009 Database (Page 3 of 4)
Survey Item % Positive Response

Item
7.
C2

Survey Items By Composite
Communication Openness
1. Staff will freely speak up if they see
something that may negatively affect patient
care.

Average
%
Positive

s.d.

H = 621
N = 185,743

76%

# Hospitals &
# Respondents

Min

10th
%ile

25th
%ile

Median/
50th
%ile

75th
%ile

90th
%ile

Max

6.80%

47%

68%

72%

75%

80%

84%

100%

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

H = 619
N = 186,331

47%

8.63%

26%

37%

42%

46%

52%

58%

94%

C6R

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

H = 619
N = 186,727

63%

8.43%

54%

57%

62%

67%

72%

100%

H = 621
N = 171,464

52%

9.45%

25%

40%

45%

52%

58%

64%

81%

8.
D1

Frequency of Events Reported
1. When a mistake is made, but is caught and
corrected before affecting the patient, how
often is this reported?

2. When a mistake is made, but has no
potential to harm the patient, how often is this
reported?

H = 617
N = 169,547

56%

9.10%

25%

45%

50%

56%

61%

68%

85%

3. When a mistake is made that could harm
the patient, but does not, how often is this
reported?

H = 621
N = 170,172

73%

7.70%

45%

63%

68%

73%

78%

83%

100%

Teamwork Across Units
1. Hospital units do not coordinate well with
each other.

H = 621
N = 182,580

45%

12.93%

29%

35%

43%

53%

61%

91%

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

H = 621
N = 181,274

58%

12.08%

11%

43%

49%

57%

67%

74%

93%

F6R

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

H = 621
N = 179,358

58%

10.54%

46%

51%

58%

65%

72%

100%

F10

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

H = 621
N = 180,279

67%

11.51%

21%

52%

58%

67%

76%

82%

95%

9.
F2R

Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).

Table 6-4. Item-level Comparative Results for the 2009 Database (Page 4 of 4)
Survey Item % Positive Response

Item
10.

Survey Items By Composite

# Hospitals &
# Respondents

Average
%
Positive

s.d.

Min

10th
%ile

25th
%ile

Median/
50th
%ile

75th
%ile

90th
%ile

Max

Staffing
1. We have enough staff to handle the
workload.

H = 620
N = 191,634

54%

13.92%

11%

37%

44%

53%

64%

73%

98%

A5R

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

H = 620
N = 185,900

52%

10.11%

40%

45%

51%

58%

65%

87%

A7R

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

H = 620
N = 181,833

65%

12.35%

50%

57%

65%

73%

78%

100%

A14R

4. We work in “crisis mode” trying to do too
much, too quickly.

H = 620
N = 187,157

49%

12.73%

34%

40%

47%

58%

67%

91%

Handoffs & Transitions
1. Things “fall between the cracks” when
transferring patients from one unit to another.

H = 622
N = 178,434

41%

13.77%

13%

25%

30%

38%

49%

60%

91%

F5R

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

H = 622
N = 176,811

49%

10.99%

19%

37%

41%

48%

55%

63%

91%

F7R

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

H = 622
N = 178,665

42%

12.15%

28%

33%

40%

48%

59%

100%

F11R

4. Shift changes are problematic for patients
in this hospital.

H = 622
N = 176,268

45%

13.27%

18%

29%

35%

44%

53%

63%

94%

Nonpunitive Response to Error
1. Staff feel like their mistakes are held
against them.

H = 621
N = 189,625

51%

9.58%

18%

40%

45%

50%

58%

63%

88%

A12R

2. When an event is reported, it feels like the
person is being written up, not the problem.

H = 621
N = 186,807

45%

9.37%

12%

35%

39%

44%

50%

57%

88%

A16R

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

H = 621
N = 187,203

35%

9.23%

12%

24%

29%

34%

41%

48%

71%

11.
F3R

12.
A8R

Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded “Strongly disagree”
or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).

Table 6-5. Average Distribution of Work Area/Unit Patient Safety Grades—2009 Database Comparative Results
Percent of Response
Work Area/Unit
Patient Safety Grade
A

Excellent

Very Good

Acceptable

Poor

Failing

# Hospitals &
# Respondents
H = 621
N = 42,850
H = 621
N = 83,619
H = 621
N = 43,854
H = 621
N = 8,769
H = 621
N = 1,631

Average
%

s.d.

Min

10th
%ile

25th
%ile

50th
%ile

75th
%ile

90th
%ile

Max

25%

9.10%

14%

18%

24%

30%

36%

63%

48%

7.91%

39%

43%

47%

52%

57%

80%

23%

8.31%

12%

17%

23%

28%

32%

57%

4.45%

62%

1.23%

18%

Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.

Table 6-6. Average Distribution of Number of Events Reported in the Past 12 Months—2009 Database Comparative Results
Percent of Response
Number of Events Reported
by Respondents
No events
1 to 2 events
3 to 5 events
6 to 10 events
11 to 20 events
21 event reports or more

# Hospitals &
# Respondents
H = 621
N = 97,624
H = 621
N = 48,996
H = 621
N = 21,330
H = 621
N = 7,321
H = 621
N = 2,744
H = 621
N = 1,807

Average
%

s.d.

Min

10th
%ile

25th
%ile

50th
%ile

75th
%ile

90th
%ile

Max

52%

10.99%

39%

46%

53%

59%

65%

96%

28%

6.67%

21%

24%

27%

31%

36%

63%

13%

5.19%

12%

15%

20%

41%

2.96%

27%

1.88%

17%

1.34%

15%

Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.

Appendixes A & B:
Overall Results by Hospital and Respondent Characteristics
In addition to the overall results on the database hospitals presented, Part II of the report
presents data tables in Appendixes A and B that show average percent positive scores on the
survey composites and items across database hospitals, broken down by the following hospital
and respondent characteristics:
Appendix A: Results by Hospital Characteristics
 Bed size
 Teaching status
 Ownership and control
 Geographic region
Appendix B: Results by Respondent Characteristics
 Work area/unit
 Staff position
 Interaction with patients
Because there are many breakout tables, they are included in Appendixes A and B.
Highlights of the findings from the breakout tables in these appendixes are provided on the
following pages.

Highlights from Appendix A:
Overall Results by Hospital Characteristics
Bed Size (Tables A-1, A-3, A-4)


Smaller hospitals (49 beds or fewer) had the highest average percent positive
response on all 12 patient safety culture composites.



The largest difference by bed size was on Handoffs & Transitions where the
smallest hospitals (6-24 beds) scored 22 percent higher than large hospitals (400499 beds) (55 percent compared to 33 percent positive).



Large hospitals (400-499 beds) scored lowest on the percent of respondents who
gave their work area/unit a patient safety grade of “Excellent” or “Very good” (64
percent for 400-499 beds compared to 78 percent for 25-49 beds).



There were no noticeable differences on number of events reported based on bed
size (all differences were 3 percent or less).

Teaching Status, and Ownership and Control (Tables A-5, A-7, A-8)


Non-teaching hospitals had the highest average percent positive response on
Handoffs & Transitions.



Government-owned hospitals were more positive than non-government on
Handoffs & Transitions (6 percent more positive), and Staffing (5 percent more
positive).



There were no noticeable differences on patient safety grade or number of events
reported based on teaching status or ownership and control (all differences were 3
percent or less).

Geographic Region (Tables A-9, A-11, A-12)


East South Central hospitals had the highest average percent positive response
across the 12 patient safety culture composites; Pacific hospitals had the lowest.



The largest difference by region was on Staffing and Handoffs & Transitions
where West North Central hospitals were 10 percent more positive than Mid
Atlantic/New England hospitals (for Staffing) and Pacific hospitals (for Handoffs
& Transitions).



West South Central hospitals scored highest on the percent of respondents who
gave their work area/unit a patient safety grade of “Excellent” or “Very good” (77
percent).



Pacific hospitals had the highest percent of respondents who reported one or more
events in the past year (53 percent); the lowest percent of respondents reporting
events was in the West South Central region (40 percent).

Highlights from Appendix B:
Overall Results by Respondent Characteristics
Work Area/Unit (Tables B-1, B-3, B-4)
 Respondents in Rehabilitation had the highest average percent positive response on 8 of
the 12 patient safety culture composites.


The largest difference by work area/unit was on Nonpunitive Response to Error (22
percent). On this composite, Rehabilitation was 59 percent positive and Emergency was
37 percent positive.



ICU (any type) had the highest percent of respondents reporting one or more events in
the past year (66 percent); Anesthesiology had the lowest percent of respondents
reporting events (43 percent).

Staff Position (Tables B-5, B-7, B-8)
 Respondents in Administration/Management had the highest average percent positive
response on 11 of the 12 patient safety culture composites.




Administration/Management had the highest percent of respondents who gave their
work area/unit a patient safety grade of “Excellent” or “Very good” (82 percent);
Registered Nurse/LVN/LPN had the lowest percent (66 percent).



Pharmacists had the highest percent of respondents reporting one or more events in the
past year (75 percent); Unit Assistants/Clerks/Secretaries had the lowest percent
reporting events (22 percent).

Interaction with Patients (Tables B-9, B-11, B-12)


Respondents with direct patient interaction were 7 percent more positive on Handoffs &
Transitions compared to those without direct patient interaction (45 percent compared to
38 percent positive).



Respondents without direct patient interaction had the highest percent of respondents
who gave their work area/unit a patient safety grade of “Excellent” or “Very good” (77
percent) compared to those with direct patient interaction (72 percent).



More respondents with direct patient interaction reported one or more events in the past
year (53 percent) than respondents without direct patient interaction (32 percent).

Chapter 7. Trending: Comparing Results Over Time
Many hospitals that have administered the hospital patient safety culture survey have
indicated that they intend to re-administer the survey on a regular basis to track changes in
patient safety culture over time. For the 2009 Comparative Database Report, some of the
hospitals that previously administered the survey and submitted data for the 2008 report also
submitted data for the 2009 report based on a follow-up survey of their staff. While the overall
benchmarks presented earlier in this report reflect only the most recent survey data from all 622
participating hospitals, we have data from two or more administrations of the survey for 204
hospitals, allowing us to examine trends over time for these hospitals. This chapter presents the
results from trend analyses comparing patient safety culture survey results for these 204 hospitals
since their previous administration. Changes in scores of 5 percent or greater are highlighted.

Highlights


For the 204 hospitals with trending data, the average length of time between
previous and most recent survey administrations was 16 months (range: 7 months
to 35 months).



The average change in percent positive scores between administrations on the
patient safety culture composites was a slight increase of 2 percent (ranging from 1
to 3 percent change).



37 percent of trending hospitals increased by 5 percent or more on Overall
Perceptions of Patient Safety (see Chart 7-1).



22 percent of hospitals decreased in percent positive scores by 5 percent or more
on Organizational Learning–Continuous Improvement (see Chart 7-1).



There were no noticeable differences on changes to the percent of respondents
who gave their work area/unit a patient safety grade of “A-Excellent” and “B-Very
Good” (average percent increased by 4 percent).



There were no noticeable differences on the number of events reported by
respondents in the last 12 months (the average percent of respondents reporting
one or more events increased by only 2 percent).


When reviewing the results in this chapter, it is important to keep in mind that the trending
results from these 204 hospitals represent approximately one-third of the total number of
database hospitals, and therefore the trending data should be viewed as preliminary. In addition,
there are a number of complex reasons why survey scores might change, or not change, over
time. Important factors to consider are whether the hospital implemented patient safety initiatives
between survey administrations and the length of the time period between administrations.
Survey methodology issues can also play a big role in score changes. Low survey response rates
for the previous or most recent administration, changes in the number of staff asked to complete
the survey, or changes in the types of staff asked to complete the survey, will make it difficult to

interpret changes in scores over time. We provide descriptive information about some of the
factors that may have affected changes in scores where possible.

Characteristics of the 204 Trending Hospitals
Table 7-1 displays summary statistics from the previous and most recent survey
administrations for the 204 trending hospitals. As shown in the table, the average number of
completed surveys increased in the most recent survey administration (from an average of 320 to
341 respondents). Overall average response rates were similar between previous and most recent
administrations. Additional characteristics of the 204 hospitals are below:


Most of the 204 trending hospitals (74 percent) administered the survey to the same types
of staff in their previous and most recent administrations.



The average change in response rate from the previous administration was 2 percent
(range: one hospital had a decrease in response rate by 90 percent and one had an
increase by 79 percent).



The average length of time between previous and most recent survey administrations was
16 months (range: 7 months to 35 months).

Table 7-1. Summary Statistics for Previous and Most Recent Data Submissions from
the 204 Trending Hospitals

Summary Statistic
Total number of hospitals

Previous
Most Recent
Survey Administration Survey Administration
Submitted for
Submitted for
2007 or 2008 database
2009 database
204
204

Total number of respondents

65,321

69,541

165

167

Number of completed surveys per
hospital

Average: 320
Range: 13 – 3,865

Average: 341
Range: 11 – 3,908

Hospital response rate

Average: 50%
Range: 6 – 100%

Average: 52%
Range: 7 – 100%

Number of hospitals (out of 204) that
administered the survey to all staff, or a
sample of all staff, from all departments

As shown in Table 7-2, the distribution of trending hospitals by bed size is similar to the
distribution of AHA-registered U.S. hospitals, as well as the distribution of database hospitals.
Similar to the AHA-registered U.S. hospitals, the largest group of trending hospitals (42
hospitals or 21 percent) fall in the bed size category of 25 to 49 beds. The majority of the
trending hospitals (132 hospitals or 65 percent) have fewer than 200 beds, which is similar to the
percentage of AHA-registered U.S. hospitals with fewer than 200 beds (74 percent). The
trending hospitals, however, disproportionately represent a larger percentage of large hospitals
(500 ore more beds), with more than twice the percentage of hospitals in comparison to the
AHA-registered U.S. hospitals (12 percent versus 5 percent).

Table 7-2. Distribution of 204 Trending Hospitals by Bed Size
2009 Trending
Hospitals
Number
Percent
21
10%
42
21%
37
18%
32
16%
22
11%
26
13%
24
12%
204
100%

Bed Size
6-24 beds
25-49 beds
50-99 beds
100-199 beds
200-299 beds
300-499 beds
500 or more beds
TOTAL

2009 Database
Hospitals
Number
Percent
60
10%
139
22%
111
18%
111
18%
74
12%
78
13%
49
8%
622
100%

AHA-registered
U.S. Hospitals
Number
Percent
607
10%
1,374
22%
1,329
21%
1,341
21%
704
11%
607
10%
318
5%
6,280
100%

Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.

Tables 7-3 and 7-4 show that most of the 204 trending hospitals were non-teaching (71
percent) and non-government owned and controlled (69 percent). Again, these distributions vary
when compared to the 2009 database overall (69 percent non-teaching and 22 percent
government-owned) and when compared to AHA hospitals (77 percent non-teaching and 26
percent government-owned). Therefore, the trending hospitals disproportionately represent a
larger percentage of non-teaching hospitals and a larger percentage of government-owned
hospitals.
Table 7-3. Distribution of 204 Trending Hospitals by Teaching Status

Teaching Status
Teaching
Non-teaching
TOTAL

2009 Trending
Hospitals
Number
Percent
59
29%
145
71%
204
100%

2009 Database
Hospitals
Number
Percent
190
31%
432
69%
622
100%

AHA-registered
U.S. Hospitals
Number
Percent
1,442
23%
4,838
77%
6,280
100%

Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.

Table 7-4. Distribution of 204 Trending Hospitals by Ownership and Control

Ownership and Control
Government (Federal or non-Federal)
Non-government (voluntary/nonprofit or
proprietary/investor-owned)
TOTAL

2009 Trending
Hospitals
Number Percent
63
31%

2009 Database
Hospitals
Number Percent
139
22%

AHA-registered
U.S. Hospitals
Number Percent
1,645
26%

141

69%

483

78%

4,635

74%

204

100%

622

100%

6,280

100%

Description of Trending Statistics
Before presenting results on the changes in survey scores over time, we provide an
explanation of the trending statistics that are presented. Table 7-5a shows examples of the
statistics shown in this chapter. The tables show the average percent of respondents who
answered positively in the most recent survey administration (left column) and the previous
administration (middle column) for the 204 trending hospitals only. The change over time [Most
Recent score minus (-) Previous score] is shown in the right column as a negative number if the
57

most recent administration showed a decline, or a positive number if the most recent
administration showed an increase.
Table 7-5a. Example of Trending Statistics
Survey Item

Most Recent

Change

Item 1

80%

84%

-4%

Item 2

80%

78%

Table 7-5b shows additional trending statistics that are provided. The maximum increase and
maximum decrease show the scores for the hospitals with the largest average percent positive
score increase and the hospitals with the largest decrease. The average increase and decrease of
percent positive scores across the 204 trending hospitals is also shown. The average increase was
calculated by only including hospitals that had an increase in their most recent score; hospitals
that showed no change or decreased were not included when calculating the average increase.
Similarly, the average decrease was calculated by only including hospitals that had a decrease in
their most recent score; hospitals that showed no change or increased were not included when
calculating the average decrease.
Table 7-5b. Example of Other Trending Statistics

Item 1

Maximum
Increase
18%

Maximum
Decrease
-45%

Average
Increase
3%

Average
Decrease
-5%

Item 2

21%

-19%

-6%

Survey Item

The pie charts in Charts 7-1, 7-2, and 7-3 show the percent of hospitals that increased or
decreased 5 percent or more on the composites, patient safety grades, and events reported
respectively. The percent of hospitals that increased or decreased less than 5 percent are
represented as “Did not change.”

Composite and Item-level Trending Results
Table 7-6 presents trending results showing average percent positive scores on each of the 12
patient safety culture composites from the 204 trending hospitals. Percent positive scores for
their most recent and previous data administration/submission are shown, as well as the
percentage of change over time, the hospital scores with the maximum increase and maximum
decrease, and the average increase and decrease over time across the 204 hospitals. Table 7-6
also shows that there was a slight overall increase in the average change in percent positive
scores over time on the patient safety culture composites (average 2 percent, ranging from 1 to 3
percent change). For hospitals with increases in scores over time, average increases ranged from
5 to 8 percent. For hospitals with decreases in scores, average decreases ranged from -4 to -6
percent.

The item-level trending results in Table 7-7 show that the average change in item-level
percent positive scores over time on the patient safety culture items ranged from a 1 percent
increase to a 4 percent increase. For hospitals with increases in item scores over time, average
increases ranged from 6 to 10 percent. For hospitals with decreases in item scores, average
decreases ranged from -4 to -9 percent.
Trending results from the item that asks respondents to give their hospital work area/unit an
overall grade on patient safety are shown in Table 7-8. The average percent of respondents
giving their work area/unit a patient safety grade of “A-Excellent” and “B-Very Good” increased
over time by 4 percent.
Trending results from the item that asked respondents to indicate the number of events they
had reported over the past 12 months are shown in Table 7-9. The average percent of
respondents reporting one or more events increased slightly over time by 2 percent.

Table 7-6. Trending: Composite-level Results
Composite Average % Positive Response

Patient Safety Culture Composites

Most
Recent

Change

Maximum
Increase

Maximum
Decrease

Average
Increase

Average
Decrease

Teamwork Within Units

79%

77%

64%

-14%

-4%

Supervisor/Manager Expectations &
Actions Promoting Patient Safety

75%

74%

39%

-19%

-5%

Organizational Learning-Continuous
Improvement

72%

69%

61%

-17%

-5%

Management Support for Patient Safety

71%

69%

52%

-24%

-6%

Overall Perceptions of Patient Safety

65%

62%

44%

-27%

-6%

Feedback & Communication About Error

63%

61%

48%

-22%

-5%

Communication Openness

62%

60%

38%

-23%

-5%

Frequency of Events Reported

61%

59%

37%

-28%

-6%

Teamwork Across Units

58%

56%

31%

-18%

-5%

10.

Staffing

55%

53%

31%

-18%

-6%

11.

Handoffs & Transitions

45%

44%

41%

-29%

-6%

12.

Nonpunitive Response to Error

45%

43%

25%

-15%

-5%

Note: Based on data from 204 hospitals that repeated survey administration and data submission; the number of respondents was 69,541 in the most recent database and
65,321 in the previous database.

Table 7-7. Trending: Item-level Results (Page 1 of 4)
Item Average % Positive Response
Item

Survey Items By Composite

Most
Recent

Change

Maximum
Increase

Maximum
Decrease

Average
Increase

Average
Decrease

Teamwork Within Units

1. People support one another in this unit.

85%

82%

75%

-18%

-4%

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

86%

84%

72%

-24%

-4%

3. In this unit, people treat each other with respect.

77%

75%

60%

-23%

-5%

69%

66%

48%

-19%

-5%

72%

69%

55%

-20%

10%

-5%

77%

74%

62%

-23%

-5%

75%

73%

51%

-20%

-5%

77%

74%

60%

-22%

-5%

A11
2.
B1
B2
B3R
B4R

4. When one area in this unit gets really busy, others help
out.
Supervisor/Manager Expectations & Actions Promoting
Patient Safety
1. My supv/mgr says a good word when he/she sees a job
done according to established patient safety procedures.
2. My supv/mgr seriously considers staff suggestions for
improving patient safety.
3. Whenever pressure builds up, my supv/mgr wants us to
work faster, even if it means taking shortcuts.
4. My supv/mgr overlooks patient safety problems that
happen over and over.

Organizational Learning— Continuous Improvement

1. We are actively doing things to improve patient safety.

82%

80%

81%

-25%

-5%

2. Mistakes have led to positive changes here.

64%

61%

62%

-22%

-6%

A13

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

69%

66%

60%

-25%

-6%

Note: Based on data from 204 hospitals that repeated survey administration and data submission. The overall number of respondents was 69,541 in the most recent database and 65,321 in
the previous database, but the exact number of respondents will vary from item to item. The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the
percent positive response is based on those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).

Table 7-7. Trending: Item-level Results (Page 2 of 4)
Item Average % Positive Response
Item
4.
F1
F8
F9R

Survey Items By Composite

Most
Recent

Change

Maximum
Increase

Maximum
Decrease

Average
Increase

Average
Decrease

80%

78%

62%

-32%

-7%

73%

70%

65%

-18%

-6%

60%

58%

36%

-27%

-7%

Management Support for Patient Safety
1. Hospital mgmt provides a work climate that promotes
patient safety.
2. The actions of hospital mgmt show that patient safety is a
top priority.
3. Hospital mgmt seems interested in patient safety only after
an adverse event happens.

Overall Perceptions of Patient Safety

A10R

1. It is just by chance that more serious mistakes don’t
happen around here.

60%

59%

33%

-43%

-8%

A15

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

65%

63%

42%

-19%

-6%

62%

61%

41%

-46%

-9%

71%

67%

63%

-21%

-6%

A17R 3. We have patient safety problems in this unit.
A18

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

Feedback and Communication About Error

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

53%

52%

47%

-32%

-7%

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

65%

63%

47%

-26%

-6%

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

70%

69%

53%

-26%

-6%

Table 7-7. Trending: Item-level Results (Page 3 of 4)
Item Average % Positive Response
Item
7.
C2
C4
C6R
8.
D1
D2
D3

Survey Items By Composite

1. Staff will freely speak up if they see something that may
negatively affect patient care.
2. Staff feel free to question the decisions or actions of those
with more authority.
3. Staff are afraid to ask questions when something does not
seem right.

1. When a mistake is made, but is caught and corrected
before affecting the patient, how often is this reported?
2. When a mistake is made, but has no potential to harm the
patient, how often is this reported?
3. When a mistake is made that could harm the patient, but
does not, how often is this reported?

F2R

1. Hospital units do not coordinate well with each other.

F10

Change

Maximum
Increase

Maximum
Decrease

Average
Increase

Average
Decrease

75%

74%

60%

-23%

-5%

47%

46%

27%

-28%

-6%

62%

61%

39%

-28%

-6%

54%

51%

37%

-34%

-7%

57%

55%

36%

-21%

-6%

74%

72%

43%

-29%

-5%

46%

44%

45%

-46%

-7%

59%

57%

36%

-25%

-6%

58%

56%

33%

-26%

-6%

68%

66%

47%

-22%

-6%

Frequency of Events Reported

Teamwork Across Units

F6R

Communication Openness

Most
Recent

2. There is good cooperation among hospital units that need
to work together.
3. It is often unpleasant to work with staff from other hospital
units.
4. Hospital units work well together to provide the best care
for patients.

Table 7-7. Trending: Item-level Results (Page 4 of 4)
Item Average % Positive Response
Item

Survey Items By Composite

10.

Staffing

1. We have enough staff to handle the workload.

2. Staff in this unit work longer hours than is best for patient
care.
3. We use more agency/temporary staff than is best for
A7R
patient care.
4. We work in “crisis mode” trying to do too much, too
A14R
quickly.
A5R

11.
F3R
F5R
F7R

Handoffs & Transitions
1. Things “fall between the cracks” when transferring patients
from one unit to another.
2. Important patient care information is often lost during shift
changes.
3. Problems often occur in the exchange of information
across hospital units.

F11R 4. Shift changes are problematic for patients in this hospital.
12.

Nonpunitive Response to Error

A8R

1. Staff feel like their mistakes are held against them.

2. When an event is reported, it feels like the person is being
written up, not the problem.
3. Staff worry that mistakes they make are kept in their
A16R
personnel file.
A12R

Most
Recent

Change

Maximum
Increase

Maximum
Decrease

Average
Increase

Average
Decrease

54%

53%

33%

-30%

-8%

52%

51%

32%

-31%

-7%

65%

62%

64%

-37%

10%

-7%

50%

48%

34%

-42%

-6%

42%

41%

45%

-38%

-6%

50%

48%

37%

-28%

-7%

43%

42%

54%

-35%

-7%

46%

45%

29%

-31%

-8%

52%

50%

34%

-20%

-5%

46%

43%

33%

-25%

-6%

36%

34%

28%

-24%

-5%

Table 7-8. Trending: Average Distribution of Work Area/Unit Patient Safety Grades
Average Percent of Respondents within Hospitals
Work Area/Unit
Patient Safety Grade

Most
Recent

Change

Maximum
Increase

Maximum
Decrease

Average
Increase

Average
Decrease

Excellent

25%

22%

25%

-27%

-5%

Very Good

47%

46%

74%

-42%

-6%

Acceptable

23%

24%

-1%

16%

-30%

-7%

Poor

-1%

44%

-51%

-5%

Failing

18%

-20%

-2%

Table 7-9. Trending: Average Distribution of Number of Events Reported in the Past 12 Months
Average Percent of Respondents within Hospitals
Number of Events
Reported by
Respondents

Most
Recent

Change

Maximum
Increase

Maximum
Decrease

Average
Increase

Average
Decrease

No events

52%

54%

-2%

24%

-45%

-9%

1 to 2 events

28%

26%

28%

-25%

-5%

3 to 5 events

13%

12%

32%

-19%

-4%

6 to 10 events

-1%

12%

-13%

-2%

11 to 20 events

17%

-8%

-1%

21 event reports or more

-6%

-1%

Pie Charts of Trending Results
The pie charts in Charts 7-1 show the percentages of hospitals that increased, decreased, or
did not change by 5 percent or more on the 12 patient safety culture composites. These charts
show that:
 The composite with the largest percentage of hospitals that increased 5 percent or
more was Overall Perceptions of Patient Safety (37 percent of trending hospitals
increased by at least 5 percent).
 The composite with the largest percentage of hospitals that decreased 5 percent or
more was Organizational Learning-Continuous Improvement (22 percent of trending
hospitals decreased by at least 5 percent).
Chart 7-2 displays results for the percent of hospitals that increased, decreased, or did not
change by 5 percent or more on the percent of respondents providing patient safety grades of “AExcellent” or “B-Very Good” and shows that:
 38 percent of hospitals increased by 5 percent or more;
 41 percent of hospitals had changes of less than 5 percent; and
 21 percent of hospitals decreased by 5 percent or more.
Chart 7-3 displays results for the percent of hospitals that increased, decreased, or did not
change by 5 percent or more on the percent of respondents reporting one or more events and
shows that:
 32 percent of hospitals increased by 5 percent or more;
 46 percent of hospitals had changes of less than 5 percent; and
 23 percent of hospitals decreased by 5 percent or more.

Chart 7-1. Trending: Percentage of Hospitals that Increased, Decreased, or Did Not Change by 5 Percent at Composite Level (Page 1 of 2)

1. Teamwork Within Units
12%

2. Supervisor/Manager Expectations
& Actions Promoting Patient Safety
14%

28%

3. Organizational LearningContinuous Improvement
22%
31%

26%

60%
61%

4. Management Support for
Patient Safety
14%

5. Overall Perceptions of
Patient Safety

47%

6. Feedback & Communication
About Error

14%
28%

31%

18%

37%

48%

55%

54%

Percentage of Hospitals that:
Increased 5% or more

Decreased 5% or more

Did Not Change (<5%)

Note: Based on 204 hospitals that repeated survey administration and data submission.

Chart 7-1. Trending: Percentage of Hospitals that Increased, Decreased, or Did Not Change by 5 Percent at Composite Level (Page 2 of 2)
7. Communication Openness
20%

8. Frequency of Events Reported
21%

9. Teamwork Across Units
19%
33%

27%

32%

54%

10. Staffing

48%

11. Handoffs & Transitions

30%

17%
19%

47%

12. Nonpunitive Response to
Error
14%

30%
32%
54%
53%

51%

Percentage of Hospitals that:
Increased 5% or more

Decreased 5% or more

Did Not Change (<5%)

Note: Based on 204 hospitals that repeated survey administration and data submission.

Chart 7-2. Trending: Percentage of Hospitals that Increased, Decreased, or
Did Not Change by 5 Percent on Work Area/Unit Patient Safety Grade
Patient Safety Grade
21%

38%
41%

Percentage of Hospitals that:
Increased 5% or more

Decreased 5% or more

Did Not Change (<5%)

Note: When determining change over time, percentages for patient safety grades
“Excellent” and “Very Good” were combined.

Chart 7-3. Trending: Percentage of Hospitals that Increased, Decreased, or
Did Not Change by 5 Percent on Number of Events Reported
Number of Events Reported
23%

32%

46%

Percentage of Hospitals that:
Increased 5% or more

Decreased 5% or more

Did Not Change (<5%)

Note: When determining change over time, percentages of respondents who
reported 1 or more events over the past 12 months were combined.

Additional Trending Analyses
The following sections present quantitative and qualitative data on changes in patient safety
culture over time. The quantitative data includes questionnaire data on actions taken by the
trending hospitals to improve their patient safety culture, as well as correlational analyses of the
actions taken with changes to Hospital Survey on Patient Safety Culture (HSOPS) scores. The
qualitative data consists of findings from nine interviews conducted with trending hospital staff
and suggest explanations for increases and decreases hospitals’ HSOPS scores.

Actions Taken by the Trending Hospitals
One hundred and sixty-five of the 204 trending hospitals (that administered the patient safety
culture survey and submitted data more than once) provided basic information about the types of
patient safety actions they had taken in between their previous and most recent survey
administrations.
Most of the trending hospitals (153 hospitals or 93 percent) reported that they had shared their
previous survey results with hospital administrators. In addition, 76 percent (125 hospitals)
reported they had also shared their previous survey results with hospital staff, but fewer had
shared the results with their Board of Directors (100 hospitals or 61 percent) or with physicians
(100 hospitals or 61 percent). Table 7-10 shows the percentages of trending hospitals that
reported they had implemented various types of actions. The action most frequently taken was
implementing SBAR (95 hospitals or 58 percent). About 10 percent (17 hospitals) indicated they
had developed action plans but had not implemented them yet.
Most of the trending hospitals (151 hospitals or 92 percent) indicated they had implemented
more than one action. Hospitals described the types of “other” actions implemented, such as:
Patient Safety Champion/Representative programs; color-coded wristbands; hand hygiene
programs; electronic medical record; medication error reduction strategies; and many other
actions. Given that the average length of time between survey administrations was 16 months, it
appears that the trending hospitals were able to begin implementation of these activities within a
relatively short period of time after their previous survey administration.

Table 7-10. Types of Patient Safety Actions Taken by the 2009 Trending Hospitals
2009 Trending
Hospitals*
Number Percent

Type of Action Taken
Implemented SBAR Communication
(Situation-Background-Assessment-Recommendation)
Made changes to policies/procedures

58%

56%

Implemented patient safety walkarounds

51%

Conducted training
Improved compliance with Joint Commission National Patient
Safety Goals

49%

39%

Conducted chart audits

38%

Improved fall prevention program

38%

Other action taken

36%

Conducted root cause analysis

35%

Improved error reporting system

33%

Purchased new hospital equipment

32%

Held education/patient safety fair for staff

29%

Formed a committee

25%

Conducted follow-up interviews/focus groups

18%

15%

12%

Developed action plans but have not implemented them yet

10%

Implemented patient safety briefing(s)

10%

Implemented TeamSTEPPS

Implemented patient safety bulletin board/ suggestion
box/hotline
Implemented “Ticket to Ride” communication tool to reduce
handoff risk

*Only 165 of the 204 trending hospitals provided information about patient safety actions they had taken.

Correlational Analyses
To explore potential reasons why some hospitals had increases in their patient safety culture
scores over time, we examined the relationship between hospital characteristics-- such as bed
size, ownership, and teaching status--and changes in patient safety culture scores over time.
Relationships were examined by calculating correlations between hospital characteristics and the
number of composites increasing by 5 percent or more per hospital. In addition, hospital
characteristics were correlated with the percent change in respondents giving their hospital a
patient safety grade of ‘Excellent’ or ‘Very Good’ and the percent change in respondents
reporting one or more events. Correlations (r) are a type of statistic that convey the extent to
which two variables have a linear relationship. Correlations range from a low of 0 to a high of
1.00 and can be either positive or negative. The closer the correlation is to 1.00 (or -1.00), the
greater the degree of association between the variables. A correlation is considered statistically
significant or not due to chance when the p-value is less than .05 (p <.05).
72

The following relationships were found between hospital characteristics and changes in
patient safety culture scores. These findings should be considered preliminary, as they are based
on a relatively small sample of 204 trending hospitals.


The smaller the hospital bed size, the greater the number of patient safety culture
composites that increased by at least 5 percent (correlation: r = -.21, p < .05) and the
greater the increase in respondents reporting one or more events (r = -.19, p < .05).



Non-teaching hospitals tended to increase by 5 percent or more on the composites than
teaching hospitals (r = .15, p < .05) and tended to have greater increases in respondents
reporting one or more events than teaching hospitals (r = .17, p < .05).



Government hospitals tended to have greater increases in respondents giving their
hospital a patient safety grade of ‘Excellent’ or ‘Very Good’ (r = .17, p < .05), and
respondents reporting one or more events (r = .20, p < .05) than non-government
hospitals.

We also examined whether hospitals that improved on Nonpunitive Response to Error also
had increases in the number of respondents who reported at least one event in the past 12
months. This finding was supported; hospitals that increased their percent positive score on
Nonpunitive Response to Error also tended to have an increase in the number of respondents
who reported at least one event in the past 12 months (correlation: r = .14, p < .05).

Interview Findings
To gain a better understanding of changes in patient safety culture and patient care practices
over time, HSOPS project team members conducted hour-long telephone interviews with staff
from nine hospitals that administered the HSOPS more than once. Six of the hospitals
experienced notable increases in their scores, and three hospitals experienced notable decreases.
Most interview participants were quality/risk managers, and one was a chief executive officer.
The nine hospitals varied with respect to system affiliation, bed size, teaching status, ownership,
and geographic region.
Explanations for notable increases in HSOPS scores. During the interviews, participants
were asked why their hospitals’ HSOPS scores increased. Some participants mentioned specific
actions including implementing the SBAR communication tool for unit-to-unit transfers, hiring a
consultant group to work with department directors on targeted patient safety problems,
addressing staffing requirements such as filling nursing vacancies and improving patient/staff
ratios, and using and displaying scorecards to monitor progress on hospital initiatives. Generally,
various themes emerged from their responses. These themes are shared here, along with
participants’ comments about actions taken by their hospitals to improve patient safety culture
and safe patient care practices. Four main themes emerged from those hospitals with notable
increases in their HSOPS scores.

Theme 1: Hospitals improved their communication between management and staff on
patient safety.

Sample Actions and Illustrative Quotes






Conducted walkarounds to learn about staff concerns about patient safety
Focused on patient safety during staff meetings
 One participant attributed her hospital’s improvement to “the engagement of our
department heads and nursing coordinators in making sure patient safety culture is
on everyone’s mind.”
Started conducting monthly staff meetings
Implemented Open Book Management and participated in biweekly “huddles” to review
the hospital budget, financial statements, and discuss patient safety issues and concerns
 “Open Book Management has had the biggest impact of all their initiatives…affected
everything we do…employees are much more aware.”

Theme 2: Hospitals focused on improving error reporting systems, responding
appropriately to reports, and applying nonpunitive “Just Culture” principles.
Sample Actions and Illustrative Quotes







Educated hospital leaders on making error reporting anonymous, easy, and convenient
 “When we went from a paper system to an electronic system, our reporting increased
about 40 percent – part of it was education, because we had to do a lot of education
as we rolled out the electronic system – part of it…is because it’s very easy.”
Set up a hotline for reporting errors and developed anonymous reporting forms for
medical errors
 “We got management to buy into that it was okay for a staff person to not provide
their name, so they wouldn’t be afraid to report.”
Trained staff to use the new reporting systems
Provided training on “Just Culture” and taught managers to use an algorithm when
examining patient safety error incidents
 “The algorithm helps management more than anything else.”

Theme 3: Hospitals engaged staff in developing solutions to patient safety problems.
Sample Actions and Illustrative Quotes







Directly involved staff in designing solutions to handoff problems
Started an employee engagement committee that includes senior leaders
Instituted nursing peer review to promote open communication
 “I personally think it is a combination of the employee engagement committee where
employees have a voice. I think it’s the peer review…having peers to go to, to voice
your concerns.”
Assigned staff to a scheduling team to accommodate staff preferences
Allocated resources for safety needs identified by staff—for example, buying safer beds

Theme 4: Hospitals developed, implemented, and monitored action plans, in some cases
focusing on specific survey items.
74

Sample Action


Charged department managers with developing and implementing an annual action plan
and held them accountable

Explanations for notable decreases in HSOPS scores. Hospital participants provided the
following explanations as possible reasons for decreases in their HSOPS scores in their most
recent administration of the survey.









Experienced issues among staff with specific managers and management styles,
especially regarding managers’ response to incident reports and lack of follow up on staff
feedback
 “They felt like the managers really didn’t act on them [incident reports] or hear them
or do anything about them…”
Had contracting issues and high turnover for managers and frontline staff – staff have had
to get used to new unit managers; some new managers were not familiar with hospital
policies on “Just Culture”
Needed to temporarily shut down hospital services because contract and financial
constraints led to a large shortage of professional providers
 “The staffing issue came up as part of contract problems. We’re in a fairly isolated
area, and we have a vacancy rate in the professional provider staff of about 40%.
During this time frame we also changed financial management systems. We’re not
able to hire contractors with the speed that we had in the past. We ended up running
very short and ended up closing beds and shutting services down for about an 18month period.”
Drilled down in the survey data and observed that scores were lower for larger than
smaller units – attributed the lower scores to less frequent and personal communications,
weaker sense of accountability to coworkers
Were in the middle of union negotiations and staff were feeling hostile
Struggled with organizational learning - how much information can be fed back to staff
given confidentiality requirements and concerns?
 “As we run into significant adverse events for patients, how much do we feed the
information back to frontline staff? Where’s that line of keeping it confidential yet
sharing our learnings with staff?”

Appendixes C & D:
Trending Results by Hospital and Respondent
Characteristics
Part III of the report contains Appendixes C and D that show trends over time for the 204
hospitals that administered the survey and submitted data more than once. Average percent
positive scores from the most recent and previous administrations are shown on the survey
composites and items, broken down by the following hospital and respondent characteristics:
Appendix C: Trending Results by Hospital Characteristics
 Bed size
 Teaching status
 Ownership and control
Appendix D: Trending Results by Respondent Characteristics
 Work area/unit
 Staff position
 Interaction with patients
Because there are many breakout tables, they are included in Appendixes C and D.
Highlights of the findings from the breakout tables in these appendixes are provided on the
following pages.
Note: Because there were fewer than 20 trending hospitals in several hospital region breakout
categories, trending results are not shown by hospital region to ensure hospital confidentiality.

Highlights from Appendix C:
Trending Results by Hospital Characteristics
Bed Size (Tables C-1, C-3, C-4)
 Hospitals with 100-299 beds had the largest increases in percent positive response
over time on 10 of the 12 patient safety culture composites (average increase across
the 10 composites was 5 percent).
 Hospitals with 200-299 beds had the greatest average change across the 12 patient
safety culture composites (average 5 percent change).
 The largest increase over time was for medium-large hospitals (200-299 beds) on
Teamwork Within Units and Organizational Learning—Continuous Improvement,
both increasing 8 percent from the previous administration.
 The largest decrease over time was for large hospitals (500 or more beds) on the
Overall Perceptions of Patient Safety, decreasing 6 percent from the previous
administration.
 Small hospitals (6-24 beds) had the highest increase in percent of respondents who
gave their work area/unit a patient safety grade of “Excellent” or “Very good” (a 7
percent increase, from 71 percent in the previous administration to 78 percent in
the most recent administration).
 Small hospitals (6-24 beds) also had the highest increase in percent of respondents
reporting one or more events in the past year (a 6 percent increase, from 41 percent
to 47 percent).
Teaching Status, and Ownership and Control (Tables C-5, C-7, C-8)
 There were no noticeable differences or changes across the patient safety culture
composites for teaching versus non-teaching hospitals or government-owned
versus non-government hospitals (all changes and differences were 4 percent or
less).
 Non-teaching hospitals had a greater increase than teaching hospitals in the
percent of respondents who gave their work area/unit a patient safety grade of
“Excellent” or “Very good” (a 5 percent increase, from 69 percent to 74 percent).
 Government-owned hospitals had a greater increase than non-government
hospitals in the percent of respondents who gave their work area/unit a patient
safety grade of “Excellent” or “Very good” (a 6 percent increase, from 69 percent
to 75 percent).
 There were no noticeable differences or changes on the percent of respondents
who reported one or more events in the past year based on teaching status.
 Government-owned hospitals had a greater increase than non-government
hospitals in the percent of respondents who reported one or more events in the
past year (a 5 percent increase, from 42 percent to 47 percent).

Highlights from Appendix D:
Trending Results by Respondent Characteristics
Work Area/Unit (Tables D-1, D-3, D-4)
 Respondents in Psych/Mental Health had the greatest average change in percent
positive response across the 12 patient safety culture composites, with an average
change of 5 percent.
 Respondents in Obstetrics had the largest increases in positive response over time on 5
of the 12 patient safety culture composites (average increase across the 5 composites
was 6 percent).
 Respondents in Anesthesiology had the largest decreases in positive response over time
on 4 of the 12 patient safety culture composites (average decrease across the 4
composites was 5 percent).
 Medicine had the largest average percent of respondents who increased over time in
giving their work area/unit a patient safety grade of “Excellent” or “Very good” (an 8
percent increase from 56 to 64 percent), followed by ICU (7 percent increase), Surgery
(6 percent increase), and Lab (5 percent increase).
 Lab had the largest average percent of respondents who increased over time in their
reporting of one or more events in the past year (a 7 percent increase: from 48 to 55
percent) followed by Anesthesiology, Radiology, and Rehabilitation (all increasing by 5
percent); the largest decrease in percent reporting was in Obstetrics (a 6 percent
decrease from 58 to 52 percent).
Staff Position (Tables D-5, D-7, D-8)
 Pharmacists had the largest increases in positive response over time on 4 of the 12
patient safety culture composites (average increase across the 4 composites was 6
percent).
 Admin/Mgmt, RN/LVN/LPN, and Technicians had the largest average percent of
respondents who increased over time in giving their work area/unit a patient safety
grade of “Excellent” or “Very good” (5 percent increases).
 There were no noticeable differences in the percent of respondents reporting one or
more events over time based on staff position (all changes over time were less than +/5 percent).
Interaction with Patients (Tables D-9, D-11, D-12)
 There were no noticeable composite differences over time based on respondent
interaction with patients (all were increases over time of 4 percent or less).
 There were no noticeable differences in the percent of respondents giving their work
unit/area a patient safety grade of “Excellent” or “Very good” or those reporting one or
more events over time based on respondent direct patient interaction.

Chapter 8. What’s Next? Action Planning for
Improvement
After the initial release of the Hospital Survey on Patient Safety Culture in November of
2004, AHRQ held a series of national conference calls to provide technical assistance and
guidance to hospitals interested in administering the survey. The seven steps of action planning
outlined in this chapter are primarily based on the third conference call presentation by an
organizational psychologist (Church, 2005; available on the AHRQ web site at
(www.ahrq.gov/qual/hospculture), and based on the book “Designing and Using Organizational
Surveys: A Seven-Step Process” (Church & Waclawski, 1998).

Highlights


The delivery of survey results is not the end point in the survey process, it is just the
beginning.



It is often the case that the perceived failure of surveys to create lasting change is
actually due to faulty or nonexistent action planning or survey follow-up.



Seven steps of action planning are provided to give hospitals guidance on next steps
to take to turn their survey results into actual patient safety culture improvement.

Seven Steps of Action Planning
While administering the Hospital Survey on Patient Safety Culture can be considered an
“intervention”—a means of educating hospital staff and building awareness about issues of
concern related to patient safety—this should not be the only goal of conducting the survey.
Administering the survey is not enough. Keep in mind that the delivery of survey results is not
the end point in the survey process, it is actually just the beginning. It is often the case that the
perceived failure of surveys as a means for creating lasting change is actually due to faulty or
nonexistent action planning or survey follow-up. Seven steps of action planning are provided to
help your hospital go beyond simply conducting a survey to realizing patient safety culture
change.

Step # 1: Understand Your Survey Results
It is important to review the survey results and interpret them before you develop action
plans. Develop an understanding of your hospital’s key strengths and areas for improvement.
Examine your hospital’s overall percent positive scores on the patient safety culture composites
and items:



Which areas were most and least positive?
How do your hospital’s results compare to the results from the database hospitals?

Next, consider examining your survey data broken down by work area/unit or staff position.





Are there different areas for improvement for different hospital units?
Are there different areas for improvement for different hospital staff?
Do any patterns emerge?
How do your hospital’s results for these breakouts compare to the results from the
database hospitals?

Finally, if your hospital administered the survey more than once, compare your most recent
results to your previous results to examine change over time.




Did your hospital have an increase in its scores on any of the survey composites or items?
Did your hospital have a decrease in its scores?
When you consider the types of patient safety actions that your hospital implemented
between each survey administration, do you notice improvements in those areas?

After reviewing the survey results carefully, identify two to three areas for improvement at
the hospital level. While your hospital may want to improve in almost all areas, it is better to
avoid focusing on too many issues at one time.

Step # 2: Communicate and Discuss the Survey Results
Common complaints among survey respondents are that they never get any feedback about
survey results and have no idea whether anything ever happens as a result of a survey. It is
therefore important to thank your staff for taking the time to complete the survey and let them
know that you value their input. Sharing results from the survey throughout the hospital shows
your commitment to the survey and improvement process.
Use survey feedback as an impetus for change. Feedback can be provided at the hospital
level and/or at the department or unit level. However, to ensure respondent anonymity/
confidentiality, it is important to only report data if there are enough respondents in a particular
category or group. One common rule-of-thumb recommends not reporting data if there are fewer
than 10 respondents in a category. For example, if there are only 4 respondents from a
department, that department’s data should not be reported separately because there are too few
respondents to provide complete assurance of anonymity/confidentiality.
Summaries of the survey results should be distributed throughout the hospital in a top-down
manner beginning with senior management, administrators, medical and senior leaders, and
committees, followed by department or unit managers and then staff. Managers at all levels
should be expected to carefully review the findings. Summarize key findings, but also encourage
discussion about the results throughout the hospital. What do others see in the data and how do
they interpret the results?
In some cases, it may not be completely clear why an area of patient safety culture was
particularly low. Keep in mind that surveys are only one way of examining culture, so strive for
a deeper understanding when needed, by conducting follow-up activities such as focus groups or
interviews with staff to find out more about an issue, why it is problematic, and how it can be
improved.
82

Step # 3: Develop Focused Action Plans
Once areas for patient safety culture improvement have been identified, formal, written
action plans need to be developed to ensure progress toward change. Hospital-wide and
department- or unit-based action plans can be developed. Major goals can be established as
hospital-wide action plans. Unit-specific goals can be fostered by encouraging and empowering
staff to develop action plans at the unit level.
Encourage action plans that are “SMART”:
 Specific
 Measurable
 Achievable
 Relevant
 Time-bound
Identify funding or other resources needed to implement action plans. It is also important to
identify quantitative and qualitative measures that can be used to evaluate progress and the
impact of changes implemented.

Step # 4: Communicate Action Plans and Deliverables
Once action plans have been developed, the plans, deliverables and expected outcomes of the
plans need to be communicated. Those directly involved or affected will need to know their
roles, responsibilities, and the time frame for implementation. Action plans and goals should also
be shared widely so that their transparency encourages further accountability and demonstrates
the hospital-wide commitments being made in response to the survey results.
At this step it is important for senior hospital managers and leaders to understand that they
are the primary owners of the change process and that success depends on their full commitment
and support. Senior-level commitment to taking action must be strong; without buy-in from the
top, including medical leadership, improvement efforts are likely to fail.

Step # 5: Implement Action Plans
Implementing action plans is one of the hardest steps. Taking action requires the provision of
necessary resources and support. It requires tracking quantitative and qualitative measures of
progress and success that have already been identified. It requires publicly recognizing those
individuals and units that take action to drive improvement. And it requires adjustments along
the way.
This step is critical to realizing patient safety culture improvement. While communicating the
survey results is important, taking action makes the real difference. However, as the Institute for
Healthcare Improvement (IHI, 2006) suggests, actions do not have to be major, permanent
changes that are enacted. In fact, it is worthwhile to strive to implement easier, smaller changes
that are likely to have a positive impact rather than big changes with unknown probability of
success.
83

The “Plan-Do-Study-Act” cycle (Langley et al, 1996) is a pilot-study approach to change that
involves first developing a small-scale plan to test a proposed change (Plan), carrying out the
plan (Do), observing and learning from the consequences (Study), and determining what
modifications should be made to the plan (Act). Implementation of action plans can occur on a
small scale, within a single unit, to examine impact and refine plans before rolling out the
changes on a larger scale to other units or hospitals.

Step # 6: Track Progress and Evaluate Impact
Use quantitative and qualitative measures to review progress and evaluate whether a specific
change actually leads to improvement. Ensure that there is timely communication of progress
toward action plans on a regular basis. If you determine that a change has worked, communicate
that success to staff by telling them what was changed, and that it was done in response to the
safety culture survey results. Be sure to make the connection to the survey so that the next time
the survey is administered, staff will know that it will be worthwhile to participate again because
actions were taken based on the prior survey’s results. Alternatively, your evaluation may
discover that a change is not working as expected or has failed to reach its goals and will need to
be modified or replaced by another approach. Before dropping the effort completely, try to
determine why it failed and whether adjustments might be worth trying.
Keep in mind that it is important not to reassess culture too frequently because lasting culture
change will be slow and may take years. Frequent assessments of culture are likely to find
temporary shifts or improvements that may come back down to baseline levels in the longer term
if changes are not sustained. When planning to reassess culture, it is also very important to obtain
high survey response rates. Otherwise, it will not be clear whether changes in survey results over
time are due to true changes in attitudes, or due to the fact that you may be surveying different
staff each time.

Step # 7: Share What Works
In step six, you tracked measures to be able to identify which changes result in improvement.
Once your hospital has found effective ways to address a particular area, the changes can be
implemented on a broader scale to other departments within the hospital and to other hospitals.
Be sure to share your successes with outside hospitals and healthcare systems as well.

References
1. American Hospital Association (AHA) Annual Survey of Hospitals (2006) Database. Health
Forum, LLC, an affiliate of the American Hospital Association, © 2007.
2. Church, A.H. The Importance of Taking Action, Not Just Sharing Survey Feedback.
Powerpoint presentation for the Third Technical Assistance Conference Call: Hospital Survey on
Patient Safety Culture (http://www.ahrq.gov/qual/hospculture), April 2005.
3. Church, A.H. and Waclawski, J. Designing and Using Organizational Surveys: A Seven-Step
Process. San Francisco: Jossey-Bass, 1998.
4. Hospital Survey on Patient Safety Culture. Rockville, MD: Agency for Healthcare Research
and Quality (http://www.ahrq.gov/qual/hospculture), 2004.
5. Institute for Healthcare Improvement (IHI). Improvement Methods: The Plan-Do-Study-Act
(PDSA) cycle.
(http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove), 2006.
6. Langley, C., Nolan, K., Nolan, T., Norman, C., and Provost, L. The Improvement Guide: A
Practical Approach to Improving Organizational Performance. San Francisco: Jossey-Bass,
1996.

Notes: Description of Data Cleaning and Calculations
This notes section provides additional detail regarding how various statistics presented in this
report were calculated.

Data Cleaning
Each participating hospital was asked to submit cleaned, individual-level survey data.
However, as an additional check, once the data were submitted, response frequencies were run
on each hospital’s data to look for out-of-range values, missing variables, or other data
anomalies. In instances where data problems were found, hospitals were contacted, asked to
make corrections and resubmit their data. In addition, each participating hospital was sent a copy
of their data frequencies as an additional way for the hospitals to verify that the dataset received
was correct.

Response Rates
As part of the data submission process, hospitals were asked to provide their response rate
numerator and denominator. Response rates were calculated using the formula below.
Response Rate =

Number of complete, returned surveys
Number of surveys distributed – Ineligibles

Numerator = Number of complete, returned surveys. The numerator equals the number of
individual survey records submitted to the database. It should exclude surveys that were
returned blank on all non-demographic survey items, but include surveys where at least one
non-demographic survey item was answered.
Denominator = The total number of surveys distributed minus ineligibles. Ineligibles
include deceased individuals or those who were not employed at the hospital during data
collection.
As a data cleaning step, we examined whether any individual survey records submitted to the
database were missing responses on all of the non-demographic survey items (indicating the
respondent did not answer any of the main survey questions). Records where all nondemographic survey items were left blank by the respondent were found (even though these
blank records should not have been submitted to the database). We therefore removed these
blank records from the larger dataset and adjusted any affected hospital’s response rate
numerator and overall response rate accordingly.

Item and Composite Percent Positive Scores
To calculate your hospital’s composite score, simply average the percent of positive response
on each item that is in the composite. Here is an example of computing a composite score for
Overall Perceptions of Patient Safety:
1. There are four items in this composite—two are positively worded (items # A15 and
# A18) and two are negatively worded (items # A10 and # A17). Keep in mind that
DISAGREEING with a negatively worded item indicates a POSITIVE response.
87

2. Calculate the percent of positive response at the item level (see example in Table 1).
Table 1. Example of Computing Item and Composite Percent Positive Scores
For positively
worded items,
count the # of
“Strongly agree” or
“Agree” responses

For negatively worded
items, count the # of
“Strongly disagree” or
“Disagree” responses

Total # of
responses
to the item

Percent
positive
response on
item

“Patient safety is never
sacrificed to get more work
done”
Item A18-positively worded

120

NA*

260

120/260=46%

“Our procedures and systems
are good at preventing errors
from happening”
Item A10-negatively worded

130

NA*

250

130/250=52%

“It is just by chance that more
serious mistakes don’t
happen around here”
Item A17-negatively worded

NA*

110

240

110/240=46%

“We have patient safety
problems in this unit”

NA*

140

250

140/250= 56%

Four items measuring
"Overall Perceptions of
Patient Safety"

Item A15-positively worded

* NA = Not applicable

Composite Score % Positive = (46% + 52% + 46% + 56%) / 4 = 50%

In this example, there were 4 items with percent positive response scores of 46 percent, 52
percent, 46 percent, and 56 percent. Averaging these item-level percent positive scores results in
a composite score of .50 or 50 percent on Overall Perceptions of Patient Safety. In this example,
an average of about 50 percent of the respondents responded positively on the survey items in
this composite.
Once you have calculated your hospital’s percent positive response on each of the 12 safety
culture composites, you can compare your results with the composite-level results from the 622
database hospitals.
Note that the method described above for calculating composite scores is slightly different
than the method described in the September 2004 Survey User’s Guide that is part of the original
survey toolkit materials on the AHRQ web site. The Guide advises computing composites by
calculating the overall percent positive across all the items within a composite. The updated
recommendation included in this report is to compute item percent positive scores first, and then
average the item percent positive scores to obtain the composite score, which gives equal weight
to each item in a composite. The Survey User’s Guide will eventually be updated to reflect this
slight change in methodology.

Percentiles
Percentiles were computed using the SAS® Software default method. The first step in this
procedure is to rank order the percent positive scores from all the participating hospitals, from
88

lowest to highest. The next step is to multiply the number of hospitals (n) by the percentile of
interest (p), which in our case would be the 10th, 25th, 50th, 75th or 90th percentile.
For example, to calculate the 10th percentile, one would multiply 622 (the total number of
hospitals) by .10 (10th percentile). The product of n x p is equal to “j+g” where “j” is the integer
and “g” is the number after the decimal. If “g” equals 0, the percentile is equal to the percent
positive value of the hospital in the jth position plus the percent positive value of the hospital in
the jth +1 position, all divided by two [(X(j) + X(j+1))/2]. If “g” is not equal to 0, the percentile is
equal to the percent positive value of the hospital in the jth +1 position.
The following examples show how the 10th and 50th percentiles would be computed using a
sample of percent positive scores from 12 hospitals (using fake data shown in Table 2). First, the
percent positive scores are sorted from low to high on Composite “A.”
Table 2. Data Table for Example of How to Compute Percentiles

Hospital
1
2
3
4
5
6
7
8
9
10
11
12

Composite “A”
% Positive Score
33%
48%
52%
60%
63%
64%
66%
70%
72%
75%
75%
78%

10 percentile score = 48%

50 percentile score = 65%

10th percentile
1. For the 10th percentile, we would first multiply the number of hospitals by .10 (n x p =
12 x .10 = 1.2).
2. The product of n x p = 1.2, where “j” = 1 and “g” = 2. Since “g” is not equal to 0, the 10th
percentile score is equal to the percent positive value of the hospital in the jth +1 position:
a. “j” equals 1
b. The 10th percentile equals the value for the hospital in the 2nd position = 48%
50th percentile
1. For the 50th percentile, we would first multiply the number of hospitals by .50 (n x p =
12 x .50 = 6.0).
2. The product of n x p = 6.0, where “j” = 6 and “g” = 0. Since “g” = 0, the 50th percentile
score is equal to the percent positive value of the hospital in the jth position plus the percent
positive value of the hospital in the jth +1 position, all divided by two:
a. “j” equals 6
b. The 50th percentile equals the average of the hospitals in the 6th and 7th position
(64%+66%)/2 = 65%

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