Attachment A -- 2012 User Comparative Database Report, Part 1

Attachment A -- 2012 User Comparative Database Report, Part 1.pdf

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Attachment A -- 2012 User Comparative Database Report, Part 1

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Agency for Healthcare Research and Quality
Advancing Excellence in Health Care www.ahrq.gov

PATIENT
SAFETY

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:
2012 User Comparative Database Report

Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
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
Scott Alan Smith, Ph.D.

AHRQ Publication No. 12-0017
February 2012

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, et al. Hospital Survey on Patient Safety Culture 2012 user
comparative database report. (Prepared by Westat, Rockville, MD, under Contract No. HHSA
290200710024C). Rockville, MD: Agency for Healthcare Research and Quality; February 2012.
AHRQ Publication No. 12-0017.
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
Executive Summary .........................................................................................................................1
Survey Content...........................................................................................................................1
2012 Database Hospitals ............................................................................................................2
Survey Administration Statistics................................................................................................2
Characteristics of Participating Hospitals ..................................................................................2
Characteristics of Respondents ..................................................................................................2
Areas of Strength for Most Hospitals ........................................................................................3
Areas With Potential for Improvement for Most Hospitals .......................................................3
Results by Hospital Characteristics ...........................................................................................4
Results by Respondent Characteristics ......................................................................................4
Trending: Comparing Results Over Time..................................................................................5
Trending Results by Hospital Characteristics ............................................................................6
Trending Results by Respondent Characteristics ......................................................................6
Action Planning for Improvement .............................................................................................7
Purpose and Use of This Report ......................................................................................................8
Chapter 1. Introduction ....................................................................................................................9
Survey Content...........................................................................................................................9
2012 User Comparative Database and Report .........................................................................10
Chapter 2. Survey Administration Statistics ..................................................................................12
Chapter 3. Characteristics of Participating Hospitals ....................................................................15
Bed Size ...................................................................................................................................15
Teaching Status ........................................................................................................................16
Ownership and Control ............................................................................................................16
Geographic Region ..................................................................................................................17
Chapter 4. Characteristics of Respondents ....................................................................................18
Work Area/Unit .......................................................................................................................18
Staff Position............................................................................................................................19
Interaction With Patients..........................................................................................................20
Chapter 5. Overall Results .............................................................................................................21
Chapter 6. Comparing Your Results ..............................................................................................30
Description of Comparative Statistics .....................................................................................30
Composite and Item-Level Comparative Tables .....................................................................33
Appendixes A and B: Overall Results by Hospital and Respondent Characteristics ..............40
Chapter 7. Trending: Comparing Results Over Time ....................................................................43
Description of Trending Statistics ...........................................................................................44
Composite and Item-Level Trending Results ..........................................................................45
Bar Charts of Trending Results................................................................................................52
Appendixes C and D: Trending Results by Hospital and Respondent Characteristics............56
Chapter 8. What’s Next? Action Planning for Improvement ........................................................59
Seven Steps of Action Planning ...............................................................................................59
References ......................................................................................................................................64
Notes: Description of Data Cleaning and Calculations .................................................................65
Data Cleaning...........................................................................................................................65
Response Rates ........................................................................................................................65
Calculation of Percent Positive Scores ....................................................................................66
Item and Composite Percent Positive Scores...........................................................................67
Minimum Number of Responses .............................................................................................68
Percentiles ................................................................................................................................68
iii

List of Tables
Table 1-1. Patient Safety Culture Composites and Definitions ........................................................ 9
Table 2-1a. Overall Statistics for the 2012 Database Participating Hospitals ................................ 13
Table 2-1b. Statistics for Nontrending and Trending Hospitals in 2012 Database ........................ 13
Table 2-2. Summary Statistics for 2012 Database Participating Hospitals .................................... 13
Table 2-3. Survey Administration Statistics ................................................................................... 13
Table 2-4. Average Hospital Response Rate by Mode ................................................................... 14
Table 2-5. Types of Staff or Work Areas/Units Surveyed .............................................................. 14
Table 3-1. Distribution of Database Hospitals and Respondents by Bed Size Compared
With AHA-Registered Hospitals .............................................................................................. 16
Table 3-2. Distribution of Database Hospitals and Respondents by Teaching Status
Compared With AHA-Registered Hospitals ............................................................................. 16
Table 3-3. Distribution of Database Hospitals and Respondents by Ownership and
Control Compared With AHA-Registered Hospitals ............................................................... 17
Table 3-4. Distribution of Database Hospitals and Respondents by Geographic Region
Compared With AHA-Registered Hospitals ............................................................................. 17
Table 4-1. Distribution of Database Respondents by Work Area/Unit .......................................... 19
Table 4-2. Distribution of Database Respondents by Staff Position .............................................. 20
Table 4-3. Distribution of Database Respondents by Interaction With Patients ............................ 20
Table 6-1. Interpretation of Percentile Scores ................................................................................ 32
Table 6-2. Sample Percentile Statistics ........................................................................................... 33
Table 6-3. Composite-Level Comparative Results for the 2012 Database ..................................... 34
Table 6-4. Item-Level Comparative Results for the 2012 Database ...................................................
Table 6-5. Average Distribution of Work Area/Unit Patient Safety Grades—2012
Database Comparative Results ................................................................................................. 39
Table 6-6. Average Distribution of Number of Events Reported in the Past 12 Months—
2012 Database Comparative Results ........................................................................................ 39
Table 7-1. Summary Statistics for Most Recent and Previous Data Submissions From the
650 Trending Hospitals ............................................................................................................. 44
Table 7-2a. Example of Trending Statistics .................................................................................... 44
Table 7-2b. Example of Other Trending Statistics ......................................................................... 45
Table 7-3. Trending: Composite-Level Results .............................................................................. 46
Table 7-4. Trending: Item-Level Results ........................................................................................ 47
Table 7-5. Trending: Distribution of Work Area/Unit Patient Safety Grades ................................ 51
Table 7-6. Trending: Distribution of Number of Events Reported in the Past 12 Months ............. 51
Notes
Table 1. Example of Computing Item and Composite Percent Positive Scores
Table 2. Data Table for Example of How To Compute Percentiles

List of Charts
Chart 5-1. Composite-Level Average Percent Positive Response—Across All 2012
Database Hospitals .................................................................................................................... 24
Chart 5-2. Item-Level Average Percent Positive Response—Across All 2012 Database
Hospitals ................................................................................................................................... 25
Chart 5-3. Average Percentage of Respondents Giving Their Work Area/Unit a Patient
Safety Grade—Across All 2012 Database Hospitals................................................................ 29
Chart 5-4. Average Percentage of Respondents Reporting Events in the Past 12 Months—
Across All 2012 Database Hospitals......................................................................................... 29
Chart 7-1. Trending: Percentage of Hospitals That Increased, Decreased, or Did Not
Change on Each Composite ...................................................................................................... 53
Chart 7-2. Trending: Percentage of Hospitals That Increased, Decreased, or Did Not
Change on Work Area/Unit Patient Safety Grade .................................................................... 54
Chart 7-3. Trending: Percentage of Hospitals That Increased, Decreased, or Did Not
Change on Number of Events Reported ................................................................................... 54
Chart 7-4. Trending: Distribution of Hospitals by Number of Composites That Increased,
Decreased, or Did Not Change by 5 Percentage Points or More .............................................. 55
Chart 8-1. Plan-Do-Study Cycle

Appendixes cited in this report are provided electronically at:
www.ahrq.gov/qual/hospsurvey12/.

Executive Summary
In response to requests from hospitals interested in comparing their results with those of 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. Since the first annual user comparative database report, which was released in 2007
and included data from 382 U.S. hospitals, the number of hospitals and respondents included in
the database has grown each year.
The 2012 user comparative database report displays results from 1,128 hospitals and 567,703
hospital staff respondents. This report also includes a chapter on trending that presents results
showing change over time for 650 hospitals that administered the survey and submitted data
more than once.
Hospitals do not necessarily administer the hospital patient safety culture survey every year.
They may administer it on an 18-month, 24-month, or other cycle. Therefore, the comparative
database is a “rolling” indicator. It retains data for up to 3.5 prior years when a hospital does not
have new data to submit, replaces older data with more recent data when available, and adds data
from hospitals submitting for the first time.
This user comparative database report was developed as a tool for the following purposes:
Comparison—To allow hospitals to compare their patient safety culture survey results
with those of 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.

Survey Content
The hospital survey, released in November 2004, was designed to assess hospital staff opinions
about patient safety issues, medical errors, and event reporting. The survey includes 42 items that
measure 12 areas, or composites, of patient safety culture:
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 reported over the
past 12 months.

2012 Database Hospitals
The 1,128 hospitals in the 2012 database fall into two categories:
508 hospitals from the previous database report that are still included in the 2012 report.
620 hospitals that submitted data for the 2012 report.

Survey Administration Statistics
The average hospital response rate was 53 percent, with an average of 503 completed
surveys per hospital.
Most hospitals (66 percent) administered Web surveys. Hospitals administering a Web
survey had, on average, lower response rates (51 percent) compared with response rates
from paper (61 percent), yet higher response rates compared with mixed-mode surveys
(49 percent).
Most hospitals (90 percent) administered the survey to all staff or a sample of all staff.

Characteristics of Participating Hospitals
Database hospitals represent a range of bed sizes and geographic regions.
Most database hospitals are nonteaching (66 percent) and non-government owned (80
percent).
Overall, the characteristics of the 1,128 database hospitals are fairly consistent with the
distribution of U.S. hospitals registered with the American Hospital Association (AHA).

Characteristics of Respondents
There were 567,703 hospital staff respondents from 1,128 hospitals.
The top three work areas of respondents were:
o Other (30 percent).i
o Medicine (12 percent).
o Surgery (10 percent).

Many respondents chose “Other,” which allowed them to note their specific work area or unit. However, this
information was not collected from the hospitals.

The top three staff positions of respondents were:
o Registered nurse or licensed vocational nurse/licensed practical nurse (35 percent).
o Other (21 percent).ii
o Technician (e.g., EKG, Lab, Radiology) (11 percent).
Most respondents (76 percent) indicated that they had direct interaction with patients.

Areas of Strength for Most Hospitals
Four areas of strength emerged. Percent positive is the percentage of positive responses (e.g.,
Agree, Strongly agree) to positively worded items (e.g., “People support one another in this
unit”) or negative responses (e.g., Disagree, Strongly disagree) to negatively worded items (e.g.,
“We have safety problems in this unit”). The four areas with the highest percent positive
responses were:
1. Teamwork Within Units (average 80 percent positive response)—the extent to which
staff support each other, treat each other with respect, and work together as a team.
2. Supervisor/Manager Expectations and Actions Promoting Patient Safety (average 75
percent positive response)—the extent to which supervisors/managers consider staff
suggestions for improving patient safety, praise staff for following patient safety
procedures, and do not overlook patient safety problems.
3. Organizational Learning—Continuous Improvement (average 72 percent positive
response)—the extent to which mistakes have led to positive changes and changes are
evaluated for effectiveness.
4. Management Support for Patient Safety (average 72 percent positive response)—the
extent to which hospital management provides a work climate that promotes patient
safety and shows that patient safety is a top priority.

Areas With Potential for Improvement for Most Hospitals
Three areas showed potential for improvement:
1. Nonpunitive Response to Error (average 44 percent positive response)—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.
2. Handoffs and Transitions (average 45 percent positive response)—the extent to which
important patient care information is transferred across hospital units and during shift
changes.
3. Staffing (average 56 percent positive response)—the extent to which there are enough
staff to handle the workload and work hours are appropriate to provide the best care for
patients.

Many respondents chose “Other,” which allowed them to specify their position. However, this information was not
collected from the hospitals.

Results by Hospital Characteristics
Bed Size
The smallest hospitals (6-24 beds) had the highest percent positive average across all
patient safety culture composites (68 percent); larger hospitals (400 beds or more) had the
lowest (60 percent).
Smaller hospitals (49 beds or less) had the highest percentage of respondents who gave
their work area/unit a patient safety grade of “Excellent” or “Very Good” (80 percent);
larger hospitals (400 beds or more) had the lowest (71 percent).
Teaching Status and Ownership and Control
Nonteaching hospitals on average scored higher than teaching hospitals by 5 percentage
points on Teamwork Across Units (60 percent positive compared with 55 percent
positive) and Handoffs and Transitions (47 percent positive compared with 42 percent).
Non-government-owned hospitals reported more events (47 percent) than governmentowned hospitals (41 percent).
Geographic Region
East South Central,iii West South Central, and South Atlantic/Associated Territories
hospitals had the highest average percent positive response across all composites (65
percent positive); New England hospitals had the lowest (60 percent positive).
West North Central hospitals had the highest percentage of respondents who gave their
work area/unit a patient safety grade of “Excellent” or “Very Good” (78 percent); New
England hospitals had the lowest (69 percent).
Pacific/Associated Territories hospitals had the highest percentage of respondents who
reported one or more events in the past year (49 percent); the lowest percentage of
respondents reporting events was in the West South Central region (41 percent).

Results by Respondent Characteristics
Work Area/Unit
Respondents in Rehabilitation had the highest average percent positive response across
the composites (69 percent positive); Emergency had the lowest (57 percent positive).

iii

States and territories are categorized into AHA-defined regions as follows:
New England: CT, MA, ME, NH, RI, VT
West North Central: IA, KS, MN, MO, ND, NE,
SD
Mid-Atlantic: NJ, NY, PA
West South Central: AR, LA, OK, TX
South Atlantic/Associated Territories: DC,
DE, FL, GA, MD, NC, SC, VA, WV, Puerto
Mountain: AZ, CO, ID, MT, NM, NV, UT, WY
Rico, Virgin Islands
Pacific/Associated Territories: AK, CA, HI, OR,
East North Central: IL, IN, MI, OH, WI
WA, American Samoa, Guam, Marshall Islands,
Northern Mariana Islands
East South Central: AL, KY, MS, TN

Rehabilitation had the highest percentage of respondents who gave their work area/unit a
patient safety grade of “Excellent” or “Very Good” (85 percent); Emergency had the
lowest (64 percent).
ICU (Any Type) had the highest percentage of respondents reporting one or more events
in the past year (64 percent); Rehabilitation had the lowest (39 percent).
Staff Position
Respondents in Administration/Management had the highest average percent positive
response across the composites (74 percent positive); Pharmacists had the lowest (60
percent positive).
Administration/Management had the highest percentage of respondents who gave their
work area/unit a patient safety grade of “Excellent” or “Very Good” (86 percent);
Pharmacists had the lowest (68 percent).
Pharmacists had the highest percentage of respondents reporting one or more events in
the past year (71 percent); Unit Assistants/Clerks/Secretaries had the lowest (17 percent).
Interaction With Patients
Respondents with direct patient interaction were more positive on Handoffs and
Transitions compared with those without direct patient interaction (47 percent positive
compared with 39 percent).
Respondents without direct patient interaction were more positive than those with direct
patient interaction on Management Support for Patient Safety (77 percent positive
compared with 71 percent).
Respondents without direct patient interaction had a higher percentage of respondents
who gave their work area/unit a patient safety grade of “Excellent” or “Very Good” (80
percent) than respondents with direct patient interaction (75 percent).
More respondents with direct patient interaction reported one or more events in the past
year (50 percent) than respondents without direct patient interaction (30 percent).

Trending: Comparing Results Over Time
Results regarding changes over time on the patient safety culture composites, patient safety
grade, and number of events reported for the 650 hospitals (of the 1,128 total database hospitals)
that administered the survey and submitted data more than once are highlighted.
Trending Hospitals
For the 650 hospitals with trending data, the average length of time between previous and
most recent survey administrations was 20 months (range: 6 months to 66 months).
The distribution of the 650 trending hospitals by bed size, teaching status, and ownership
and control is similar to the distribution of the 1,128 database hospitals.
Trending: Overall Summary Statistics
The average percent positive scores on the patient safety culture composites increased by
1 percentage point (ranging from 0 to 2 percentage points).

The average percentage of respondents who gave their work area/unit a patient safety
grade of “A-Excellent” or “B-Very Good” increased by 1 percentage point.
The average number of respondents reporting one or more events decreased by 1
percentage point.
Additional Trending Statistics
The charts in Chapter 7 provide results for two additional ways of summarizing changes in
patient safety composite scores over time. The first series of charts displays the number of
hospitals that increased, decreased, or did not change by 5 percentage points or more for each
composite, patient safety grade, and number of events reported. The second set of charts displays
the distribution of trending hospitals by number of composites that increased, decreased, or
changed less than 5 percentage points.

Trending Results by Hospital Characteristics
Trending: Bed Size
Hospitals with 50-99 beds had the greatest increases in percent positive response over
time on all 12 composites (an average increase of 2 percentage points).
Hospitals with 50-99 beds had the greatest increase in the percentage of respondents who
gave their work area/unit a patient safety grade of “Excellent” or “Very Good” (a 3
percentage point increase, from 75 percent to 78 percent).
Trending: Teaching Status and Ownership and Control
Nonteaching hospitals showed increases up to 2 percentage points on all 12 patient safety
composites; teaching hospitals showed increases up to 1 percentage point on half of the
composites and decreases of 1 percentage point on Supervisor/Manager Expectations.
Government-owned hospitals showed increases up to 2 percentage points across 11
composites; non-government-owned hospitals showed increases up to 2 percentage points
on 9 composites.
Trending: Region
West North Central hospitals had the greatest increases in percent positive response over
time on 6 of the 12 composites (average increase of 2 percentage points).
West North Central hospitals had the greatest increase in the percentage of respondents
who gave their work area/unit a patient safety grade of “Excellent” or “Very Good” (a 3
percentage point increase, from 75 percent to 78 percent).

Trending Results by Respondent Characteristics
Trending: Work Area/Unit
Rehabilitation had the greatest increase in percent positive response on all 12 patient
safety culture composites (average increases of 3 percentage points).
Emergency, Radiology, and Rehabilitation had the greatest increases over time in the
average percentage of respondents giving their work area/unit a patient safety grade of

“Excellent” or “Very Good” (3 percentage point increases, from 62 percent to 65 percent,
79 percent to 82 percent, and 82 percent to 85 percent, respectively).
Anesthesiology and Lab had the greatest increases in the average percentage of
respondents reporting one or more events in the past year (3 percentage point increases).
The largest decrease was in Psychiatry/Mental Health (a 4 percentage point decrease).
Trending: Staff Position
Patient Care Asst./Aide/Care Partner had the greatest increase in positive response over
time on 4 of the 12 patient safety composites (average increase of 2 percentage points).
Pharmacists had the greatest increase over time in the average percentage of respondents
giving their work area/unit a patient safety grade of “Excellent” or “Very Good” (a 3
percentage point increase).
Dietitians had the greatest decrease over time in the average percentage of respondents
reporting one or more events in the past year (an 11 percentage point decrease).
Trending: Interaction With Patients
Respondents with direct interaction with patients showed an increase of 1 percentage
point across 11 patient safety culture composites; respondents without direct interaction
showed an increase of 1 percentage point across 10 composites.

Action Planning for Improvement
The delivery of survey results is not the end point in the survey process; it is just the beginning.
Often, the perceived failure of surveys to create lasting change is actually due to faulty or
nonexistent action planning or survey followup.
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.
2.
3.
4.
5.
6.
7.

Understand your survey results.
Communicate and discuss the survey results.
Develop focused action plans.
Communicate action plans and deliverables.
Implement action plans.
Track progress and evaluate impact.
Share what works.

Purpose and Use of This Report
In response to requests from hospitals interested in comparing their results with those of 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. Since the first annual comparative database report, which was released in 2007 and
included data from 382 U.S. hospitals, the number of hospitals and respondents contributing to
the database report has grown each year.
The Hospital Survey on Patient Safety Culture 2012 User Comparative Database Report consists
of data from 1,128 hospitals and 567,703 hospital staff respondents who completed the survey.
The 1,128 hospitals in the 2012 report fall into two categories:
508 hospitals from the previous database report that are still included in the 2012 report.
620 hospitals that submitted data for the 2012 report.
Hospitals do not necessarily administer the hospital patient safety culture survey every year.
They may administer it on an 18-month, 24-month, or other cycle. Therefore, the comparative
database is a “rolling” indicator. It retains data for up to 3.5 prior years when a hospital does not
have new data to submit, replaces older data with more recent data when available, and adds data
from hospitals submitting for the first time.
This user comparative database report was developed as a tool for the following purposes:
Comparison—To allow hospitals to compare their patient safety culture survey results
with those of 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.
The report presents statistics (averages, standard deviations, minimum and maximum scores, and
percentiles) on the patient safety culture composites and items from the survey. This 2012 report
also includes a trending chapter that describes patient safety culture change over time for 650
hospitals with data from two administrations of the survey.
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). Appendixes C and D show trend results for
the 650 trending hospitals, broken down by hospital characteristics (bed size, teaching status,
ownership and control, and geographic region) in Appendix C and respondent characteristics
(hospital work area/unit, staff position, interaction with patients) in Appendix D.

Chapter 1. Introduction
Patient safety is a critical component of health care quality. As health care organizations
continually strive to improve, there is 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.

Survey Content
Recognizing the need for a measurement tool to assess the culture of patient safety in health care
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.
The Agency for Healthcare Research and Quality (AHRQ) funded and supervised development
of the Hospital Survey on Patient Safety Culture. Developers reviewed research pertaining to
safety, patient safety, error and accidents, and error reporting. They also examined 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 Hospital Survey on Patient Safety Culture, released by AHRQ in November 2004, was
designed to assess hospital staff opinions about patient safety issues, medical errors, and event
reporting. The survey 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
Definition: The extent to which…

Patient Safety Culture Composite
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

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)
Definition: The extent to which…

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

Mistakes have led 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 each other, 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 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 at the AHRQ Web site
(www.ahrq.gov/qual/patientsafetyculture/) and include the survey, survey items and dimensions,
user’s guide, feedback report template, information about the Microsoft Excel™ Data Entry and
Analysis Tool, and the Hospital Patient Safety Improvement Resource List. 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.

2012 User Comparative Database and Report
Since its release, the hospital survey has been widely implemented across the United States.
Hospitals administering the survey have expressed interest in comparing their results with those
of other hospitals as an additional source of information to help them identify areas of strength
and areas for improvement. In response to these requests, AHRQ funded the Hospital Survey on
Patient Safety Culture comparative database to enable hospitals to compare their survey results
with those of 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/hospsurveydb/y2dbsubmission.htm).

Data Limitations
The survey results presented in this report represent the largest compilation of hospital survey
data currently available and therefore provide a useful reference for comparison. However,
several limitations to these data 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 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 surveys, 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 whether and how different modes affect the results.
In addition, some hospitals conducted a census, surveying all hospital staff, while others
administered the survey to a sample of staff. When 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, the data hospitals submitted 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). In addition, some logic checks were made. Otherwise, data are presented as
submitted. No additional attempts were made to verify or audit the accuracy of the data
submitted.

Chapter 2. Survey Administration Statistics
This chapter presents descriptive information regarding how the 2012 database hospitals
conducted their survey administration.

Highlights
The 2012 database consists of data from 567,703 hospital staff respondents across
1,128 participating hospitals.
The average hospital response rate was 53 percent, with an average of 503
completed surveys per hospital.
Most hospitals (66 percent) administered Web surveys, which resulted in lower
response rates (51 percent) compared with response rates from paper (61 percent)
but higher response rates compared with mixed-mode surveys (49 percent).
Most hospitals (90 percent) administered the survey to all staff or a sample of all
staff from all hospital departments.

The 2012 database consists of survey data from 1,128 hospitals with a total of 567,703 hospital
staff respondents. Participating hospitals administered the hospital survey to their staff between
January 2008 and June 2011 and voluntarily submitted their data for inclusion in the database.
Hospitals do not necessarily administer the hospital patient safety culture survey every year.
They may administer it on an 18-month, 24-month, or other cycle. Therefore, the comparative
database is a “rolling” indicator. Data from prior years are retained in the database when a
hospital does not have new data to submit; older data are replaced with more recent data when
available; and data are added from hospitals submitting for the first time.
In order to keep the database current, data more than 3.5 years old are removed. Thus, 129
hospitals that administered the survey prior to January 1, 2008, were dropped from the 2012
database.
Overall statistics for the hospitals included in the 2012 database are shown in Table 2-1a
according to when the data were submitted. The 2012 database includes 508 hospitals carried
over from the 2011 report and new data submissions from 620 hospitals. As shown in Table 21b, the 2012 database includes 478 hospitals that submitted data to the database once and 650
trending hospitals that submitted data to the database more than once.

Table 2-1a. Overall Statistics for the 2012 Database Participating Hospitals
Overall Statistic

Retained From the
2011 Database

Submitted for the 2012
Database

Total 2012
Database

508
263,543

620
304,160

1,128
567,703

Number of hospitals
Number of individual survey
respondents

Table 2-1b. Statistics for Nontrending and Trending Hospitals in 2012 Database
Overall Statistic

Nontrending
(Submitted Once)

Trending (Submitted
More Than Once)

Total 2012
Database

478
218,167

650
349,536

1,128
567,703

Number of hospitals
Number of individual survey
respondents

Table 2-2 presents data on the number of surveys completed and administered, as well as
response rate information.
Table 2-2. Summary Statistics for 2012 Database Participating Hospitals
Summary Statistic
Number of completed surveys per hospital
Number of surveys administered per hospital
Hospital response rate

Average

Minimum

Maximum

503

8,725

1,182
53%

15
4%

13,000
100%

Table 2-3 presents data on the type of survey administration mode (paper, Web, or mixed mode).
Table 2-3. Survey Administration Statistics

Survey Administration Mode
Paper only
Web only
Both paper and Web
TOTAL

2012 Database
Hospitals
Number
Percent

2012 Database
Respondents
Number
Percent

239
746
143

21%
66%
13%

55,194
424,366
88,143

10%
75%
16%

1,128

100%

567,703

101%

Note: Percentages may not add to 100 due to rounding.

Table 2-4 shows average response rate by survey mode. Paper survey administration had a
higher average response rate than Web or mixed mode.
Table 2-4. Average Hospital Response Rate by Mode
Survey Administration Mode

Average Hospital Response Rate

Paper only
Web only

61%
51%

Both Web and paper

49%

Table 2-5 displays results for the types of staff and work areas/units surveyed within the
hospitals.
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

2012 Database
Hospitals

2012 Database
Respondents

Number

Percent

Number

Percent

1,014

90%

533,915

94%

63
31
20
1,128

6%
3%
2%
101%

18,918
7,137
7,733
567,703

3%
1%
1%
99%

Note: Percentages may not add to 100 due to rounding.

Chapter 3. Characteristics of Participating Hospitals
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 hospitals registered
with the American Hospital Association (AHA). The characteristics of database hospitals by bed
size, teaching status, ownership and control, and geographic region are presented in the
following tablesiv and are compared with the distribution of AHA-registered hospitals included
in the 2010 AHA Annual Survey of Hospitals.v

Highlights
Database hospitals represent a range of bed sizes and geographic regions.
Most database hospitals are nonteaching (66 percent) and non-government owned
(voluntary/nonprofit or proprietary/investor owned) (80 percent).
Overall, the characteristics of the 1,128 database hospitals are fairly consistent with
the distribution of hospitals registered with the American Hospital Association.

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. Most of the database hospitals (61 percent) have fewer than 200 beds,
which is similar to but lower than the percentage of AHA-registered U.S. hospitals (74 percent).

To ensure hospital confidentiality, at least 20 hospitals had to be in a particular breakout category before data
would be displayed for that category.
v
Data for U.S. and U.S. territory AHA-registered hospitals were obtained from the 2006 or 2010 AHA Annual
Survey of Hospitals Database, © 2010 Health Forum, LLC, an affiliate of the American Hospital Association.
Hospitals not registered with AHA were asked to provide information on their hospital’s characteristics such as bed
size, teaching status, and ownership.

Table 3-1. Distribution of Database Hospitals and Respondents by Bed Size Compared With AHARegistered 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
Hospitals
Number
Percent
657
10%
1,418
22%
1,347
21%
1,326
21%
709
11%
409
6%
218
3%
323
5%
6,407
99%

2012 Database
Hospitals
Number
Percent
74
7%
165
15%
196
17%
250
22%
192
17%
94
8%
63
6%
94
8%
1,128
100%

2012 Database
Respondents
Number
Percent
7,322
1%
22,687
4%
47,914
8%
94,361
17%
120,566
21%
72,147
13%
68,752
12%
133,954
24%
567,703
100%

Note: Percentages may not add to 100 due to rounding.

Teaching Status
As shown in Table 3-2, similar to the distribution of AHA-registered hospitals, most database
hospitals were nonteaching. However, there was a smaller percentage of nonteaching hospitals in
the database (66 percent) compared with AHA-registered hospitals (76 percent).
Table 3-2. Distribution of Database Hospitals and Respondents by Teaching Status Compared
With AHA-Registered Hospitals

Teaching Status
Teaching
Nonteaching
TOTAL

AHA-Registered
Hospitals
Number
Percent
1,516
4,891
6,407

24%
76%
100%

2012 Database
Hospitals
Number
Percent
386
742
1,128

34%
66%
100%

2012 Database
Respondents
Number
Percent
322,030
245,673
567,703

57%
43%
100%

Note: Percentages may not add to 100 due to rounding.

Ownership and Control
As shown in Table 3-3, most database hospitals were non-government owned (80 percent),
which is similar to the distribution of AHA-registered U.S. hospitals.

Table 3-3. Distribution of Database Hospitals and Respondents by Ownership and Control
Compared With AHA-Registered Hospitals

Ownership and Control
Government (Federal or nonFederal)
Nongovernment
(voluntary/nonprofit or
proprietary/investor owned)
TOTAL

AHA-Registered
Hospitals
Number Percent

2012 Database
Hospitals
Number Percent

2012 Database
Respondents
Number Percent

1,645

26%

229

20%

109,656

19%

4,762

74%

899

80%

458,047

81%

6,407

100%

1,128

100%

567,703

100%

Note: Percentages may not add to 100 due to rounding.

Geographic Region
Table 3-4 shows the distribution of database hospitals by AHA-defined geographic regions.vi The
largest percentages of database hospitals are from the East North Central region (25 percent) and
the South Atlantic/Associated Territories region (16 percent).
Table 3-4. Distribution of Database Hospitals and Respondents by Geographic Region Compared
With AHA-Registered Hospitals

Region
New England

AHA-Registered
Hospitals
Number Percent

2012 Database
Respondents
Number Percent

70,275

12%

271

23,838

1,016

16%

182

16%

101,597

18%

East North Central

925

14%

279

25%

142,124

25%

East South Central

533

110

10%

36,841

West North Central

803

13%

142

13%

47,469

West South Central

1,089

17%

139

12%

56,740

10%

509

39,543

659
6,407

10%
99%

91
1,128

8%
100%

49,276
567,703

9%
99%

Mid-Atlantic
South Atlantic/Associated
Territories

Mountain
Pacific/Associated Territories
TOTAL

602

2012 Database
Hospitals
Number Percent

Note: Percentages may not add to 100 due to rounding.

States and territories are categorized into AHA-defined regions as follows:
New England: CT, MA, ME, NH, RI, VT
West North Central: IA, KS, MN, MO, ND,
NE, SD
Mid-Atlantic: NJ, NY, PA
West South Central: AR, LA, OK, TX
South Atlantic/Associated Territories: DC, DE,
FL, GA, MD, NC, SC, VA, WV, Puerto Rico,
Mountain: AZ, CO, ID, MT, NM, NV, UT, WY
Virgin Islands
Pacific/Associated Territories: AK, CA, HI,
East North Central: IL, IN, MI, OH, WI
OR, WA, American Samoa, Guam, Marshall
Islands, Northern Mariana Islands
East South Central: AL, KY, MS, TN

Chapter 4. Characteristics of Respondents
This chapter describes respondents within the participating hospitals. The data presented here are
based on respondents’ answers to survey questions about the hospital work area/unit where they
spent most of their work time, their staff position, and their direct interaction with patients.

Highlights
There were 567,703 hospital staff respondents from 1,128 hospitals.
The top three work areas of respondents were:
o Other (30 percent).
o Medicine (12 percent).
o Surgery (10 percent).
The top three staff positions of respondents were:
o Registered nurse or licensed vocational nurse/licensed practical nurse (35
percent).
o Other (21 percent).
o Technician (e.g., EKG, Lab, Radiology) (11 percent).
Most respondents (76 percent) indicated they had direct interaction with patients.

Work Area/Unit
Close to one-third of respondents (30 percent) selected “Other” as their work area, followed by
“Medicine” (12 percent), and “Surgery” (10 percent) (Table 4-1). The Hospital Survey on
Patient Safety Culture uses generic categories for hospital work areas and units. Therefore, a
large percentage of respondents chose the “Other” response option, which allowed them to note
their specific work area or unit. Participating hospitals were not asked to submit written or
“other-specify” 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
2012 Database Respondents
Number
Percent

Work Area/Unit
Other

159,889

30%

Medicine
Surgery
Many different hospital units/no specific unit
Intensive care unit (any type)
Radiology
Emergency

62,688
52,072
44,024
36,402
30,215
30,111

12%
10%
8%
7%
6%
6%

Laboratory
Obstetrics
Rehabilitation
Pediatrics
Pharmacy
Psychiatry/mental health
Anesthesiology

25,705
23,917
18,293
16,976
15,725
15,600
3,538

5%
4%
3%
3%
3%
3%
1%

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

535,155
32,548
567,703

101%

Note: Percentages may not add to 100 due to rounding.

Staff Position
More than one-third of respondents (35 percent) selected “Registered Nurse” or “Licensed
Vocational Nurse/Licensed Practical Nurse (LVN/LPN)” as their staff position, followed by
“Other” (21 percent) and “Technician (e.g., EKG, Lab, Radiology)” (11 percent), as shown in
Table 4-2. As with the work area/unit question, many respondents chose the “Other” response
option, which allowed them to note 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
2012 Database
Respondents
Number
Percent

Staff Position
Registered nurse (RN) or licensed vocational nurse (LVN)/licensed
practical nurse (LPN)
Other
Technician (EKG, Lab, Radiology)

191,402

35%

114,425
58,495

21%
11%

Administration/management
Unit assistant/clerk/secretary
Attending/staff physician, resident physician/physician in training, or
physician assistant (PA)/nurse practitioner (NP)
Patient care assistant/hospital aide/care partner
Therapist (respiratory, physical, occupational, or speech)
Pharmacist
Dietitian
TOTAL

42,021
34,782
29,832

8%
6%
6%

29,726
25,160
10,339
3,332
539,514

6%
5%
2%
1%
101%

Missing: Did not answer or were not asked the question
Overall total

28,189
567,703

Note: Percentages may not add to 100 due to rounding.

Interaction With Patients
As shown in Table 4-3, most respondents (76 percent) indicated they had direct interaction with
patients.
Table 4-3. Distribution of Database Respondents by Interaction With Patients
2012 Database
Respondents
Number
Percent

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

407,884
130,135
538,019
29,684

Overall total

567,703

Note: Percentages may not add to 100 due to rounding.

76%
24%
100%

Chapter 5. Overall Results
This chapter presents the overall survey results for the database, showing the average percentage
of positive responses across the database hospitals on each of the survey’s items and composites.
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 characteristic and is not considered to be a solely
individual characteristic.
An alternative method would be to report a straight percentage of positive responses across all
respondents, but this method would give greater weight to respondents from larger hospitals.
(There are almost twice as many respondents from larger hospitals as from smaller hospitals.)

Highlights
Teamwork Within Units—This composite had the highest average percent
positive response (80 percent), indicating it is a strength for most hospitals.
Supervisor/Manager Expectations and Actions Promoting Patient Safety—This
composite had the second highest average percent positive response (75 percent),
indicating it is a strength for most hospitals.
Nonpunitive Response to Error—This composite had the lowest average percent
positive response (44 percent), indicating it is an area with potential for
improvement for most hospitals.
Handoffs and Transitions—This composite had the second lowest average
percent positive response (45 percent), indicating it is an area with potential for
improvement for most hospitals.
On average, most respondents within hospitals (75 percent) gave their work area
or unit a grade of “A-Excellent” (30 percent) or “B-Very Good” (45 percent) on
patient safety; this was identified as an area of strength for most hospitals.
On average, most respondents within hospitals (55 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.

This section provides the overall item and composite-level results. The method for calculating
the percent positive scores at the item and composite level is described in the Notes section of
this document.

Composite-Level Resultsvii
Chart 5-1 shows the average percent positive response for each of the 12 patient safety culture
composites across hospitals in the database. The patient safety culture composites are shown in
order from the highest average percent positive response to the lowest.
Areas of Strength
Teamwork Within Units—the extent to which staff support one another, treat each other
with respect, and work together as a team. This patient safety culture composite had the
highest average percent positive response (80 percent), indicating it is an area of strength
across the database hospitals.
Supervisor/Manager Expectations and Actions Promoting Patient Safety—the extent to
which supervisors/managers consider staff suggestions for improving patient safety,
praise staff for following patient safety procedures, and do not overlook patient safety
problems. This patient safety culture composite had the second highest average percent
positive response (75 percent).
Organizational Learning—Continuous Improvement—the extent to which mistakes
have led to positive changes and changes are evaluated for effectiveness. This patient
safety culture composite tied for the third highest average percent positive response (72
percent).
Management Support for Patient Safety—the extent to which hospital management
provides a work climate that promotes patient safety and shows that patient safety is a top
priority. This patient safety culture composite tied for the third highest average percent
positive response (72 percent).
Areas With Potential for Improvement
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. This patient safety culture composite had the lowest average percent
positive response (44 percent), indicating it is an area with potential for improvement
across the database hospitals.
Handoffs and Transitions—the extent to which important patient care information is
transferred across hospital units and during shift changes. This patient safety culture
composite had the second lowest average percent positive response (45 percent).
Staffing—the extent to which there are enough staff to handle the workload and work
hours are appropriate to provide the best care for patients. This patient safety culture
composite had the third lowest average percent positive response (56 percent).

Item-Level Results
Chart 5-2 shows 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.

vii

Some hospitals excluded one or more survey items and are therefore excluded from composite-level calculations
when the omitted items pertain to a particular composite. For the 2012 report, 44 hospitals were excluded from one
or more composite-level calculations for this reason.

Areas of Strength
The survey items with the highest average percent positive response (86 percent) were
from the patient safety culture composite Teamwork Within Units: “People support one
another in this unit” and “When a lot of work needs to be done quickly, we work together
as a team to get the work done.”
Area With Potential for Improvement
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.” (In other words, an average of only
35 percent of respondents in each hospital Strongly disagreed or Disagreed with this
negatively worded item.)
Patient Safety Grade—Chart 5-3 shows the results from the item that asked respondents to give
their hospital work area/unit an overall grade on patient safety. On average across hospitals, most
respondents were positive, with 75 percent giving their work area or unit a patient safety grade of
“A-Excellent” (30 percent) or “B-Very Good” (45 percent).
Number of Events Reported—Chart 5-4 shows the results from the item that asked respondents
to indicate the number of events they reported over the past 12 months. On average across
hospitals, most respondents (55 percent) reported no events in their hospital over the past 12
months. Event reporting was identified as an area for improvement for most hospitals because
underreporting of events means 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 2012 Database
Hospitals

Chart 5-2. Item-Level Average Percent Positive Response, Across All 2012 Database Hospitals
(Page 1 of 4)

Note: The item’s survey location is shown to the right in parentheses. 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 2012 Database Hospitals
(Page 2 of 4)

Chart 5-2. Item-Level Average Percent Positive Response, Across All 2012 Database Hospitals
(Page 3 of 4)

Chart 5-2. Item-Level Average Percent Positive Response, Across All 2012 Database Hospitals
(Page 4 of 4)

Chart 5-3. Average Percentage of Respondents Giving Their Work Area/Unit a Patient Safety
Grade, Across All 2012 Database Hospitals
100%

Percent

80%

60%
45%
40%
30%
20%
20%
4%

0%
A = Excellent

B = Very Good

C = Acceptable

D = Poor

E = Failing

Overall Patient Safety Grade

Note: Percentages may not add to 100 due to rounding.
Chart 5-4. Average Percentage of Respondents Reporting Events in the Past 12 Months, Across
All 2012 Database Hospitals
100%

Percent

80%

60%

55%

40%
27%
20%

12%
4%

6 to 10

11 to 20

21 or more

0%
None

1 to 2

3 to 5

Number of Events Reported

Note: Percentages may not add to 100 due to rounding.

Chapter 6. Comparing Your Results
To compare your hospital’s survey results with the results from the database, 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 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 with 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 with results from the database, keep in mind that the
database provides only 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 on. 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
There was considerable variability in the range of hospital scores (lowest to
highest) across the 12 patient safety culture composites.
Patient safety grades also had a wide range of response. In at least one hospital,
only 4 percent of the respondents provided their unit with a patient safety grade of
“A-Excellent,” yet at another hospital 73 percent provided their unit with a patient
safety grade of “A-Excellent”.
The number of events reported showed a wide range of response as well. In at
least one hospital, 91 percent of respondents had not reported a single event over
the past 12 months, while another hospital had 7 percent of respondents report 21
events or more.

Description of Comparative Statistics
In addition to the average percent positive scores presented in Chapter 5, a number of other
statistics are provided to facilitate comparisons with the database hospitals. A description of each
statistic shown in this chapter is provided next.

Average Percent Positive
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 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.viii
Standard Deviation
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 were 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 (hospital bed size, teaching status, etc.). Statistical
significance is greatly influenced by sample size, so as the number of observations in comparison
groups gets larger, small differences in scores will be 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.

viii

As described in the Notes section, an alternative method would be to report a straight percentage of positive
response across all respondents, but this method would give greater weight to respondents from larger hospitals
since they account for approximately twice as many responses as those from smaller hospitals.

Keep in mind that statistically significant differences are not always important, and
nonsignificant differences are not always trivial. Therefore, we recommend the following
guideline:
Use a 5 percentage point difference as a rule of thumb when comparing your
hospital’s results with the database averages. Your hospital’s percent positive score
should be at least 5 percentage points greater than the database average to be considered
“better” and should be at least 5 percentage points less to be considered “lower” than the
database average. A 5 percentage point 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 with 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 score and the 10th percentile score, or between the 90th percentile score and the
maximum score).
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 percentage 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

Interpretation

10 percentile
Represents the lowest scoring hospitals.
th
25 percentile
Represents lower scoring hospitals.
th
50 percentile (or median)
Represents the middle of the distribution of hospitals.
th
75 percentile
Represents higher scoring hospitals.
th
90 percentile
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 with the database percentiles, compare your hospital’s percent positive scores with
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
Item 1

Min

10th
%ile

25th
%ile

Median/50th
%ile

75th
%ile

90th
%ile

Max

10%

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.
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. The
standard deviation around the average percent positive scores ranged from 5.82 percent to
10.86 percent on the composites and ranged from 5.57 percent to 12.71 percent on the
items.
Patient safety grades, shown in Table 6-5, had a wide range of response, from at least one
hospital where few of the respondents (4 percent) provided their unit with a patient safety
grade of “A-Excellent” to a hospital where 73 percent did.
Number of events reported also had a wide range of response, as shown in Table 6-6,
from a hospital where 91 percent of respondents had not reported a single event over the
past 12 months to a hospital where 89 percent of all respondents reported one event or
more.

34
58%
56%
45%
44%

10. Staffing

11. Handoffs & Transitions

12. Nonpunitive Response to Error

64%

6. Feedback & Communication About Error

9. Teamwork Across Units

66%

5. Overall Perceptions of Patient Safety

62%

72%

4. Management Support for Patient Safety

8. Communication Openness

72%

3. Organizational Learning—Continuous
Improvement

63%

75%

2. Supervisor/Manager Expectations & Actions
Promoting Patient Safety

7. Frequency of Events Reported

80%

1. Teamwork Within Units

Patient Safety Culture Composites

Average
%
Positive

8.43%

10.86%

9.24%

9.82%

6.46%

7.51%

7.83%

8.26%

9.17%

7.00%

6.40%

5.82%

s.d.

Table 6-3. Composite-Level Comparative Results for the 2012 Database

20%

14%

27%

31%

36%

25%

30%

37%

46%

49%

51%

Min

34%

33%

45%

47%

54%

55%

56%

61%

63%

67%

73%

10th
%ile

38%

50%

52%

58%

59%

60%

67%

68%

71%

76%

25th
%ile

43%

44%

56%

58%

62%

63%

64%

66%

72%

75%

80%

Median/
50th
%ile

48%

52%

62%

64%

66%

68%

70%

71%

78%

77%

79%

84%

75th
%ile

54%

60%

68%

72%

69%

73%

74%

76%

84%

81%

83%

87%

90th
%ile

Composite % Positive Response

75%

88%

85%

93%

83%

92%

89%

95%

94%

95%

98%

Max

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.
2. Mistakes have led to positive changes here.

A11

69%

64%

84%

76%

74%

76%

73%

69%

78%

86%

8.91%

8.07%

6.41%

6.53%

9.13%

7.15%

7.71%

7.49%

7.19%

5.57%

5.75%

s.d.

25%

38%

50%

47%

24%

41%

30%

54%

52%

Min

58%

54%

75%

68%

64%

67%

64%

60%

69%

79%

64%

58%

80%

72%

69%

71%

68%

65%

74%

83%

82%

69%

64%

84%

76%

74%

76%

74%

69%

79%

87%

86%

75%

69%

88%

81%

79%

81%

78%

74%

83%

90%

89%

80%

74%

91%

85%

84%

85%

83%

79%

87%

93%

Survey Item % Positive Response
Median/
10th
25th
50th
75th
90th
%ile
%ile
%ile
%ile
%ile

95%

89%

100%

95%

97%

100%

98%

100%

Max

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).

A13

B4R

B3R

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

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.

Teamwork Within Units
1. People support one another in this unit.

Survey Items by Composite

1.
A1

Item

Average
%
Positive

Table 6-4. Item-Level Comparative Results for the 2012 Database (Page 1 of 4)

Survey Items by Composite

4. Our procedures and systems are good at
preventing errors from happening.
Feedback & Communication About Error
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.

10.46%

9.39%
9.41%
9.67%

61%

62%
64%
64%

72%

65%

56%

7.73%

8.66%

9.71%

8.41%

9.65%

75%

72%

8.67%

81%

s.d.

43%

26%

30%

23%

25%

27%

24%

38%

42%

Min

62%

54%

45%

62%

52%

53%

51%

48%

62%

69%

66%

60%

50%

67%

58%

56%

54%

69%

76%

72%

65%

56%

72%

64%

62%

60%

75%

82%

77%

71%

63%

78%

70%

68%

67%

81%

87%

81%

76%

69%

83%

76%

77%

74%

87%

91%

Survey Item % Positive Response
Median/
10th 25th
50th
75th 90th
%ile
%ile
%ile
%ile
%ile

93%

88%

97%

92%

94%

93%

92%

100%

Max

6.
C1

A18

Management Support for Patient Safety
1. Hospital mgmt provides a work climate that
promotes patient safety.
F8
2. The actions of hospital mgmt show that
patient safety is a top priority.
F9R 3. Hospital mgmt seems interested in patient
safety only after an adverse event happens.
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.

4.
F1

Item

Average
%
Positive

Table 6-4. Item-Level Comparative Results for the 2012 Database (Page 2 of 4)

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?
3. When a mistake is made that could harm the
patient, but does not, how often is this
reported?
Communication Openness
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.
Teamwork Across Units
1. Hospital units do not coordinate well with
each other.
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.

Survey Items by Composite

68%

59%

60%

46%

63%

47%

75%

74%

59%

57%

10.17%

9.44%

10.51%

11.49%

7.33%

7.78%

6.61%

6.91%

8.42%

8.83%

s.d.

19%

29%

21%

12%

35%

19%

47%

41%

15%

13%

Min

56%

49%

47%

32%

54%

37%

67%

66%

49%

46%

62%

53%

38%

58%

42%

71%

69%

53%

51%

68%

59%

45%

63%

47%

75%

74%

59%

57%

75%

65%

66%

53%

67%

51%

80%

78%

65%

63%

82%

72%

74%

61%

71%

56%

84%

82%

70%

68%

Survey Item % Positive Response
Median/
10th 25th
50th
75th 90th
%ile
%ile
%ile
%ile %ile

100%

93%

95%

93%

90%

75%

95%

100%

92%

87%

Max

F10

F6R

9.
F2R

C6R

8.
C2

7.
D1

Item

Average
%
Positive

Table 6-4. Item-Level Comparative Results for the 2012 Database (Page 3 of 4)

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 patient care.
4. We work in ―crisis mode‖ trying to do too
much, too quickly.
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.
4. Shift changes are problematic for patients in
this hospital.
Nonpunitive Response to Error
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 personnel file.

Survey Items by Composite

35%

46%

50%

45%

44%

51%

41%

50%

68%

53%

56%

9.14%

8.84%

9.05%

11.79%

11.14%

10.34%

12.40%

11.02%

10.38%

9.73%

12.71%

s.d.

17%

15%

16%

14%

13%

Min

25%

36%

40%

32%

31%

39%

27%

37%

55%

40%

39%

29%

40%

44%

37%

36%

44%

32%

42%

62%

46%

47%

34%

46%

49%

44%

42%

50%

40%

49%

69%

53%

56%

40%

51%

55%

52%

50%

56%

48%

56%

75%

59%

64%

47%

58%

61%

59%

64%

58%

65%

80%

65%

72%

Survey Item % Positive Response
Median/
10th 25th
50th
75th 90th
%ile
%ile
%ile
%ile
%ile

82%

80%

82%

92%

88%

89%

88%

95%

85%

100%

Max

A16R

A12R

12.
A8R

F11R

F7R

F5R

11.
F3R

A14R

A7R

A5R

10.
A2

Item

Average
%
Positive

Table 6-4. Item-Level Comparative Results for the 2012 Database (Page 4 of 4)

Very Good

Acceptable

Poor

Failing

E
1%

20%

45%

30%

Average %

1.02%

3.02%

7.00%

6.94%

9.52%

s.d.

12%

Min

12%

38%

19%

10th %ile

15%

42%

23%

20%

45%

29%

24%

49%

35%

29%

54%

42%

90th %ile

27%
12%
4%
2%
1%

1 to 2 events

3 to 5 events

6 to 10 events

11 to 20 events

21 events or more

s.d.

1.04%

1.33%

2.44%

4.46%

6.21%

10.39%

Note: Percentages for “Average %” may not add to 100 due to rounding.

55%

Average
%

No events

Number of Events Reported by
Respondents

11%

Min

19%

42%

10th
%ile

23%

48%

11%

27%

55%

14%

31%

62%

Percentage of Responses
Median/
25th
50th
75th
%ile
%ile
%ile

Table 6-6. Average Distribution of Number of Events Reported in the Past 12 Months—2012 Database Comparative Results

Note: Percentages for “Average %” may not add to 100 due to rounding.

Excellent

Work Area/Unit Patient Safety Grade

Percentage of Responses
Median/
50th
25th %ile
%ile
75th %ile

Table 6-5. Average Distribution of Work Area/Unit Patient Safety Grades—2012 Database Comparative Results

17%

35%

68%

90th
%ile

14%

35%

56%

80%

73%

Max

11%

19%

32%

51%

91%

Max

Appendixes A and 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 showing 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
The breakout tables are included as appendixes because there are a large number of them.
Highlights of the findings from the breakout tables in these appendixes are provided on the
following pages. The appendixes are available on the Web at:
www.ahrq.gov/qual/hospsurvey12/.

Highlights From Appendix A: Overall Results by Hospital Characteristics
Bed Size (Tables A-1, A-3)
The smallest hospitals (6-24 beds) had the highest percent positive average across all
patient safety culture composites (68 percent); larger hospitals (400 beds or more) had the
lowest (60 percent).
Smaller hospitals (49 beds or less) had the highest percentage of respondents who gave
their work area/unit a patient safety grade of “Excellent” or “Very Good” (80 percent);
larger hospitals (400 beds or more) had the lowest (71 percent).
Teaching Status and Ownership and Control (Tables A-5, A-8)
Nonteaching hospitals on average scored higher than teaching hospitals by 5 percentage
points on Teamwork Across Units (60 percent positive compared with 55 percent
positive) and Handoffs and Transitions (47 percent positive compared with 42 percent).
A higher percentage of respondents in non-government-owned hospitals (47 percent) than
in government-owned hospitals (41 percent) reported events.
Geographic Region (Tables A-9, A-11, A-12)
East South Central, West South Central, and South Atlantic/Associated Territories
hospitals had the highest average percent positive response across all composites (65
percent positive); New England hospitals had the lowest (60 percent positive).
West North Central hospitals had the highest percentage of respondents who gave their
work area/unit a patient safety grade of “Excellent” or “Very Good” (78 percent); New
England hospitals had the lowest (69 percent).
Pacific/Associated Territories hospitals had the highest percentage of respondents who
reported one or more events in the past year (49 percent); the lowest percentage of
respondents reporting events was in the West South Central region (41 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 across
the composites (69 percent positive); Emergency had the lowest (57 percent positive).
Rehabilitation had the highest percentage of respondents who gave their work area/unit a
patient safety grade of “Excellent” or “Very Good” (85 percent); Emergency had the
lowest (64 percent).
ICU (Any Type) had the highest percentage of respondents reporting one or more events
in the past year (64 percent); Rehabilitation had the lowest (39 percent).

Staff Position (Tables B-5, B-7, B-8)
Respondents in Administration/Management had the highest average percent positive
response across the composites (74 percent positive); Pharmacists had the lowest (60
percent positive).
Administration/Management had the highest percentage of respondents who gave their
work area/unit a patient safety grade of “Excellent” or “Very Good” (86 percent);
Pharmacists had the lowest (68 percent).
Pharmacists had the highest percentage of respondents reporting one or more events in
the past year (71 percent); Unit Assistants/Clerks/Secretaries had the lowest (17 percent).
Interaction With Patients (Tables B-9, B-11, B-12)
Respondents with direct patient interaction were more positive on Handoffs and
Transitions compared with those without direct patient interaction (47 percent positive
compared with 39 percent).
Respondents without direct patient interaction were more positive than those with direct
patient interaction on Management Support for Patient Safety (77 percent positive
compared with 71 percent).
Respondents without direct patient interaction had a higher percentage of respondents
who gave their work area/unit a patient safety grade of “Excellent” or “Very Good” (80
percent) than respondents with direct patient interaction (75 percent).
More respondents with direct patient interaction reported one or more events in the past
year (50 percent) than respondents without direct patient interaction (30 percent).

Chapter 7. Trending: Comparing Results Over Time
Many hospitals that administer the hospital survey have indicated that they intend to readminister
the survey on a regular basis to track changes in patient safety culture over time. While the
overall results presented earlier in this report reflect only the most recent survey data from all
1,128 participating hospitals, we have data from two administrations of the survey for 650
hospitals, allowing us to examine trends over time for these hospitals. This chapter presents
trending results from these 650 hospitals.

Highlights
For the 650 hospitals with trending data, the average length of time between
previous and most recent survey administrations was 20 months (range: 6 months
to 66 months).
The distribution of the 650 trending hospitals by bed size, teaching status, and
ownership and control is similar to the distribution of the 1,128 database
hospitals.
The average percent positive scores on the patient safety culture composites
increased by 1 percentage point (ranging from 0 to 2 percentage points).
The average percentage of respondents who gave their work area/unit a patient
safety grade of “A-Excellent” or “B-Very Good” increased by 1 percentage point.
The average number of respondents reporting one or more events decreased by 1
percentage point.

When reviewing the results in this chapter, keep in mind that survey scores might change, or not
change, over time for a number of complex reasons. Important factors to consider are whether
the hospital implemented patient safety initiatives or took actions between survey
administrations and the length of time 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.

Table 7-1 displays summary statistics from the previous and most recent survey administrations
for the 650 trending hospitals.
Table 7-1. Summary Statistics for Most Recent and Previous Data Submissions From the 650
Trending Hospitals
Summary Statistic
Total number of respondents
Number of completed surveys per hospital
Hospital response rate
Number of hospitals (out of 650) that
administered the survey to all staff, or a
sample of all staff, from all departments

Most Recent Survey
Administration

Previous Survey
Administration

349,536
Average: 538
Range: 12–8,725
Average: 54%
Range: 4–100%
595 (92%)

306,864
Average: 472
Range: 10–5,045
Average: 52%
Range: 3–100%
543 (84%)

Additional characteristics of the 650 trending hospitals follow:
Most of the 650 trending hospitals (80 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 a decrease of 1
percentage point (range: one hospital had a 90 percentage point decrease in response rate
and one had an 85 percentage point increase).
The average time between the previous and most recent survey administrations was 20
months (range: 6 months to 66 months).
Note: Descriptive statistics on the 650 trending hospitals by bed size, teaching status, ownership
and control, and region are provided in Appendix C (Tables C-1, C-2, C-3, and C-4).

Description of Trending Statistics
Table 7-2a shows examples of the types of statistics provided in this chapter. The tables show the
average percentage of respondents who answered positively in the most recent survey
administration (left column) and the previous administration (middle column) for the trending
hospitals only. The change over time (Most Recent score minus Previous score) is shown in the
right column. The change is a negative number if the most recent administration showed a
decline and a positive number if the most recent administration showed an increase.
Table 7-2a. Example of Trending Statistics
Survey Item

Most Recent

Change

Item 1
Item 2

80%
80%

84%
78%

-4%
2%

Table 7-2b shows additional types of trending statistics that are provided. The maximum increase
shows the score from the hospital or hospitals with the largest percent positive score increase on
a particular composite or item. Similarly, the maximum decrease shows the score from the
hospital or hospitals with the largest percent positive score decrease.

The average increase was calculated by including only 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 including
only 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 7-2b. Example of Other Trending Statistics
Survey Item

Maximum
Increase

Maximum
Decrease

Average
Increase

Average
Decrease

Item 1
Item 2

18%
21%

-45%
-19%

3%
5%

-5%
-6%

Composite and Item-Level Trending Results
Table 7-3 presents trending results on each of the 12 patient safety culture composites. The table
shows average percent positive scores for the most recent and previous administrations, average
change over time, maximum increase and decrease, and average increase and decrease over time.
Table 7-4 presents similar trending results for the 42 survey items. Table 7-5 and Table 7-6
present the trending results for patient safety grade and number of events reported over the past
12 months, respectively.

Frequency of Events Reported

Communication Openness

Teamwork Across Units

44%

46%

57%

59%

62%

64%

65%

67%

73%

75%

80%

Most
Recent

44%

45%

56%

58%

62%

63%

64%

65%

72%

75%

79%

Change

21%

33%

38%

36%

21%

20%

34%

28%

27%

24%

23%

25%

Maximum
Increase

-22%

-24%

-32%

-25%

-24%

-21%

-28%

-20%

-22%

-27%

-24%

-21%

Maximum
Decrease

Composite % Positive Response

Average
Increase

-4%

-5%

-4%

-3%

-5%

-4%

-5%

-4%

-3%

Average
Decrease

Note: Based on data from 650 trending hospitals that had composite-level scores; the number of respondents was 349,536 for the most recent results and 306,864
for the previous results. Most recent, previous, and change columns display average percent positive scores across the trending hospitals.

Nonpunitive Response to Error

Feedback & Communication About Error

12.

Overall Perceptions of Patient Safety

Handoffs & Transitions

Management Support for Patient Safety

11.

Organizational Learning—Continuous
Improvement

Staffing

Supervisor/Manager Expectations &
Actions Promoting Patient Safety

10.

Teamwork Within Units

Patient Safety Culture Composites

Table 7-3. Trending: Composite-Level Results

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.
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.
2. Mistakes have led to positive changes
here.
3. After we make changes to improve
patient safety, we evaluate their
effectiveness.

Survey Items by Composite

70%

65%

84%

77%

74%

76%

74%

70%

78%

86%
86%

Most
Recent

69%

64%

83%

76%

74%

76%

73%

69%

78%

85%
86%

1%
0%

32%

30%

19%

24%

22%

27%

38%

42%

26%

28%
28%

-37%

-41%

-25%

-23%

-30%

-41%

-28%

-19%
-20%

Item % Positive Response
Maximum Maximum
Change
Increase
Decrease

4%
4%

Average
Increase

-5%

-4%

-5%

-4%

-4%
-4%

Average
Decrease

Note: Based on data from 650 trending hospitals. The number of respondents was 349,536 for the most recent results and 306,864 for the previous results, but
the exact number of respondents will vary from item to item. Most recent, previous, and change columns display average percent positive scores across the
trending hospitals. 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).

A13

B4R

B3R

A11

1.
A1
A3

Item

Table 7-4. Trending: Item-Level Results (Page 1 of 4)

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
1. It is just by chance that more serious
mistakes don’t happen around here.
2. Patient safety is never sacrificed to get
more work done.
3. We have patient safety problems in this
unit.
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.
2. We are informed about errors that
happen in this unit.
3. In this unit, we discuss ways to prevent
errors from happening again.

Survey Items by Composite

72%

66%

58%

73%

65%

63%

61%

76%

81%

Most
Recent

71%

65%

56%

72%

64%

62%

60%

74%

81%

33%

41%

29%

33%

37%

30%

28%

29%

27%

-34%

-23%

-41%

-23%

-25%

-27%

-22%

-28%

-26%

-27%

Item % Positive Response
Maximum
Maximum
Change
Increase
Decrease

Average
Increase

-5%

-6%

-4%

-5%

Average
Decrease

A18

A17R

A15

5.
A10R

F9R

4.
F1

Item

Table 7-4. Trending: Item-Level Results (Page 2 of 4)

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?
3. When a mistake is made that could harm
the patient, but does not, how often is this
reported?
Communication Openness
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.
Teamwork Across Units
1. Hospital units do not coordinate well with
each other.
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.

Survey Items by Composite

69%

60%

46%

63%

47%

76%

74%

60%

58%

Most
Recent

68%

59%

45%

63%

47%

75%

74%

59%

56%

39%

45%

38%

41%

49%

31%

20%

21%

27%

28%

-24%

-35%

-33%

-37%

-25%

-39%

-28%

-34%

-22%

Item % Positive Response
Maximum
Maximum
Change
Increase
Decrease

Average
Increase

-5%

-6%

-5%

-6%

-4%

Average
Decrease

F10

F6R

9.
F2R

C6R

8.
C2

7.
D1

Item

Table 7-4. Trending: Item-Level Results (Page 3 of 4)

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 patient care.
4. We work in ―crisis mode‖ trying to do
too much, too quickly.
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.
4. Shift changes are problematic for
patients in this hospital.
Nonpunitive Response to Error
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 personnel file.

Survey Items by Composite

36%

47%

50%

46%

44%

51%

42%

51%

68%

53%

56%

35%

46%

50%

45%

43%

50%

41%

49%

67%

53%

55%

27%

29%

42%

36%

58%

37%

38%

78%

34%

32%

-34%

-25%

-29%

-28%

-44%

-32%

-31%

-36%

-80%

-33%

-42%

Item % Positive Response
Maximum
Maximum
Change
Increase
Decrease

Average
Increase

-5%

-6%

-5%

-6%

-8%

Average
Decrease

A16R

A12R

12.
A8R

F11R

F7R

F5R

11.
F3R

A14R

A7R

A5R

10.
A2

Item

Most
Recent

Table 7-4. Trending: Item-Level Results (Page 4 of 4)

Very Good

Acceptable

Poor

Failing

E
1%

20%

45%

31%

Most Recent

21%

46%

29%

-1%

Change

13%

31%

27%

32%

35%

Maximum
Increase

-7%

-20%

-29%

-35%

-44%

Maximum
Decrease

Average
Increase

-1%

-2%

-5%

Average
Decrease

27%
11%
4%
2%
1%

1 to 2 events

3 to 5 events

6 to 10 events

11 to 20 events

21 events or more
1%

12%

27%

54%

-1%

Change

10%

17%

22%

35%

Maximum
Increase

-7%

-8%

-11%

-34%

-26%

-33%

Maximum
Decrease

Average
Increase

-1%

-2%

-3%

-4%

-5%

Average
Decrease

Note: Based on data from 650 trending hospitals that had data for this item. The number of respondents was 349,536 for the most recent results and 306,864 for
the previous results. Most recent, previous, and change columns display average percent positive scores across the trending hospitals. Column totals in the table
may not add to 100 percent due to rounding.

55%

Most Recent

No events

Number of Events Reported
by Respondents

Percentage of Respondents Within Hospitals

Table 7-6. Trending: Distribution of Number of Events Reported in the Past 12 Months

Excellent

Work Area/Unit Patient Safety
Grade

Percentage of Respondents Within Hospitals

Table 7-5. Trending: Distribution of Work Area/Unit Patient Safety Grades

Bar Charts of Trending Results
Chart 7-1 shows the percentages of trending hospitals that increased, decreased, or did not change for
each of the 12 patient safety culture composites. The chart shows that:
Most hospitals changed less than 5 percentage points on the 12 composites.
Staffing had the largest percentage of hospitals that increased 5 percentage points or more; 29
percent of hospitals increased by at least 5 percentage points.
Communication Openness had the largest percentage of hospitals that decreased 5 percentage
points or more; 19 percent of hospitals decreased by at least 5 percentage points.
Chart 7-2 displays results for the percentages of trending hospitals that increased, decreased, or did not
change on patient safety grades (percent providing grades of “A-Excellent” or “B-Very Good”;
percentages may not add to 100 due to rounding) and shows that:
29 percent of hospitals increased by 5 percentage points or more.
52 percent of hospitals changed less than 5 percentage points.
18 percent of hospitals decreased by 5 percentage points or more.
Chart 7-3 displays results for the percentages of trending hospitals that increased, decreased, or did not
change in the proportion of respondents reporting one or more events and shows that:
19 percent of hospitals increased by 5 percentage points or more.
51 percent of hospitals changed less than 5 percentage points.
30 percent of hospitals decreased by 5 percentage points or more.
Chart 7-4 displays the overall number of composites for which trending hospitals increased, decreased,
or did not change:
Most hospitals (64 percent) increased by 5 percentage points or more on at least one composite.
51 percent of hospitals decreased by 5 percentage points or more on at least one composite.
More than half the hospitals (62 percent) changed less than 5 percentage points on seven or more
composites.

53
Did Not Change
(less than 5 percentage point change)

(by 5 percentage points or more)

Decreased

Note: Based on data from 650 trending hospitals that responded to this item. Percentages may not add to 100 due to rounding.

(by 5 percentage points or more)

Increased

Chart 7-1. Trending: Percentage of Hospitals That Increased, Decreased, or Did Not Change on Each Composite

Chart 7-2. Trending: Percentage of Hospitals That Increased, Decreased, or Did Not Change on
Work Area/Unit Patient Safety Grade

Increased

Did Not Change

Decreased

(by 5 percentage points or more)

(increased or decreased by
less than 5 percentage points)

(by 5 percentage points
or more)

Note: Based on data from 650 trending hospitals that had data for this item. For each hospital, change over time was
calculated for the percentage of respondents reporting a grade of “Excellent” or “Very Good.” Percentages may not
add to 100 due to rounding.
Chart 7-3. Trending: Percentage of Hospitals That Increased, Decreased, or Did Not Change on
Number of Events Reported

Increased

Did Not Change

Decreased

(by 5 percentage points or more)

(increased or decreased by
less than 5 percentage points)

(by 5 percentage points
or more)

Note: Based on data from 650 trending hospitals that had data for this item. For each hospital, change over time was
calculated for the percentage of respondents who reported one or more events over the past 12 months. Percentages
may not add to 100 due to rounding.

Chart 7-4. Trending: Distribution of Hospitals by Number of Composites That Increased,
Decreased, or Did Not Change by 5 Percentage Points or More

Percentage of Trending Hospitals

Distribution of Hospitals by Number of Composites That Did Not Change
100%
80%
60%
40%

25%

20%

31%

7-9

10-12

11%
1%

0%
None

1-3

4-6
Number of Composites

Note: Based on data from 605 trending hospitals that measured all 12 survey dimensions. Twenty-four trending
hospitals that did not measure all 12 survey dimensions are not included. Percentages may not add to 100 due to
rounding.

Appendixes C and D: Trending Results by Hospital and Respondent
Characteristics
Part III of the report contains Appendixes C and D, which show trends over time for the 650
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
Geographic region
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.
The appendixes are available on the Web at: www.ahrq.gov/qual/hospsurvey12/.

Highlights From Appendix C: Trending Results by Hospital Characteristics
Bed Size (Tables C-5, C-7)
Hospitals with 50-99 beds had the greatest increases in percent positive response over
time on all 12 composites (an average increase of 2 percentage points).
Hospitals with 50-99 beds had the greatest increase in the percentage of respondents who
gave their work area/unit a patient safety grade of “Excellent” or “Very Good” (a 3
percentage point increase, from 75 percent to 78 percent).
Teaching Status and Ownership and Control (Table C-9)
Nonteaching hospitals showed increases up to 2 percentage points on all 12 patient safety
composites; teaching hospitals showed increases up to 1 percentage point on half of the
composites and decreased by 1 percentage point on Supervisor/Manager Expectations.
Government-owned hospitals showed increases up to 2 percentage points across 11
composites; non-government-owned hospitals showed increases up to 2 percentage points
on 9 composites.
Geographic Region (Tables C-13, C-15)
West North Central hospitals had the greatest increases in percent positive response over
time on 6 of the 12 composites (average increase of 2 percentage points).
West North Central hospitals had the greatest increase in the percentage of respondents
who gave their work area/unit a patient safety grade of “Excellent” or “Very Good” (a 3
percentage point increase, from 75 percent to 78 percent).
Highlights From Appendix D: Trending Results by Respondent Characteristics
Work Area/Unit (Tables D-1, D-3, D-4)
Rehabilitation had the greatest increase in percent positive response on all 12 patient
safety culture composites (average increases of 3 percentage points).
Emergency, Radiology, and Rehabilitation had the greatest increases over time in the
average percentage of respondents giving their work area/unit a patient safety grade of
“Excellent” or “Very Good” (3 percentage point increases, from 62 percent to 65 percent,
79 percent to 82 percent, and 82 percent to 85 percent, respectively).
Anesthesiology and Lab had the greatest increases in the average percentage of
respondents reporting one or more events in the past year (3 percentage point increases).
The largest decrease was in Psychiatry/Mental Health (a 4 percentage point decrease).
Staff Position (Tables D-5, D-7, D-8)
Patient Care Asst./Aide/Care Partner had the greatest increase in positive response over
time on 4 of the 12 patient safety composites (average increase of 2 percentage points).
Pharmacists had the greatest increase over time in the average percentage of respondents
giving their work area/unit a patient safety grade of “Excellent” or “Very Good” (a 3
percentage point increase).
Dietitians had the greatest decrease over time in the average percentage of respondents
reporting one or more events in the past year (an 11 percentage point decrease).

Interaction With Patients (Table D-9)
Respondents with direct interaction with patients showed an increase of 1 percentage
point across 11 patient safety culture composites; respondents without direct interaction
showed an increase of 1 percentage point across 10 composites.

Chapter 8. What’s Next? Action Planning for Improvement
The seven steps of action planning outlined in this chapter are primarily based on the book
Designing and Using Organizational Surveys: A Seven-Step Process (Church and Waclawski,
1998).

Highlights
The delivery of survey results is not the end point in the survey process; it is just
the beginning.
Often, the perceived failure of surveys to create lasting change is actually due to
faulty or nonexistent action planning or survey followup.
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
Administering the hospital survey can be considered an “intervention,” a means of educating
hospital staff and building awareness about issues of concern related to patient safety. But it
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. Often, the perceived failure of surveys as a means for creating lasting
change is actually due to faulty or nonexistent action planning or survey followup.
Seven steps of action planning are provided to help your hospital go beyond simply conducting a
survey to realizing patient safety culture change. The progression is getting survey results,
developing an action plan, and implementing the plan and tracking progress.
The seven steps of action planning are:
1.
2.
3.
4.
5.
6.
7.

Understand your survey results.
Communicate and discuss survey results.
Develop focused action plans.
Communicate action plans and deliverables.
Implement action plans.
Track progress and evaluate impact.
Share what works.

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 with 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 with the results from the
database hospitals?
Finally, if your hospital administered the survey more than once, compare your most recent
results with 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 or three areas for improvement 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 at the department or unit level. However, to ensure respondent anonymity and
confidentiality, it is important to report data only if there are enough respondents in a particular
category or group. Common rules of thumb recommend not reporting data if a category has
fewer than 5 or 10 respondents. For example, if a department has only four respondents, that
department’s data should not be reported separately because there are too few respondents to
provide complete assurance of anonymity and 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. Conduct followup 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.
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. Hospitalwide, department-based,
or unit-based action plans can be developed. Major goals can be established as hospitalwide
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
When deciding whether a particular action plan or initiative would be a good fit in your facility,
you may find the guide Will It Work Here? A Decisionmaker’s Guide to Adopting Innovations
(Brach, Lenfestey, Roussel, et al., 2008) a useful resource (available at:
www.innovations.ahrq.gov/content.aspx?id=2380). The guide helps users answer four
overarching questions:
Does this innovation fit?
Should we do it here?
Can we do it here?
How can we do it here?
Lack of resources is often a fundamental obstacle hindering implementation of action plans.
Identify funding, staffing, or other resources needed to implement action plans and take steps to
obtain these resources. It is also important to identify other obstacles you may encounter when
trying to implement change and to anticipate and understand the rationale behind any potential
resistance toward proposed action plans.
In the planning stage, it is also important to identify quantitative and qualitative measures that
can be used to evaluate progress and the impact of changes implemented. Evaluative measures
will need to be assessed before, during, and after implementation of your action plan initiatives.

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
and responsibilities, as well as the timeframe for implementation. Action plans and goals should
also be shared widely so that their transparency encourages further accountability and
demonstrates the hospitalwide 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 who 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 (2006) suggests, actions do not have to be major permanent changes. 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.
The “Plan-Do-Study-Act” cycle (Langley, Nolan, Nolan, et al., 1996), shown in Chart 8-1, is a
pilot-study approach to change. It 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.
Chart 8-1. Plan-Do-Study-Act Cycle

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 show 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 you drop
the effort completely, try to determine why it failed and whether it might be worth it to make
adjustments.
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 are caused by surveying different staff each time.
Step # 7: Share What Works
In step # 6, you tracked measures 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 health care systems as well.

References
Agency for Healthcare Research and Quality. Hospital Survey on Patient Safety Culture.
Available at: www.ahrq.gov/qual/patientsafetyculture. Accessed January 28, 2011.
American Hospital Association (AHA) Annual Survey of Hospitals database. Chicago: Health
Forum; multiple years (data used from 2006 and 2010).
Brach C, Lenfestey N, Roussel A, et al. Will it work here? A decisionmaker’s guide to adopting
innovations. (Prepared by RTI International under Contract No. 233-02-0090). Rockville, MD:
Agency for Healthcare Research and Quality; September 2008. AHRQ Publication No. 08-0051.
Available at: www.innovations.ahrq.gov/content.aspx?id=2380.
Church AH, Waclawski J. Designing and using organizational surveys: a seven-step process. San
Francisco: Jossey-Bass; 1998.
Improvement methods: the Plan-Do-Study-Act (PDSA) cycle. Washington, DC: Institute for
Healthcare Improvement; 2006. Available at:
www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove. Accessed January
28, 2011.
Langley C, Nolan K, Nolan T, et al. 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. When
data problems were found, hospitals were contacted and asked to make corrections and resubmit
their data. In addition, each participating hospital was sent a copy of its data frequencies to verify
that the dataset received was correct.
In order to keep the database current, data more than 3.5 years old are removed from the
database. Thus, 129 hospitals that administered the survey prior to January 1, 2008, were
dropped from the database.

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 ofcomplete,returned surveys
Number ofsurveys 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 nondemographic survey items but include surveys where at least one
nondemographic survey item was answered.
Denominator = The total number of surveys distributed minus ineligibles. Ineligibles include
deceased individuals and 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 nondemographic 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.

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 9 composites use
the agreement response option.
Item-Level Percent Positive Response
Both positively worded items (such as “People support one another in this unit”) and negatively
worded items (such as “We have patient safety problems in this unit”) 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 unit,” 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 unit,” 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 three-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 percent positive.ix

This method for calculating composite scores differs slightly from 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.

Item and Composite Percent Positive Scores
To calculate your hospital’s composite score, simply average the percentage of positive response
to each item 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.
2. Calculate the percentage of positive responses at the item level. (See example in Table 1.)
Table 1. Example of Computing Item and Composite Percent Positive Scores
For Positively
Worded Items,
Number of
“Strongly Agree”
or “Agree”
Responses

For Negatively
Worded Items,
Number of
“Strongly
Disagree” or
“Disagree”
Responses

Total Number
of Responses
to the Item

Percent
Positive
Response on
Item

Item A15: positively
worded
―Patient safety is never
sacrificed to get more
work done‖

120

NA*

260

120/260=46%

Item A18: positively
worded
―Our procedures and
systems are good at
preventing errors from
happening‖

130

NA*

250

130/250=52%

Item A10: negatively
worded
―It is just by chance
that more serious
mistakes don’t happen
around here‖

NA*

110

240

110/240=46%

Item A17: negatively
worded
―We have patient
safety problems in this
unit‖

NA*

140

250

140/250= 56%

Items Measuring
Overall Perceptions
of Patient Safety

Composite Score % Positive = (46% + 52% + 46% + 56%) / 4 = 50%
* NA = Not applicable.

In this example, there were four 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 to the survey
items in this composite.
Once you calculate your hospital’s percent positive response for each of the 12 safety culture
composites, you can compare your results with the composite-level results from the 1,128
database hospitals.

Minimum Number of Responses
Beginning with the 2010 database report, we enacted several new rules regarding a minimum
number of responses for calculating the percent positive scores. First, we calculated percent
positive scores only for hospitals that had at least 10 completed surveys. Second, item-level
results were calculated only when there were at least three responses to the item. If a hospital had
fewer than three responses to a survey item, the hospital’s score for that item was set to missing.
Third, if a hospital had fewer than five respondents in a breakout category (e.g., work area/unit,
staff position, direct interaction with patients), then no statistics were calculated for that breakout
category (i.e., all scores were set to missing). For example, if a hospital had five respondents
indicating they worked in the Anesthesiology unit and four respondents indicating they worked
in Pharmacy, that hospital would be included in the statistics displayed for Anesthesiology units
but not in those displayed for Pharmacy units. These minimums also apply to the statistics
displayed in Appendixes B and D (results by respondent characteristics).

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
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 1,128 (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, divided by 2 [(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

Composite “A” % Positive Score

1
2

33%
48%

3
4
5
6
7
8

52%
60%
63%
64%
66%
70%

9
10
11
12

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, divided by 2:
a. j equals 6.
b. The 50th percentile equals the average of the hospitals in the 6th and 7th positions
(64% + 66%)/2 = 65%.

File Type	application/pdf
File Title	Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report
Author	Agency for Healthcare Research and Quality (AHRQ)
File Modified	2012-02-24
File Created	2012-01-24