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pdfHospital Survey on Patient Safety Culture
2009 Comparative Database
Report for Trending Hospitals
ABC Hospital
Nowhere, USA
Part I: Main Report
March 2009
Report prepared by:
Westat
1650 Research Blvd.
Rockville, MD 20850
Email: [email protected]
Funded by:
Agency for Healthcare Research and Quality (AHRQ)
U.S. Department of Health and Human Services (HHS)
540 Gaither Road
Rockville, MD 20850
http://www.ahrq.gov
Table of Contents
PART I: MAIN REPORT
Page
PURPOSE AND USE OF THIS REPORT FOR TRENDING HOSPITALS .......................... iii
CHAPTER 1. INTRODUCTION................................................................................................1
CHAPTER 2. SURVEY ADMINISTRATION & RESPONDENTS.........................................3
CHAPTER 3. COMPARING YOUR HOSPITAL’S RESULTS AGAINST THE
DATABASE HOSPITALS............................................................................................6
Calculation of Percent Positive Scores ..........................................................................6
Composite and Item-level Comparative Charts.............................................................8
Description of Comparative Statistics .........................................................................15
Composite and Item-level Comparative Tables...........................................................16
CHAPTER 4. TRENDING: COMPARING YOUR HOSPITAL'S RESULTS
OVER TIME................................................................................................................23
Characteristics of the 204 Trending Hospitals and Your Hospital ..............................23
Description of Trending Statistics ...............................................................................25
Composite and Item-level Trending Results................................................................26
Pie Charts of Trending Results ....................................................................................33
Additional Trending Analyses .....................................................................................33
CHAPTER 5. WHAT’S NEXT? ACTION PLANNING FOR IMPROVEMENT ..................42
Seven Steps of Action Planning...................................................................................42
REFERENCES..........................................................................................................................46
NOTES: DESCRIPTION OF DATA CLEANING AND CALCULATIONS .........................47
PART II: APPENDIXES
APPENDIXES A AND B: OVERALL AND TRENDING RESULTS BY RESPONDENT
CHARACTERISTICS
Appendix A: Overall Results by Respondent Characteristics—.............................1
(1) Work area/Unit.........................................................................................................1
(2) Staff Position ..........................................................................................................13
(3) Interaction With Patients........................................................................................23
Appendix B: Trending Results by Respondent Characteristics — .......................30
(1) Work area/Unit.......................................................................................................30
(2) Staff Position ..........................................................................................................41
(3) Interaction With Patients........................................................................................52
March 2009 Trending Report for ABC Hospital, Page i
List of Tables
Page
Table 1-1. Patient Safety Culture Composites and Definitions ...................................................... 1
Table 2-1. Survey Administration Statistics: Database Hospitals Compared to Your Hospital..... 3
Table 2-2. Distribution of Respondents by Work Area/Unit: Database Compared to Your
Hospital .......................................................................................................................... 4
Table 2-3. Distribution of Respondents by Staff Position: Database Compared to Your
Hospital .......................................................................................................................... 5
Table 2-4. Distribution of Respondents by Interaction with Patients: Database Compared
to Your Hospital ............................................................................................................. 5
Table 3-1. Interpretation of Percentile Scores .............................................................................. 15
Table 3-2. Sample Percentile Statistics........................................................................................ 16
Table 3-3. Composite-level Comparative Results for the 2009 Database .................................... 17
Table 3-4. Item-level Comparative Results for the 2009 Database .............................................. 18
Table 3-5. Average Distribution of Work Area/Unit Patient Safety Grade— 2009 Database
Comparative Results..................................................................................................... 22
Table 3-6. Average Distribution of Number of Events Reported in the Past 12 Months—2009
Database Comparative Results..................................................................................... 22
Table 4-1. Summary Statistics for Previous and Most Recent Data Submissions from the 204
Trending Hospitals ....................................................................................................... 24
Table 4-2. Distribution of 204 Trending Hospitals by Bed Size .................................................. 24
Table 4-3. Distribution of 204 Trending Hospitals by Teaching Status ....................................... 25
Table 4-4. Distribution of 204 Trending Hospitals by Ownership and Control ........................... 25
Table 4-5a. Example of Trending Statistics.................................................................................. 25
Table 4-5b. Example of Other Trending Statistics ....................................................................... 26
Table 4-6. Trending: Composite-level Comparative Results ....................................................... 27
Table 4-7. Trending: Item-level Comparative Results ................................................................. 28
Table 4-8. Trending: Average Distribution of Work Area/Unit Patient Safety Grades ............... 32
Table 4-9. Trending: Average Distribution of Number of Events Reported in the Past 12
Months.......................................................................................................................... 32
Table 4-10. Types of Patient Safety Actions Taken by the 2009 Trending Hospitals.................. 35
NOTES
Table 1. Example of Computing Item and Composite Percent Positive Scores........................... 48
Table 2. Data Table for Example of How to Compute Percentiles .............................................. 49
List of Charts
Page
Chart 3-1. Composite-level % Positive Response—Comparative Results......................................9
Chart 3-2. Item-level % Positive Response— Comparative Results.............................................10
Chart 3-3. Work Area/Unit Patient Safety Grades—Comparative Results ...................................14
Chart 3-4. Number of Events Reported in Past 12 Months—Comparative Results………….…..... 14
Chart 4-1. Trending: Percentage of Hospitals that Increased, Decreased, or Did Not Change
by 5 Percent at Composite Level............................................................................................39
Chart 4-2. Trending: Percentage of Hospitals that Increased, Decreased, or Did Not Change
by 5 Percent on Work Area/Unit Patient Safety Grade..........................................................41
Chart 4-3. Trending: Percentage of Hospitals that Increased, Decreased, or Did Not Change
by 5 Percent on Number of Events Reported .........................................................................41
ii
Purpose and Use of This Report for Trending
Hospitals
In response to requests from hospitals interested in comparing their results against other
hospitals on the Hospital Survey on Patient Safety Culture, the Agency for Healthcare
Research and Quality (AHRQ) established the Hospital Survey on Patient Safety Culture
Comparative Database. The first comparative database report was released in 2007 and
was comprised of data from 382 U.S. hospitals that administered the AHRQ patient safety
culture survey to 108,621 hospital staff and voluntarily submitted their data for inclusion in
this new database. The second comparative database report was released in 2008 and was
comprised of data from 519 hospitals that administered the survey to 160,176 hospital staff.
The Hospital Survey on Patient Safety Culture 2009 Comparative Database Report is an
update of the 2008 report. The 2009 report consists of data from a total of 622 hospitals and
196,462 hospital staff respondents who completed the survey. The hospitals in the 2009
report fall into three categories:
•
•
395 hospitals from the previous database report that are still included in the 2009 report;
of which
o 314 hospitals submitted data one time; and
o 81 hospitals submitted data twice, older data was replaced by data from their readministration data so the database reflects their most recent survey data.
227 hospitals that submitted data for the 2009 report; of which
o 104 hospitals submitted data for the first time; and
o 123 hospitals submitted data from a re-administration of the survey; older data
from these hospitals was replaced by data from their re-administration data so the
database reflects their most recent survey data.
Because hospitals will not necessarily administer the hospital patient safety culture survey
every single year, but may administer it on an 18-month, 24-month, or other administration
cycle, the comparative database will be a “rolling” benchmark that retains data from prior
years when a hospital does not have new data to submit, replaces older data with more
recent data when it is available, and adds new data from hospitals submitting for the first
time. The comparative database report will be produced yearly through at least 2012.
This Report for Trending Hospitals was developed as a tool for:
•
Comparison—To allow your hospital to compare its patient safety culture survey results
against other hospitals in your ongoing efforts to establish, improve and maintain a
culture of patient safety in your institution.
•
Assessment and Learning—To provide data to your hospital to facilitate internal
assessment and learning in the patient safety improvement process, rather than as a basis
for determining punitive actions or for external judgment of hospital performance.
iii
•
Supplemental Information—To provide supplemental information to help your hospital
identify areas of strength and areas with potential for improvement in patient safety
culture.
• Trending—To provide data that describe changes in patient safety culture over time for
your hospital and other trending hospitals.
This Report for Trending Hospitals is customized to present the overall results from the
2009 Comparative Database compared to the results from your hospital based on data
submitted by your hospital for both your most recent and previous submissions. Although
the Report for Trending Hospitals contains much of the same information as the 2009
Comparative Database Report, this report provides information specifically tailored to your
hospital, while the 2009 Comparative Database Report presents more information about the
622 participating hospitals. The 2009 Comparative Database Report is available from the
AHRQ web site (www.ahrq.gov/qual/hospculture).
This Report for Trending Hospitals presents statistics (averages, minimum and maximum
scores and percentiles) on the patient safety culture areas or composites assessed in the
survey as well as the survey’s items. In addition, there is a chapter on trending that
describes patient safety culture change over time based on data submitted from your
previous and most recent safety culture surveys. All results are shown for the overall
comparative database compared to the results for your hospital. In addition, results for
breakouts of the data by respondent characteristics are presented in Appendix A with
trending breakouts by respondent characteristics presented in Appendix B. For additional
results on the survey’s patient safety culture composites and items by hospital
characteristics (bed size, teaching status, ownership and control, geographic region) refer to
the 2009 Comparative Database Report available from the AHRQ web site
(www.ahrq.gov/qual/hospculture).
Appendix A—Overall Results by Respondent Characteristics
¾ Work area/unit
¾ Staff position
¾ Interaction with patients
Appendix B—Trending Results by Respondent Characteristics
¾ Work area/unit
¾ Staff position
¾ Interaction with patients
iv
Chapter 1. Introduction
Patient safety is a critical component of healthcare quality. As healthcare organizations
continually strive to improve, there is a growing recognition of the importance of
establishing a culture of patient safety. Achieving a culture of patient safety requires an
understanding of the values, beliefs, and norms about what is important in a hospital and
what attitudes and behaviors related to patient safety are supported, rewarded and expected.
Funded by the Agency for Healthcare Research and Quality (AHRQ), the Hospital Survey on
Patient Safety Culture was developed under contract by Westat, a private research
organization. The survey was pilot tested, revised, and then released by AHRQ in November
2004. Additional information on the development of the survey is available from the AHRQ
web site (www.ahrq.gov/qual/hospculture). It was designed to assess hospital staff opinions
about patient safety issues, medical error, and event reporting and includes 42 items that
measure 12 areas or composites of patient safety culture listed and defined in Table 1-1.
Table 1-1. Patient Safety Culture Composites and Definitions
Patient Safety Culture Composite
Definition: The extent to which….
1. Communication openness
2. Feedback & communication about error
3. Frequency of events reported
4. Handoffs & transitions
5. Management support for patient safety
6. Nonpunitive response to error
7. Organizational learning–Continuous
improvement
8. Overall perceptions of patient safety
9. Staffing
10. Supervisor/manager expectations & actions
promoting safety
11. Teamwork across units
12. Teamwork within units
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
There is a learning culture in which mistakes lead to
positive changes and changes are evaluated for
effectiveness
Procedures and systems are good at preventing errors
and there is a lack of patient safety problems
There are enough staff to handle the workload and work
hours are appropriate to provide the best care for patients
Supervisors/managers consider staff suggestions for
improving patient safety, praise staff for following patient
safety procedures, and do not overlook patient safety
problems
Hospital units cooperate and coordinate with one another
to provide the best care for patients
Staff support one another, treat each other with respect,
and work together as a team
March 2009 Trending Report for ABC Hospital, Page 1
The survey also includes two questions that ask respondents to provide an overall grade on
patient safety for their work area/unit and to indicate the number of events they have
reported over the past 12 months. In addition, respondents are asked to provide limited
background demographic information about themselves (their work area/unit, staff position,
whether they have direct interaction with patients, etc).
The survey’s toolkit materials are available from the AHRQ web site
(www.ahrq.gov/qual/hospculture) and include the survey, survey items and dimensions,
Hospital Survey User’s Guide, Hospital Survey Feedback Report Template, information
about acquiring the Microsoft Excel™ Data Entry and Analysis Tool, an article about safety
culture assessment, and a series of three national technical assistance conference calls. The
toolkit provides hospitals with the basic knowledge and tools needed to conduct a patient
safety culture assessment and ideas regarding how to use the data.
March 2009 Trending Report for ABC Hospital, Page 2
Chapter 2. Survey Administration & Respondents
This chapter presents descriptive information on the database hospitals compared to your
hospital in terms of survey administration and respondent characteristics. The 2009 database
consists of data from 196,462 hospital staff respondents across 622 participating hospitals.
Your hospital completed survey data collection in May 2008. Your hospital’s survey
administration statistics are shown in Table 2-1 below.
Table 2-1. Survey Administration Statistics: Database Hospitals Compared to Your
Hospital
Survey Administration Statistics
Number of completed surveys (response rate numerator)
(Database range: 11 to 3,908 surveys)
Number of surveys administered (response rate denominator)
(Database range: 15 to 11,269)
Hospital response rate
(Database range: 4% to 100%)
Database
Hospitals
316
(average)
833
(average)
52%
(average)
Your
Hospital
103
161
64%
NOTE: Any blank records (where all non-demographic survey items were missing) submitted by hospitals were
removed from the database. Any affected hospital’s response rate numerator and overall response rate was adjusted
accordingly.
The tables on the following pages show the percentages of respondents who indicated the
specific hospital work area/unit where they spend most of their work time (Table 2-2), their
staff position (Table 2-3), and whether they typically have direct interaction with patients
(Table 2-4). Respondents from hospitals that omitted one of these questions, or individuals
who did not respond to the question, are shown as missing in the tables and are excluded
from total percentages.1 Responses are presented in order from the highest to the lowest
percentages based on the results from the database hospitals overall. Results from your
hospital are shown in the columns on the right in each table.
Because the Hospital Survey on Patient Safety Culture uses generic categories for hospital
work areas and staff positions, in Tables 2-2 and 2-3 it appears that a large percentage of
database respondents selected “Other” for their work area and staff position. Participating
hospitals were not asked to submit written or other-specify responses so no data are available
to further describe the respondents in the “Other” category.
1
Column percent totals in the tables may not sum to exactly 100% due to rounding of decimals.
March 2009 Trending Report for ABC Hospital, Page 3
Work Area/Unit
Table 2-2. Distribution of Respondents by Work Area/Unit: Database
Compared to Your Hospital
Work Area/Unit
Other
Surgery
Medicine
Many different hospital
units/No specific unit
Intensive care unit (any type)
Radiology
Emergency
Laboratory
Obstetrics
Rehabilitation
Pharmacy
Pediatrics
Psychiatry/mental health
Anesthesiology
TOTAL
Missing: No answer or not
asked the question
Overall total
Database
Respondents
Number Percent
60,617
33%
17,393
10%
17,143
9%
Your Hospital’s
Respondents
Number
Percent
0
0%
0
0%
3
3%
14,428
8%
1
1%
12,040
10,528
9,703
9,273
8,088
7,429
5,226
4,534
4,298
1,184
181,884
7%
6%
5%
5%
4%
4%
3%
2%
2%
1%
100%
11
25
22
2
0
8
6
10
4
0
92
12%
27%
24%
2%
0%
9%
7%
11%
4%
0%
100%
14,578
11
196,462
103
March 2009 Trending Report for ABC Hospital, Page 4
Staff Position
Table 2-3. Distribution of Respondents by Staff Position: Database Compared to Your
Hospital
Database
Respondents
Number Percent
Staff Position
Registered Nurse (RN) or Licensed Vocational
Nurse (LVN)/Licensed Practical Nurse (LPN)
Other
Technician (EKG, Lab, Radiology)
Administration/Management
Unit Assistant/Clerk/Secretary
Patient Care Asst/Hospital Aide/Care Partner
Therapists (Respiratory, Physical,
Occupational or Speech)
Attending/Staff Physician, Resident Physician/
Physician in Training, or Physician Assistant
(PA)/Nurse Practitioner (NP)
Pharmacist
Dietician
TOTAL
Missing: No answer or not asked the question
Overall total
Your Hospital’s
Respondents
Number Percent
66,261
36%
34
37%
40,839
19,230
13,750
11,914
10,386
22%
10%
7%
6%
6%
0
0
0
0
26
0%
0%
0%
0%
28%
9,026
5%
0
0%
8,084
4%
32
35%
3,123
1,195
183,808
12,654
196,462
2%
1%
100%
0
0
92
11
103
0%
0%
100%
Interaction with Patients
Table 2-4. Distribution of Respondents by Interaction with Patients: Database Compared to Your
Hospital
Respondent Interaction
with Patients
YES, have direct patient interaction
NO, do NOT have direct patient interaction
TOTAL
Missing: No answer or not asked the question
Overall total
Database
Respondents
Number
Percent
143,052
77%
43,658
23%
186,710
100%
9,752
196,462
Your Hospital’s
Respondents
Number
Percent
85
85%
15
15%
100
100%
3
103
March 2009 Trending Report for ABC Hospital, Page 5
Chapter 3. Comparing Your Hospital’s Results
Against the Database Hospitals
To compare your hospital’s survey results to the results from the database hospitals, we
present your hospital’s percent positive response on the survey’s 42 items and 12 composites
against the averages from the 622 comparative database hospitals. The charts and tables
presented in this chapter allow you to compare your hospital’s results against the database
averages, and to examine the percentile scores to place your hospital’s results relative to the
distribution of database hospitals.
When comparing your hospital’s results against results from the database, keep in mind that
the database only provides relative comparisons. Even though your hospital’s survey results
may be better than the database statistics, you may still believe there is room for
improvement in a particular area within your hospital in an absolute sense. As you will
notice from the database results, there are some patient safety composites that even the
highest-scoring hospitals could improve upon. Therefore, the comparative data provided in
this report should be used to supplement your hospital’s own efforts toward identifying areas
of strength and areas on which to focus patient safety culture improvement efforts.
Statistically “significant” differences between scores. You may be interested in
determining the statistical significance of differences between your hospital’s scores and the
averages in the database, or between scores in various breakout categories (differences in
scores by hospital work area/unit, staff position, and interaction with patients) in Appendix
A. Statistical significance is greatly influenced by samples sizes, so that as the number of
observations in comparison groups gets larger, small differences in scores will end up being
statistically significant. While a 1% difference between percent positive scores might be
“statistically” significant (that is, not due to chance), the difference is not likely to be
meaningful or “practically” significant. Keep in mind that statistically significant differences
are not always important, and non-significant differences are not always trivial. Therefore,
we recommend the following guideline:
•
Use a 5% difference as a rule of thumb when comparing your hospital’s results to the
database averages. Your hospital’s percent positive score should be at least 5% higher
than the database average to be considered “better,” and should be at least 5% lower to be
considered “lower” than the database average. A 5% 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.
Calculation of Percent Positive Scores
Most of the survey’s items ask respondents to answer using 5-point response categories in
terms of agreement (Strongly agree, Agree, Neither, Disagree, Strongly disagree) or
frequency (Always, Most of the time, Sometimes, Rarely, Never). Three of the 12 patient
safety culture composites use the frequency response option (Feedback and Communication
About Error, Communication Openness, and Frequency of Events Reported) while the other
nine composites use the agreement response option.
March 2009 Trending Report for ABC Hospital, Page 6
Item-level Percent Positive Response. Both positively worded items (such as “People
support one another in this work area”) and negatively worded items (such as “We have
patient safety problems in this work area”) are included in the survey. Calculating the
percent positive response on an item is different for positively and negatively worded items:
•
For positively worded items, percent positive response is the combined percentage of
respondents within a hospital who answered “Strongly agree” or “Agree,” or “Always” or
”Most of the time,” depending on the response categories used for the item.
For example, for the item “People support one another in this work area,” if 50% of
respondents within a hospital Strongly agree and 25% 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,” since a negative answer on a negatively worded item indicates a positive
response.
For example, for the item “We have patient safety problems in this work area,” if 60% of
respondents within a hospital Strongly disagree and 20% Disagree, the item-level percent
positive response for that hospital would be 60% + 20% = 80% positive (meaning 80% of
respondents do not believe they have patient safety problems in their work area).
Composite-level Percent Positive Response. The survey’s 42 items measure 12 areas or
composites of patient safety culture. Each of the 12 patient safety culture composites
includes 3 or 4 survey items. Composite scores were calculated for each hospital by
averaging the percent positive response on the items within a composite. For example, for a
3-item composite, if the item-level percent positive responses were 50%, 55%, and 60%, the
hospital’s composite-level percent positive response would be the average of these three
percentages or (50% + 55% + 60%)/3 = 55% positive.2 If one or more items in a patient
safety culture composite were omitted by a hospital, a composite score was not calculated for
that hospital on that composite.
Average Percent Positive Response for Database. Average percent positive scores for
each of the 12 patient safety culture composites and for the survey’s 42 items are displayed
in the charts in this chapter and are also provided in the comparative results tables. These
average percent positive scores for the database were calculated by averaging compositelevel percent positive scores across hospitals in the database, as well as averaging item-level
percent positive scores across hospitals. Since the percent positive is displayed as an overall
2
Note that this method for calculating composite scores is slightly different than the method described in the September 2004
Survey User’s Guide that is part of the original survey toolkit materials on the AHRQ web site. The guide advises computing
composites by calculating the overall percent positive across all the items within a composite. The updated recommendation
included in this report is to compute item percent positive scores first, and then average the item percent positive scores to obtain
the composite score, which gives equal weight to each item in a composite. The Survey User’s Guide will eventually be updated to
reflect this slight change in methodology.
March 2009 Trending Report for ABC Hospital, Page 7
average, scores from each hospital are weighted equally in their contribution to the
calculation of the average.3
Composite and Item-level Comparative Charts
Composite-level Results
The composite-level results in Chart 3-1 show the average percent positive response for
each of the 12 patient safety culture composites across all hospitals in the database compared
to the percent positive results for your hospital. The patient safety culture composites are
shown in order from the highest average percent positive response to the lowest based on the
database results.
Item-level Results
The item-level results in Chart 3-2 (over 4 pages) show the average percent positive
response for each of the 42 survey items across all hospitals in the database compared to the
percent positive results for your hospital. 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.
Results from the item that asked respondents to give their hospital work area/unit an overall
grade on patient safety are shown in Chart 3-3. The chart shows the average percent of
respondents within each database hospital providing grades from “A-Excellent” to “EFailing” compared to the response percentages for your hospital.
Results from the item that asked respondents to indicate the number of events they had
reported over the past 12 months are shown in Chart 3-4. The chart shows the average
percent of respondents within each database hospital who indicated they reported “No event
reports” up to “21 or more event reports” compared to the response percentages for your
hospital.
3
An alternative method would be to report a straight percent of positive response across all respondents, but this method would
give greater weight to respondents from larger hospitals since they account for almost twice as many responses as those from
smaller hospitals.
March 2009 Trending Report for ABC Hospital, Page 8
Chart 3-1. Composite-level % Positive Response—Comparative Results
Patient Safety Culture Composites
% Positive Response
79%
88%
1. Teamwork Within Units
75%
76%
2.
Supervisor/Manager Expectations & Actions
Promoting Patient Safety
3
Organizational Learning--Continuous
Improvement
71%
76%
4
Management Support for
Patient Safety
70%
85%
64%
5. Overall Perceptions of Patient Safety
79%
63%
6. Feedback & Communication About Error
74%
62%
69%
7. Communication Openness
60%
8. Frequency of Events Reported
72%
57%
9. Teamwork Across Units
70%
55%
64%
10. Staffing
44%
11. Handoffs & Transitions
58%
44%
12. Nonpunitive Response to Error
60%
Database
Hospitals
Your
Hospital
0%
20%
40%
60%
March 2009 Trending Report for ABC Hospital, Page 9
80%
100%
Chart 3-2. Item-level % Positive Response—Comparative Results (Page 1 of 4)
Item
Survey Items By Composite
Survey Item % Positive Response
1. Teamwork Within Units
A1
1. People support one another in this unit.
85%
90%
A3
2. When a lot of work needs to be done
quickly, we work together as a team to get the
work done.
86%
93%
A4
3. In this unit, people treat each other with
respect.
A11
4. When one area in this unit gets really busy,
others help out.
78%
89%
68%
79%
2. Supervisor/Manager Expectations &
Actions Promoting Patient Safety
B1
1. My supervisor/manager says a good word
when he/she sees a job done according to
established patient safety procedures.
B2
2. My supervisor/manager seriously considers
staff suggestions for improving patient safety.
76%
75%
B3
R
3. Whenever pressure builds up, my
supervisor/manager wants us to work faster,
even if it means taking shortcuts.
74%
78%
B4
R
4. My supervisor/manager overlooks patient
safety problems that happen over and over.
72%
70%
77%
80%
3. Organizational Learning-Continuous
Improvement
A6
1. We are actively doing things to improve
patient safety.
A9
2. Mistakes have led to positive changes here.
A13
3. After we make changes to improve patient
safety, we evaluate their effectiveness.
Database
Hospitals
82%
88%
63%
63%
68%
76%
0%
20%
40%
60%
80%
Your
Hospital
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).
March 2009 Trending Report for ABC Hospital, Page 10
100%
Chart 3-2. Item-level % Positive Response—Comparative Results (Page 2 of 4)
Item
Survey Items By Composite
Survey Item % Positive Response
4. Management Support for Patient Safety
F1
1. Hospital management provides a work
climate that promotes patient safety.
F8
2. The actions of hospital management show
that patient safety is a top priority.
F9R
3. Hospital management seems interested in
patient safety only after an adverse event
happens.
80%
92%
72%
87%
59%
76%
5. Overall Perceptions of Patient Safety
A10
R
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.
A17
R
3. We have patient safety problems in this unit.
A18
4. Our procedures and systems are good at
preventing errors from happening.
60%
75%
64%
78%
62%
83%
70%
79%
6. Feedback and Communication About Error
C1
1. We are given feedback about changes put
into place based on event reports.
C3
2. We are informed about errors that happen in
this unit.
C5
3. In this unit, we discuss ways to prevent
errors from happening again.
Database
Hospitals
53%
66%
64%
78%
70%
77%
0%
20%
40%
60%
80%
Your
Hospital
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).
March 2009 Trending Report for ABC Hospital, Page 11
100%
Chart 3-2. Item-level % Positive Response—Comparative Results (Page 3 of 4)
Item
C2
Survey Items By Composite
Survey Item % Positive Response
7. Communication Openness
1. Staff will freely speak up if they see
something that may negatively affect patient
care.
C4
2. Staff feel free to question the decisions or
actions of those with more authority.
C6
R
3. Staff are afraid to ask questions when
something does not seem right.
76%
87%
47%
52%
63%
68%
8. Frequency of Events Reported
D1
1. When a mistake is made, but is caught and
corrected before affecting the patient, how
often is this reported?
D2
2. When a mistake is made, but has no
potential to harm the patient, how often is this
reported?
D3
3. When a mistake is made that could harm the
patient, but does not, how often is this
reported?
52%
65%
56%
67%
73%
83%
9. Teamwork Across Units
45%
F2
R
1. Hospital units do not coordinate well with
each other.
F4
2. There is good cooperation among hospital
units that need to work together.
58%
67%
F6
R
3. It is often unpleasant to work with staff from
other hospital units.
58%
F10
4. Hospital units work well together to provide
the best care for patients.
Database
Hospitals
56%
77%
67%
79%
0%
20%
40%
60%
80%
Your
Hospital
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).
March 2009 Trending Report for ABC Hospital, Page 12
100%
Chart 3-2. Item-level % Positive Response—Comparative Results (Page 4 of 4)
Item
Survey Items By Composite
Survey Item % Positive Response
10. Staffing
A2
1. We have enough staff to handle the
workload.
A5
R
2. Staff in this unit work longer hours than is
best for patient care.
A7
R
3. We use more agency/temporary staff than is
best for patient care.
A14
R
4. We work in “crisis mode” trying to do too
much, too quickly.
54%
48%
52%
65%
65%
78%
49%
64%
11. Handoffs & Transitions
F3
R
1. Things “fall between the cracks” when
transferring patients from one unit to another.
F5
R
2. Important patient care information is often
lost during shift changes.
F7
R
3. Problems often occur in the exchange of
information across hospital units.
F11
R
4. Shift changes are problematic for patients in
this hospital.
41%
48%
49%
63%
42%
53%
45%
68%
12. Nonpunitive Response to Error
A8
R
1. Staff feel like their mistakes are held against
them.
A12
R
2. When an event is reported, it feels like the
person is being written up, not the problem.
A16
R
3. Staff worry that mistakes they make are kept
in their personnel file.
Database
Hospitals
51%
66%
45%
63%
35%
50%
0%
20%
40%
60%
80%
Your
Hospital
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).
March 2009 Trending Report for ABC Hospital, Page 13
100%
Chart 3-3. Work Area/Unit Patient Safety Grades - Comparative Results
Percent of Respondents
100%
80%
60%
Database
Hospitals
48% 50%
41%
Your
Hospital
40%
25%
23%
20%
8%
4%
1%
1%
0%
0%
A
Excellent
B
Very Good
C
Acceptable
D
Poor
E
Failing
Patient Safety Grade
Chart 3-4. Number of Events Reported in Past 12 Months Comparative Results
Percent of Respondents
100%
80%
60%
52%
Database
Hospitals
48%
40%
28%
Your
Hospital
32%
13% 14%
20%
4% 4%
2% 0%
1% 1%
6 to 10
11 to 20
21 or
more
0%
None
1 to 2
3 to 5
Number of Events Reported
March 2009 Trending Report for ABC Hospital, Page 14
Description of Comparative Statistics
This Report for Trending Hospitals presents several statistics to facilitate comparisons
against the database hospitals. A description of each statistic shown in the comparative
results tables is provided next.
Minimum and Maximum Scores
The minimum (lowest) and maximum (highest) percent positive scores are presented for
each composite and item. These scores provide information about the range of percent
positive scores obtained by hospitals in the database and are actual scores from the lowest
and highest-scoring hospitals. When comparing against the minimum and maximum scores,
keep in mind that these scores may represent hospitals that are extreme outliers (indicated by
large differences between the minimum and the 10th percentile score, or between the 90th
percentile score and the maximum).
Percentiles
The 10th, 25th, 50th (or median), 75th and 90th percentile scores are displayed for the survey
composites and items. Percentiles provide information about the distribution of hospital
scores. To calculate percentile scores, all hospital percent positive scores were ranked in
order from low to high. A specific percentile score shows the percent of hospitals that scored
at or below a particular score. For example, the 50th percentile, or median, is the percent
positive score where 50% of the hospitals scored the same or lower, and 50% 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 3-1.
Table 3-1. Interpretation of Percentile Scores
Percentile Score
10 percentile
Interpretation
th
This score represents the lowest scoring
hospitals
25th percentile
This score represents lower-scoring hospitals
50th percentile (or median)
This score represents the middle of the
distribution of hospitals
75th percentile
This score represents higher-scoring hospitals
90th percentile
This score represents the highest scoring
hospitals
10% of the hospitals scored the same or lower
90% of the hospitals scored higher
25% of the hospitals scored the same or lower
75% of the hospitals scored higher
50% of the hospitals scored the same or lower
50% of the hospitals scored higher
75% of the hospitals scored the same or lower
25% of the hospitals scored higher
90% of the hospitals scored the same or lower
10% of the hospitals scored higher
March 2009 Trending Report for ABC Hospital, Page 15
To compare against the database percentiles, compare your hospital’s percent positive
scores against the percentile scores for each composite and item. Look for the highest
percentile where your hospital’s score is higher than that percentile.
For example: On survey item 1 in Table 3-2, the 75th percentile score is 49% positive, and
the 90th percentile score is 62% positive.
Table 3-2. Sample Percentile Statistics
Survey Item % Positive Response
Survey Item
Min
10th
%ile
Item 1
8%
10%
25th
%ile
Median/
50th
%ile
75th
%ile
90th
%ile
Max
25%
35%
49%
62%
96%
If your hospital’s score is 55%, your score falls here:
If your hospital’s score is 65%, your score falls here:
•
If your hospital’s score on the survey item is 55% positive, it falls above the 75th
percentile (but below the 90th), meaning that your hospital scored higher than at least 75%
of the hospitals in the database.
•
If your hospital’s score on the survey item is 65% positive, it falls above the 90th
percentile, meaning your hospital scored higher than at least 90% of the hospitals in the
database.
Your Hospital’s Percent Positive Scores
The average percent positive scores on the composites and items for the database and for
your hospital are presented. Your hospital’s scores are shown in the far right column in each
table, and the database’s average scores are shown in the second column from the right.
Composite and Item-level Comparative Tables
Table 3-3 presents comparative statistics (average percent positive, 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 based on the database results. Your hospital’s results are shown in the
far right column in each table.
Table 3-4 presents comparative statistics for each of the 42 survey items. The survey items
are grouped by the patient safety culture composite they are intended to measure, and within
each composite the items are presented in the order in which they appear in the survey.
Comparative statistics for patient safety grade are shown in Table 3-5 and for the number of
events reported in the past 12 months in Table 3-6.
March 2009 Trending Report for ABC Hospital, Page 16
Table 3-3. Composite-level Comparative Results for the 2009 Database
Database Composite % Positive Response
75th
%ile
90th
%ile
Max
Database
Ave %
Positive
Your
Hospital
% Positive
Patient Safety Culture Composites
Min
10th
%ile
25th
%ile
Median/
50th
%ile
1.
Teamwork Within Units
52%
72%
76%
80%
83%
87%
97%
79%
88%
2.
Supervisor/Manager Expectations
& Actions Promoting Patient
Safety
47%
66%
70%
75%
79%
83%
95%
75%
76%
3.
Organizational LearningContinuous Improvement
39%
61%
66%
71%
76%
80%
94%
71%
4.
Management Support for Patient
Safety
37%
57%
64%
71%
78%
84%
97%
70%
85%
5.
Overall Perceptions of Patient
Safety
27%
52%
58%
64%
70%
77%
89%
64%
79%
6.
Feedback & Communication
About Error
32%
52%
57%
62%
68%
74%
90%
63%
74%
7.
Communication Openness
40%
54%
58%
61%
66%
70%
98%
62%
69%
8.
Frequency of Events Reported
33%
50%
55%
60%
66%
71%
84%
60%
72%
9.
Teamwork Across Units
14%
44%
49%
56%
65%
72%
91%
57%
70%
10.
Staffing
25%
42%
48%
54%
62%
69%
87%
55%
64%
11.
Handoffs & Transitions
19%
30%
36%
42%
51%
61%
93%
44%
58%
12.
Nonpunitive Response to Error
14%
34%
38%
43%
49%
55%
82%
44%
60%
March 2009 Trending Report for ABC Hospital, Page 17
76%
Table 3-4. Item-level Comparative Results for the 2009 Database (Page 1 of 4)
Item
Survey Items By Composite
1.
Teamwork Within Units
A1
1. People support one another in this unit.
A3
A4
A11
2.
B1
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.
Database
Ave %
Positive
Your
Hospital
%
Positive
Min
Database Item % Positive Response
Median/
50th
10th 25th
75th
90th
Max
%ile
%ile
%ile
%ile
%ile
45%
77%
82%
86%
89%
93%
100%
85%
90%
62%
79%
82%
86%
90%
93%
100%
86%
93%
31%
68%
73%
78%
83%
87%
100%
78%
89%
26%
58%
63%
68%
73%
79%
97%
68%
79%
41%
61%
67%
72%
78%
81%
95%
72%
70%
B2
2. My supv/mgr seriously considers staff
suggestions for improving patient safety.
41%
66%
71%
76%
82%
86%
100%
76%
75%
B3
R
3. Whenever pressure builds up, my
supv/mgr wants us to work faster, even if
it means taking shortcuts.
43%
64%
68%
74%
80%
85%
100%
74%
78%
52%
68%
72%
77%
81%
86%
100%
77%
80%
19%
73%
77%
82%
87%
91%
100%
82%
88%
33%
53%
57%
63%
68%
74%
100%
63%
63%
12%
56%
61%
68%
74%
79%
94%
68%
76%
B4
R
3.
A6
A9
A13
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.
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).
March 2009 Trending Report for ABC Hospital, Page 18
Table 3-4. Item-level Comparative Results for the 2009 Database (Page 2 of 4)
Item
4.
F1
F8
F9
R
Survey Items By Composite
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.
Database Item % Positive Response
Median/
50th
25th
75th
90th
%ile
%ile
%ile
%ile
Max
Database
Ave %
Positive
Your
Hospital
%
Positive
Min
10th
%ile
30%
67%
73%
80%
87%
91%
100%
80%
92%
36%
58%
65%
72%
79%
85%
100%
72%
87%
15%
45%
51%
59%
67%
76%
93%
59%
76%
18%
47%
53%
60%
68%
74%
85%
60%
75%
5.
A10
R
Overall Perceptions of Patient Safety
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.
27%
51%
57%
63%
71%
78%
100%
64%
78%
A17
R
3. We have patient safety problems in this
unit.
22%
48%
55%
62%
69%
77%
92%
62%
83%
35%
59%
64%
70%
76%
81%
100%
70%
79%
18%
40%
47%
54%
60%
65%
90%
53%
66%
A18
6.
C1
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.
C3
2. We are informed about errors that
happen in this unit.
35%
53%
58%
63%
70%
77%
93%
64%
78%
C5
3. In this unit, we discuss ways to prevent
errors from happening again.
33%
59%
65%
70%
76%
82%
100%
70%
77%
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).
March 2009 Trending Report for ABC Hospital, Page 19
Table 3-4. Item-level Comparative Results for the 2009 Database (Page 3 of 4)
Item
Survey Items By Composite
7.
Communication Openness
1. Staff will freely speak up if they see
something that may negatively affect
patient care.
C2
Database Item % Positive Response
Median/
50th
25th
75th
90th
%ile
%ile
%ile
%ile
Max
Database
Ave %
Positive
Your
Hospital
%
Positive
Min
10th
%ile
47%
68%
72%
75%
80%
84%
100%
76%
87%
C4
2. Staff feel free to question the decisions
or actions of those with more authority.
26%
37%
42%
46%
52%
58%
94%
47%
52%
C6
R
3. Staff are afraid to ask questions when
something does not seem right.
7%
54%
57%
62%
67%
72%
100%
63%
68%
8.
Frequency of Events Reported
1. When a mistake is made, but is caught
and corrected before affecting the
patient, how often is this reported?
25%
40%
45%
52%
58%
64%
81%
52%
65%
D1
D2
2. When a mistake is made, but has no
potential to harm the patient, how often is
this reported?
25%
45%
50%
56%
61%
68%
85%
56%
67%
D3
3. When a mistake is made that could
harm the patient, but does not, how often
is this reported?
45%
63%
68%
73%
78%
83%
100%
73%
83%
9.
F2
R
Teamwork Across Units
1. Hospital units do not coordinate well
with each other.
5%
29%
35%
43%
53%
61%
91%
45%
56%
F4
2. There is good cooperation among
hospital units that need to work together.
11%
43%
49%
57%
67%
74%
93%
58%
67%
F6
R
3. It is often unpleasant to work with staff
from other hospital units.
7%
46%
51%
58%
65%
72%
100%
58%
77%
F10
4. Hospital units work well together to
provide the best care for patients.
21%
52%
58%
67%
76%
82%
95%
67%
79%
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).
March 2009 Trending Report for ABC Hospital, Page 20
Table 3-4. Item-level Comparative Results for the 2009 Database (Page 4 of 4)
Item
Survey Items By Composite
10.
Staffing
1. We have enough staff to handle the
workload.
A2
Database
Ave %
Positive
Your
Hospital
%
Positive
Min
Database Item % Positive Response
Median/
50th
10th
25th
75th
90th
%ile
%ile
%ile
%ile
%ile
Max
11%
37%
44%
53%
64%
73%
98%
54%
48%
A5
R
2. Staff in this unit work longer hours than
is best for patient care.
9%
40%
45%
51%
58%
65%
87%
52%
65%
A7
R
3. We use more agency/temporary staff
than is best for patient care.
0%
50%
57%
65%
73%
78%
100%
65%
78%
A14
R
4. We work in “crisis mode” trying to do
too much, too quickly.
6%
34%
40%
47%
58%
67%
91%
49%
64%
11.
13%
25%
30%
38%
49%
60%
91%
41%
48%
F5
R
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.
19%
37%
41%
48%
55%
63%
91%
49%
63%
F7
R
3. Problems often occur in the exchange
of information across hospital units.
0%
28%
33%
40%
48%
59%
100%
42%
53%
F11
R
4. Shift changes are problematic for
patients in this hospital.
18%
29%
35%
44%
53%
63%
94%
45%
68%
12.
A8
R
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.
18%
40%
45%
50%
58%
63%
88%
51%
66%
12%
35%
39%
44%
50%
57%
88%
45%
63%
12%
24%
29%
34%
41%
48%
71%
35%
50%
F3
R
A12
R
A16
R
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).
March 2009 Trending Report for ABC Hospital, Page 21
Table 3-5. Average Distribution of Work Area/Unit Patient Safety Grades—2009 Database Comparative Results
Max
Database
Average
%
Your
Hospital
%
Response
36%
63%
25%
41%
52%
57%
80%
48%
50%
23%
28%
32%
57%
23%
8%
2%
4%
6%
9%
62%
4%
1%
0%
0%
1%
2%
18%
1%
0%
Database Percent of Response
Work Area/Unit
Patient Safety Grade
Min
10th
%ile
25th
%ile
50th
%ile
75th
%ile
90th
%ile
A
Excellent
0%
14%
18%
24%
30%
B
Very Good
6%
39%
43%
47%
C
Acceptable
0%
12%
17%
D
Poor
0%
0%
E
Failing
0%
0%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
Table 3-6. Average Distribution of Number of Events Reported in the Past 12 Months—2009 Database Comparative
Results
Max
Database
Average
%
Your
Hospital
%
Response
65%
96%
52%
48%
31%
36%
63%
28%
32%
12%
15%
20%
41%
13%
14%
3%
4%
6%
8%
27%
4%
4%
0%
1%
1%
2%
4%
17%
2%
0%
0%
0%
1%
1%
3%
15%
1%
1%
Database Percent of Response
Number of Events
Reported by
Respondents
Min
10th
%ile
25th
%ile
50th
%ile
75th
%ile
90th
%ile
No events
5%
39%
46%
53%
59%
1 to 2 events
4%
21%
24%
27%
3 to 5 events
0%
7%
9%
6 to 10 events
0%
2%
11 to 20 events
0%
21 event reports or
more
0%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
March 2009 Trending Report for ABC Hospital, Page 22
Chapter 4. Trending: Comparing Your Hospital’s
Results Over Time
Many hospitals that have administered the hospital patient safety culture survey have
indicated that they intend to re-administer the survey on a regular basis to track changes in
patient safety culture over time. For the 2009 Comparative Database Report, your hospital
and a number of other hospitals that previously administered the survey and submitted data
for the 2008 report, also submitted data for the 2009 report based on a follow-up survey of
hospital staff. While the overall benchmarks presented earlier in this report reflect only the
most recent survey data from all 622 participating hospitals, we have data from two or
more administrations of the survey for 204 hospitals, allowing us to examine trends over
time for these hospitals. These two survey administrations allow us to examine trends over
time for your hospital as well as all the trending hospitals combined. This chapter presents
your hospital’s results from the trending analyses and allows you to compare your results to
the patient safety culture survey results for the 204 trending hospitals combined. Changes
in scores of 5% or greater are highlighted.
When reviewing the results in this chapter, it is important to keep in mind that the trending
results from these 204 hospitals represent approximately one-third of the total number of
database hospitals, and therefore the trending data should be viewed as preliminary. In
addition, there are a number of complex reasons why your survey scores or the combined
trending hospital’s survey scores might change, or not change, over time. Important factors
to consider are whether the hospital implemented patient safety initiatives between survey
administrations and the length of the time period between administrations. Survey
methodology issues can also play a big role in score changes. Low survey response rates
for either the previous or most recent administration, changes in the number of staff asked
to complete the survey, or changes in the types of staff asked to complete the survey, will
make it difficult to interpret changes in scores over time. We provide descriptive
information about some of the factors that may have affected changes in scores where
possible.
Characteristics of the 204 Trending Hospitals and Your Hospital
Table 4-1 displays summary statistics from the previous and most recent survey
administrations from the 204 trending hospitals. As shown in the table, the average number
of completed surveys increased in the most recent survey administration (from an average
of 320 to 341 respondents). Overall average response rates were similar between previous
and most recent administrations. Additional characteristics of the 204 hospitals are below:
Most of the 204 trending hospitals (74%) administered the survey to the same types of staff
in their previous and most recent administrations. Your hospital administered the survey to
All Staff or a Sample of All Staff in the previous administration and All Staff or a Sample of
All Staff in the most recent administration.
The average change in response rate from the previous administration was 2% (range: one
hospital had a decrease in response rate by 90% and one had an increase by 79%). Your
hospital’s change in response rate was 10%.
March 2009 Trending Report for ABC Hospital, Page 23
The average length of time between previous and most recent survey administrations was
16 months (range: 7 months to 35 months). Your hospital’s length of time between
administrations was 12 months, from May 2007 to May 2008.
Table 4-1. Summary Statistics for Previous and Most Recent Data Submissions from the 204
Trending Hospitals and Your Hospital
Database
Summary
Statistic
Number of
completed
surveys
Your Hospital
Previous
Most Recent
Survey
Survey
Administration Administration
Previous
Survey Administration
Most Recent
Survey Administration
Submitted for
2007 or 2008 database
Submitted for
2009 database
65,321 respondents
Average per hospital: 320
Range: 13 – 3,865
69,541 respondents
Average per hospital: 341
Range: 11 – 3,908
72
103
Average: 50%
Range: 6 – 100%
Average: 52%
Range: 7 – 100%
54%
64%
Hospital
response rate
Submitted for Submitted for
2007 or 2008
2009
database
database
As shown in Table 4-2, the distribution of trending hospitals by bed size is similar to the
distribution of AHA-registered U.S. hospitals, as well as the distribution of database hospitals.
Similar to the AHA-registered U.S. hospitals, the largest group of trending hospitals (42
hospitals or 21%) fall in the bed size category of 25 to 49 beds. The majority of the trending
hospitals (132 hospitals or 65%) have fewer than 200 beds, which is similar to the percentage of
AHA-registered U.S. hospitals with fewer than 200 beds (74%). The trending hospitals,
however, disproportionately represent a larger percentage of large hospitals (500 ore more beds),
with more than twice the percentage of hospitals in comparison to the AHA-registered U.S.
hospitals (12 %versus 5%).
Table 4-2. Distribution of 204 Trending Hospitals by Bed Size
Bed Size
6-24 beds
25-49 beds
50-99 beds
100-199 beds
200-299 beds
300-499 beds
500 or more beds
TOTAL
204 Trending
Hospitals
Number
Percent
21
10%
42
21%
37
18%
32
16%
22
11%
26
13%
24
12%
204
100%
2009 Database
Hospitals
Number
Percent
60
10%
139
22%
111
18%
111
18%
74
12%
78
13%
49
8%
622
100%
AHA-registered
U.S. Hospitals
Number
Percent
607
10%
1,374
22%
1,329
21%
1,341
21%
704
11%
607
10%
318
5%
6,280
100%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
Tables 4-3 and 4-4 show that most of the 204 trending hospitals were non-teaching (71%)
and non-government owned and controlled (69%). Again, these distributions vary when
compared to the 2009 database overall (69% non-teaching and 22% government-owned) and
when compared to AHA hospitals (77% non-teaching and 26% government-owned). Therefore,
March 2009 Trending Report for ABC Hospital, Page 24
the trending hospitals disproportionately represent a larger percentage of non-teaching hospitals
and a larger percentage of government-owned hospitals.
Table 4-3. Distribution of 204 Trending Hospitals by Teaching Status
Teaching Status
Teaching
Non-teaching
TOTAL
204 Trending
Hospitals
Number
Percent
59
29%
145
71%
204
100%
2009 Database
Hospitals
Number
Percent
190
31%
432
69%
622
100%
AHA-registered
U.S. Hospitals
Number
Percent
1,442
23%
4,838
77%
6,280
100%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
Table 4-4. Distribution of 204 Trending Hospitals by Ownership and Control
Ownership and Control
Government (Federal or non-Federal)
Non-government (voluntary/nonprofit or
proprietary/investor-owned)
TOTAL
204 Trending
Hospitals
Number Percent
63
31%
2009 Database
Hospitals
Number
Percent
139
22%
AHA-registered
U.S. Hospitals
Number Percent
1,645
26%
141
69%
483
78%
4,635
74%
204
100%
622
100%
6,280
100%
Description of Trending Statistics
Before presenting results on the changes in survey scores over time, we provide an
explanation of the trending statistics that are presented. Table 4-5a shows examples of the
statistics shown in this chapter. The tables show the average percent of respondents who
answered positively in the most recent survey administration (left column) and the previous
administration (middle column) for the 204 trending hospitals. The change over time [Most
Recent score minus (-) Previous score] is shown in the right column as a negative number
if the most recent administration showed a decline, or a positive number if the most recent
administration showed an increase. Your hospital’s data will appear in the same format in
the three columns on the far right side of the table. Changes in scores of 5 percent or
greater, whether positive or negative, are bolded.
Table 4-5a. Example of Trending Statistics
Survey Item
Most Recent
Previous
Change
Item 1
80%
84%
-4%
Item 2
80%
78%
2%
Table 4-5b shows additional trending statistics that are provided. The maximum increase
and maximum decrease show the scores for the hospitals with the largest average percent
positive score increase and the hospitals with the largest decrease. The average increase
and decrease of percent positive scores across the 204 trending hospitals is also shown. The
average increase was calculated by only including hospitals that had an increase in their
most recent score; hospitals that showed no change or decreased were not included when
calculating the average increase. Similarly, the average decrease was calculated by only
March 2009 Trending Report for ABC Hospital, Page 25
including hospitals that had a decrease in their most recent score; hospitals that showed no
change or increased were not included when calculating the average decrease.
Table 4-5b. Example of Other Trending Statistics
Item 1
Maximum
Increase
18%
Maximum
Decrease
-45%
Average
Increase
3%
Average
Decrease
-5%
Item 2
21%
-19%
5%
-6%
Survey Item
The pie charts in Charts 4-1, 4-2, and 4-3 show the percent of the 98 trending hospitals
that increased or decreased 5% or more on the composites, patient safety grades, and events
reported respectively. The percent of hospitals that increased or decreased less than 5% are
represented as “Did not change.” At the bottom of each pie chart, your hospital’s status
(i.e., increased, decreased, or did not change) is shown.
Composite and Item-level Trending Results
Table 4-6 presents trending results showing average percent positive scores on each of the
12 patient safety culture composites for your hospital as well as for the 204 trending
hospitals. Percent positive scores for the most recent and previous data
administration/submission are shown, and so are the change over time, the hospital scores
with the maximum increase and maximum decrease, and the average increase and decrease
over time across the 204 hospitals. Your hospital’s information is shown in the three
columns on the far right side of the table. Table 4-6 also shows that there was a slight
overall increase in the average change in percent positive scores over time on the patient
safety culture composites (average 2%, ranging from 1% to 3% change). For hospitals with
increases in scores over time, average increases ranged from 5% to 8%. For hospitals with
decreases in scores, average decreases ranged from -4% to -6%.
The item-level trending results in Table 4-7 show that the average change in item-level
percent positive scores over time on the patient safety culture items ranged from a 1%
increase to a 4% increase. For hospitals with increases in item scores over time, average
increases ranged from 6% to 10%. For hospitals with decreases in item scores, average
decreases ranged from -4% to -9%.
Trending results from the item that asks respondents to give their hospital work area/unit
an overall grade on patient safety are shown in Table 4-8. The average percent of
respondents giving their work area/unit a patient safety grade of “A-Excellent” and “BVery Good” increased over time by 4%.
Trending results from the item that asked respondents to indicate the number of events
they had reported over the past 12 months are shown in Table 4-9. The average percent of
respondents reporting one or more events increased slightly over time by 2%.
NOTE: Changes in scores of 5% or greater, whether positive or negative, are bolded.
March 2009 Trending Report for ABC Hospital, Page 26
Table 4-6. Trending: Composite-level Comparative Results
Database:
% Positive Response*
Patient Safety Culture Composites
Most
Recent
Previous Change
Your Hospital:
% Positive Response
Maximum
Increase
Maximum
Decrease
Average
Increase
Average
Decrease
Most
Recent
Previous
Change
1.
Teamwork Within Units
79%
77%
2%
64%
-14%
7%
-4%
88%
89%
-1%
2.
Supervisor/Manager
Expectations & Actions
Promoting Patient Safety
75%
74%
1%
39%
-19%
5%
-5%
76%
86%
-10%
3.
Organizational LearningContinuous Improvement
72%
69%
3%
61%
-17%
8%
-5%
76%
87%
-11%
4.
Management Support for
Patient Safety
71%
69%
2%
52%
-24%
8%
-6%
85%
81%
4%
5.
Overall Perceptions of Patient
Safety
65%
62%
3%
44%
-27%
7%
-6%
79%
72%
7%
6.
Feedback & Communication
About Error
63%
61%
2%
48%
-22%
7%
-5%
74%
76%
-2%
7.
Communication Openness
62%
60%
2%
38%
-23%
7%
-5%
69%
70%
-1%
8.
Frequency of Events
Reported
61%
59%
2%
37%
-28%
7%
-6%
72%
81%
-9%
9.
Teamwork Across Units
58%
56%
2%
31%
-18%
7%
-5%
70%
72%
-2%
10.
Staffing
55%
53%
2%
31%
-18%
6%
-6%
64%
54%
10%
11.
Handoffs & Transitions
45%
44%
1%
41%
-29%
6%
-6%
58%
61%
-3%
12.
Nonpunitive Response to
Error
45%
43%
2%
25%
-15%
5%
-5%
60%
52%
8%
Note: Based on data from 204 hospitals that repeated survey administration and data submission; the number of respondents was 69,541 in the most recent database and 65,321 in the
previous database.
March 2009 Trending Report for ABC Hospital, Page 27
Table 4-7. Trending: Item-level Comparative Results (Page 1 of 4)
Database:
% Positive Response*
Item
1.
A1
A3
Survey Items By Composite
Most
Maximum
Recent Previous Change Increase
Your Hospital:
% Positive Response
Maximum
Decrease
Average
Increase
Average
Decrease
Most
Recent Previous
Change
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.
85%
82%
3%
75%
-18%
8%
-4%
90%
93%
-3%
86%
84%
2%
72%
-24%
8%
-4%
93%
90%
3%
A4
3. In this unit, people treat each other
with respect.
77%
75%
2%
60%
-23%
8%
-5%
89%
92%
-3%
A11
4. When one area in this unit gets really
busy, others help out.
69%
66%
3%
48%
-19%
8%
-5%
79%
82%
-3%
72%
69%
3%
55%
-20%
10%
-5%
70%
82%
-12%
77%
74%
3%
62%
-23%
8%
-5%
75%
88%
-13%
75%
73%
2%
51%
-20%
7%
-5%
78%
80%
-2%
77%
74%
3%
60%
-22%
7%
-5%
80%
92%
-12%
82%
80%
2%
81%
-25%
8%
-5%
88%
97%
-9%
64%
61%
3%
62%
-22%
9%
-6%
63%
77%
-14%
69%
66%
3%
60%
-25%
9%
-6%
76%
87%
-11%
2.
B1
B2
B3R
B4R
3.
A6
A9
A13
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.
* Note: Based on data from 204 hospitals that repeated survey administration and data submission. The overall number of respondents was 69,541 in the most recent database and 65,321 in
the previous database, but the exact number of respondents will vary from item to item. The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the
percent positive response is based on those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
March 2009 Trending Report for ABC Hospital, Page 28
Table 4-7. Trending: Item-level Comparative Results (Page 2 of 4)
Database:
% Positive Response*
Your Hospital:
% Positive Response
Most
Recent
Previous
Change
Maximum
Increase
Maximum
Decrease
Average
Increase
Average
Decrease
Most
Recent
Previous
Change
80%
78%
2%
62%
-32%
9%
-7%
92%
90%
2%
73%
70%
3%
65%
-18%
9%
-6%
87%
84%
3%
60%
58%
2%
36%
-27%
8%
-7%
76%
68%
8%
Overall Perceptions of Patient
Safety
1. It is just by chance that more
A10R serious mistakes don’t happen
around here.
2. Patient safety is never
A15
sacrificed to get more work done.
60%
59%
1%
33%
-43%
8%
-8%
75%
72%
3%
65%
63%
2%
42%
-19%
9%
-6%
78%
68%
10%
3. We have patient safety
problems in this unit.
62%
61%
1%
41%
-46%
8%
-9%
83%
71%
12%
71%
67%
4%
63%
-21%
8%
-6%
79%
78%
1%
53%
52%
1%
47%
-32%
8%
-7%
66%
61%
5%
65%
63%
2%
47%
-26%
8%
-6%
78%
79%
-1%
70%
69%
1%
53%
-26%
9%
-6%
77%
89%
-12%
Item
4.
F1
F8
F9R
Survey Items By Composite
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.
5.
A17R
A18
6.
C1
C3
C5
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.
* Note: Based on data from 204 hospitals that repeated survey administration and data submission. The overall number of respondents was 69,541 in the most recent database and 65,321 in
the previous database, but the exact number of respondents will vary from item to item. The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the
percent positive response is based on those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
March 2009 Trending Report for ABC Hospital, Page 29
Table 4-7. Trending: Item-level Comparative Results (Page 3 of 4)
Database:
% Positive Response*
Item
7.
C2
C4
C6R
8.
D1
D2
D3
9.
F2R
F4
F6R
F10
Survey Items By Composite
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.
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?
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.
Your Hospital:
% Positive Response
Most
Recent
Previous
Change
Maximum
Increase
Maximum
Decrease
Average
Increase
Average
Decrease
Most
Recent
Previous
Change
75%
74%
1%
60%
-23%
8%
-5%
87%
86%
1%
47%
46%
1%
27%
-28%
8%
-6%
52%
51%
1%
62%
61%
1%
39%
-28%
8%
-6%
68%
74%
-6%
54%
51%
3%
37%
-34%
8%
-7%
65%
71%
-6%
57%
55%
2%
36%
-21%
8%
-6%
67%
80%
-13%
74%
72%
2%
43%
-29%
8%
-5%
83%
91%
-8%
46%
44%
2%
45%
-46%
8%
-7%
56%
64%
-8%
59%
57%
2%
36%
-25%
8%
-6%
67%
69%
-2%
58%
56%
2%
33%
-26%
8%
-6%
77%
74%
3%
68%
66%
2%
47%
-22%
8%
-6%
79%
81%
-2%
* Note: Based on data from 204 hospitals that repeated survey administration and data submission. The overall number of respondents was 69,541 in the most recent database and 65,321 in
the previous database, but the exact number of respondents will vary from item to item. The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the
percent positive response is based on those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
March 2009 Trending Report for ABC Hospital, Page 30
Table 4-7. Trending: Item-level Comparative Results (Page 4 of 4)
Database:
% Positive Response*
Item
10.
A2
A5R
Survey Items By Composite
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
A14R
to do too much, too quickly.
A7R
Handoffs & Transitions
1. Things “fall between the cracks”
F3R when transferring patients from
one unit to another.
2. Important patient care
F5R information is often lost during shift
changes.
3. Problems often occur in the
F7R exchange of information across
hospital units.
4. Shift changes are problematic
F11R
for patients in this hospital.
Your Hospital:
% Positive Response
Most
Recent
Previous
Change
Maximum
Increase
Maximum
Decrease
Average
Increase
Average
Decrease
Most
Recent
Previous
Change
54%
53%
1%
33%
-30%
9%
-8%
48%
44%
4%
52%
51%
1%
32%
-31%
7%
-7%
65%
47%
18%
65%
62%
3%
64%
-37%
10%
-7%
78%
77%
1%
50%
48%
2%
34%
-42%
8%
-6%
64%
48%
16%
42%
41%
1%
45%
-38%
7%
-6%
48%
58%
-10%
50%
48%
2%
37%
-28%
8%
-7%
63%
61%
2%
43%
42%
1%
54%
-35%
7%
-7%
53%
58%
-5%
46%
45%
1%
29%
-31%
7%
-8%
68%
67%
1%
52%
50%
2%
34%
-20%
6%
-5%
66%
53%
13%
46%
43%
3%
33%
-25%
7%
-6%
63%
56%
7%
36%
34%
2%
28%
-24%
6%
-5%
50%
48%
2%
11.
12.
Nonpunitive Response to Error
1. Staff feel like their mistakes are
A8R
held against them.
2. When an event is reported, it
A12R feels like the person is being
written up, not the problem.
3. Staff worry that mistakes they
A16R make are kept in their personnel
file.
* Note: Based on data from 204 hospitals that repeated survey administration and data submission. The overall number of respondents was 69,541 in the most recent database and 65,321 in
the previous database, but the exact number of respondents will vary from item to item. The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the
percent positive response is based on those who responded “Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
March 2009 Trending Report for ABC Hospital, Page 31
Table 4-8. Trending: Average Distribution of Work Area/Unit Patient Safety Grades
Your Hospital:
Average Percent of
Respondents
Database:
Average Percent of Respondents
Work Area/Unit
Patient Safety Grade
Most
Recent
Previous
Change
Maximum
Increase
Maximum
Decrease
Average
Increase
Average
Decrease
Most
Recent
Previous
Change
A
Excellent
25%
22%
3%
25%
-27%
7%
-5%
41%
27%
14%
B
Very Good
47%
46%
1%
74%
-42%
8%
-6%
50%
63%
-13%
C
Acceptable
23%
24%
-1%
16%
-30%
4%
-7%
8%
10%
-2%
D
Poor
5%
6%
-1%
44%
-51%
3%
-5%
1%
0%
1%
E
Failing
1%
1%
0%
18%
-20%
1%
-2%
0%
0%
0%
Note: Based on data from 204 hospitals that repeated survey administration and data submission. The overall number of respondents was 69,541 in the most recent database
and 65,321 in the previous database. Average percent positive totals in the table may not sum to exactly 100% due to rounding of decimals.
Table 4-9. Trending: Average Distribution of Number of Events Reported in the Past 12 Months
Your Hospital:
Average Percent of
Respondents
Database:
Average Percent of Respondents
Number of Events
Reported by Respondents
Most
Recent
Previous
Change
Maximum
Increase
Maximum
Decrease
Average
Increase
Average
Decrease
Most
Recent
Previous
Change
No events
52%
54%
-2%
24%
-45%
5%
-9%
48%
45%
3%
1 to 2 events
28%
26%
2%
28%
-25%
6%
-5%
32%
24%
8%
3 to 5 events
13%
12%
1%
32%
-19%
4%
-4%
14%
21%
-7%
6 to 10 events
4%
5%
-1%
12%
-13%
2%
-2%
4%
6%
-2%
11 to 20 events
2%
2%
0%
17%
-8%
2%
-1%
0%
3%
-3%
21 event reports or more
1%
1%
0%
7%
-6%
1%
-1%
1%
1%
0%
Note: Based on data from 204 hospitals that repeated survey administration and data submission. The overall number of respondents was 69,541 in the most recent database
and 65,321 in the previous database. Average percent positive totals in the table may not sum to exactly 100% due to rounding of decimals
March 2009 Trending Report for ABC Hospital, Page 32
Pie Charts of Trending Results
The pie charts in Chart 4-1 show the percentages of hospitals that increased, decreased, or
did not change by 5% or more on the 12 patient safety culture composites. These charts show
that:
• The composite with the largest percentage of hospitals that increased 5% or more was
Overall Perceptions of Patient Safety (37% of trending hospitals increased by at least 5%).
• The composite with the largest percentage of hospitals that decreased 5% or more was
Organizational Learning-Continuous Improvement (22% of trending hospitals decreased by
at least 5%).
Chart 4-2 displays results for the percent of hospitals that increased, decreased, or did not
change by 5% or more on the percent of respondents providing patient safety grades of “AExcellent” or “B-Very Good” and shows that:
• 38% of hospitals increased by 5% or more;
• 41% of hospitals had changes of less than 5%; and
• 21% of hospitals decreased by 5% or more.
Chart 4-3 displays results for the percent of hospitals that increased, decreased, or did not
change by 5% or more on the percent of respondents reporting one or more events and shows
that:
• 32% of hospitals increased by 5% or more;
• 46% of hospitals had changes of less than 5%; and
• 23% of hospitals decreased by 5% or more
Your hospital’s results are shown at the bottom of each pie chart and are compared to the
trending hospitals.
Additional Trending Analyses
The following sections present quantitative and qualitative data on changes in patient safety
culture over time. The quantitative data includes questionnaire data on actions taken by the
trending hospitals to improve their patient safety culture, as well as correlational analyses of the
actions taken with changes to Hospital Survey on Patient Safety Culture (HSOPS) scores. The
qualitative data consists of findings from nine interviews conducted with trending hospital staff
and suggest explanations for increases and decreases hospitals’ HSOPS scores.
Actions Taken by the Trending Hospitals
One hundred and sixty-five of the 204 trending hospitals (that administered the patient safety
culture survey and submitted data more than once) provided basic information about the types of
patient safety actions they had taken in between their previous and most recent survey
administrations.
March 2009 Trending Report for ABC Hospital, Page 33
Most of the trending hospitals (153 hospitals or 93 percent) reported that they had shared
their previous survey results with hospital administrators. In addition, 76 percent (125 hospitals)
reported they had also shared their previous survey results with hospital staff, but fewer had
shared the results with their Board of Directors (100 hospitals or 61 percent) or with physicians
(100 hospitals or 61 percent). Table 7-10 shows the percentages of trending hospitals that
reported they had implemented various types of actions. The action most frequently taken was
implementing SBAR (95 hospitals or 58 percent). About 10 percent (17 hospitals) indicated they
had developed action plans but had not implemented them yet.
Most of the trending hospitals (151 hospitals or 92 percent) indicated they had implemented
more than one action. Hospitals described the types of “other” actions implemented, such as:
Patient Safety Champion/Representative programs; color-coded wristbands; hand hygiene
programs; electronic medical record; medication error reduction strategies; and many other
actions. Given that the average length of time between survey administrations was 16 months, it
appears that the trending hospitals were able to begin implementation of these activities within a
relatively short period of time after their previous survey administration.
March 2009 Trending Report for ABC Hospital, Page 34
Table 4-10. Types of Patient Safety Actions Taken by the 2009 Trending Hospitals
Type of Action Taken
2009 Trending
Hospitals*
Number Percent
Implemented SBAR Communication
(Situation-Background-Assessment-Recommendation)
Made changes to policies/procedures
95
58%
92
56%
Implemented patient safety walkarounds
84
51%
Conducted training
Improved compliance with Joint Commission National Patient Safety
Goals
81
49%
65
39%
Conducted chart audits
63
38%
Improved fall prevention program
62
38%
Other action taken
59
36%
Conducted root cause analysis
58
35%
Improved error reporting system
54
33%
Purchased new hospital equipment
52
32%
Held education/patient safety fair for staff
48
29%
Formed a committee
42
25%
Conducted follow-up interviews/focus groups
29
18%
Implemented patient safety bulletin board/ suggestion box/hotline
24
15%
Implemented “Ticket to Ride” communication tool to reduce handoff risk
19
12%
Developed action plans but have not implemented them yet
17
10%
Implemented patient safety briefing(s)
16
10%
Implemented TeamSTEPPS
8
5%
*Only 165 of the 204 trending hospitals provided information about patient safety actions
they had taken.
Correlational Analyses
To explore potential reasons why some hospitals had increases in their patient safety culture
scores over time, we examined the relationship between hospital characteristics-- such as bed
size, ownership, and teaching status--and changes in patient safety culture scores over time.
Relationships were examined by calculating correlations between hospital characteristics and the
number of composites increasing by 5 percent or more per hospital. In addition, hospital
characteristics were correlated with the percent change in respondents giving their hospital a
patient safety grade of ‘Excellent’ or ‘Very Good’ and the percent change in respondents
reporting one or more events. Correlations (r) are a type of statistic that convey the extent to
which two variables have a linear relationship. Correlations range from a low of 0 to a high of
1.00 and can be either positive or negative. The closer the correlation is to 1.00 (or -1.00), the
greater the degree of association between the variables. A correlation is considered statistically
significant or not due to chance when the p-value is less than .05 (p <.05).
March 2009 Trending Report for ABC Hospital, Page 35
The following relationships were found between hospital characteristics and changes in
patient safety culture scores. These findings should be considered preliminary, as they are based
on a relatively small sample of 204 trending hospitals.
•
The smaller the hospital bed size, the greater the number of patient safety culture
composites that increased by at least 5 percent (correlation: r = -.21, p < .05) and the
greater the increase in respondents reporting one or more events (r = -.19, p < .05).
•
Non-teaching hospitals tended to increase by 5 percent or more on the composites than
teaching hospitals (r = .15, p < .05) and tended to have greater increases in respondents
reporting one or more events than teaching hospitals (r = .17, p < .05).
•
Government hospitals tended to have greater increases in respondents giving their
hospital a patient safety grade of ‘Excellent’ or ‘Very Good’ (r = .17, p < .05), and
respondents reporting one or more events (r = .20, p < .05) than non-government
hospitals.
We also examined whether hospitals that improved on Nonpunitive Response to Error also
had increases in the number of respondents who reported at least one event in the past 12
months. This finding was supported; hospitals that increased their percent positive score on
Nonpunitive Response to Error also tended to have an increase in the number of respondents
who reported at least one event in the past 12 months (correlation: r = .14, p < .05).
Interview Findings
To gain a better understanding of changes in patient safety culture and patient care practices
over time, HSOPS project team members conducted hour-long telephone interviews with staff
from nine hospitals that administered the HSOPS more than once. Six of the hospitals
experienced notable increases in their scores, and three hospitals experienced notable decreases.
Most interview participants were quality/risk managers, and one was a chief executive officer.
The nine hospitals varied with respect to system affiliation, bed size, teaching status, ownership,
and geographic region.
Explanations for notable increases in HSOPS scores. During the interviews, participants
were asked why their hospitals’ HSOPS scores increased. Some participants mentioned specific
actions including implementing the SBAR communication tool for unit-to-unit transfers, hiring a
consultant group to work with department directors on targeted patient safety problems,
addressing staffing requirements such as filling nursing vacancies and improving patient/staff
ratios, and using and displaying scorecards to monitor progress on hospital initiatives. Generally,
various themes emerged from their responses. These themes are shared here, along with
participants’ comments about actions taken by their hospitals to improve patient safety culture
and safe patient care practices. Four main themes emerged from those hospitals with notable
increases in their HSOPS scores.
March 2009 Trending Report for ABC Hospital, Page 36
Theme 1: Hospitals improved their communication between management and staff on
patient safety.
Sample Actions and Illustrative Quotes
•
•
•
•
Conducted walkarounds to learn about staff concerns about patient safety
Focused on patient safety during staff meetings
¾ One participant attributed her hospital’s improvement to “the engagement of our
department heads and nursing coordinators in making sure patient safety culture is
on everyone’s mind.”
Started conducting monthly staff meetings
Implemented Open Book Management and participated in biweekly “huddles” to review
the hospital budget, financial statements, and discuss patient safety issues and concerns
¾ “Open Book Management has had the biggest impact of all their initiatives…affected
everything we do…employees are much more aware.”
Theme 2: Hospitals focused on improving error reporting systems, responding
appropriately to reports, and applying nonpunitive “Just Culture” principles.
Sample Actions and Illustrative Quotes
•
•
•
•
Educated hospital leaders on making error reporting anonymous, easy, and convenient
¾ “When we went from a paper system to an electronic system, our reporting increased
about 40 percent – part of it was education, because we had to do a lot of education
as we rolled out the electronic system – part of it…is because it’s very easy.”
Set up a hotline for reporting errors and developed anonymous reporting forms for
medical errors
¾ “We got management to buy into that it was okay for a staff person to not provide
their name, so they wouldn’t be afraid to report.”
Trained staff to use the new reporting systems
Provided training on “Just Culture” and taught managers to use an algorithm when
examining patient safety error incidents
¾ “The algorithm helps management more than anything else.”
Theme 3: Hospitals engaged staff in developing solutions to patient safety problems.
Sample Actions and Illustrative Quotes
•
•
•
•
•
Directly involved staff in designing solutions to handoff problems
Started an employee engagement committee that includes senior leaders
Instituted nursing peer review to promote open communication
¾ “I personally think it is a combination of the employee engagement committee where
employees have a voice. I think it’s the peer review…having peers to go to, to voice
your concerns.”
Assigned staff to a scheduling team to accommodate staff preferences
Allocated resources for safety needs identified by staff—for example, buying safer beds
March 2009 Trending Report for ABC Hospital, Page 37
Theme 4: Hospitals developed, implemented, and monitored action plans, in some cases
focusing on specific survey items.
Sample Action
•
Charged department managers with developing and implementing an annual action plan
and held them accountable
Explanations for notable decreases in HSOPS scores. Hospital participants provided the
following explanations as possible reasons for decreases in their HSOPS scores in their most
recent administration of the survey.
•
•
•
•
•
•
Experienced issues among staff with specific managers and management styles,
especially regarding managers’ response to incident reports and lack of follow up on staff
feedback
¾ “They felt like the managers really didn’t act on them [incident reports] or hear them
or do anything about them…”
Had contracting issues and high turnover for managers and frontline staff – staff have had
to get used to new unit managers; some new managers were not familiar with hospital
policies on “Just Culture”
Needed to temporarily shut down hospital services because contract and financial
constraints led to a large shortage of professional providers
¾ “The staffing issue came up as part of contract problems. We’re in a fairly isolated
area, and we have a vacancy rate in the professional provider staff of about 40%.
During this time frame we also changed financial management systems. We’re not
able to hire contractors with the speed that we had in the past. We ended up running
very short and ended up closing beds and shutting services down for about an 18month period.”
Drilled down in the survey data and observed that scores were lower for larger than
smaller units – attributed the lower scores to less frequent and personal communications,
weaker sense of accountability to coworkers
Were in the middle of union negotiations and staff were feeling hostile
Struggled with organizational learning - how much information can be fed back to staff
given confidentiality requirements and concerns?
¾ “As we run into significant adverse events for patients, how much do we feed the
information back to frontline staff? Where’s that line of keeping it confidential yet
sharing our learnings with staff?”
March 2009 Trending Report for ABC Hospital, Page 38
Chart 4-1. Trending: Percentage of Hospitals that Increased, Decreased, or Did Not Change by 5 Percent at Composite Level (Page 1 of 2)
1. Teamwork Within Units
12%
3. Organizational Learning Continuous Improvement
22%
2. Supervisor/Manager Expectations &
Actions Promoting Patient Safety
14%
28%
31%
26%
60%
60%
Most Trending Hospitals: Did not change
Your Hospital: Did Not Change
Most Trending Hospitals: Did not change
Your Hospital: Decreased 5% or more
4. Management Support for
Patient Safety
14%
47%
Most Trending Hospitals: Did not change
Your Hospital: Decreased 5% or more
5. Overall Perceptions of
Patient Safety
6. Feedback & Communication
About Error
14%
18%
28%
31%
37%
49%
55%
54%
Most Trending Hospitals: Did not change
Your Hospital: Did Not Change
Most Trending Hospitals: Did not change
Your Hospital: Increased 5% or more
Most Trending Hospitals: Did not change
Your Hospital: Did Not Change
Percentage of Hospitals that:
Increased 5% or more
Decreased 5% or more
Did Not Change (<5%)
Note: Based on 204 hospitals that repeated survey administration and data submission.
March 2009 Trending Report for ABC Hospital, Page 39
Chart 4-1. Trending: Percentage of Hospitals that Increased, Decreased, or Did Not Change by 5 Percent at Composite Level (Page 2 of 2)
7. Communication Openness
20%
9. Teamwork Across Units
8. Frequency of Events Reported
21%
19%
33%
27%
32%
53%
47%
Most Trending Hospitals: Did not change
Your Hospital: Did Not Change
Most Trending Hospitals: Did not change
Your Hospital: Decreased 5% or more
48%
Most Trending Hospitals: Did not change
Your Hospital: Did Not Change
11. Handoffs & Transitions
10. Staffing
12. Nonpunitive Response to Error
14%
30%
17%
19%
30%
32%
54%
53%
51%
Most Trending Hospitals: Did not change
Your Hospital: Did Not Change
Most Trending Hospitals: Did not change
Your Hospital: Increased 5% or more
Most Trending Hospitals: Did not change
Your Hospital: Increased 5% or more
Percentage of Hospitals that:
Increased 5% or more
Decreased 5% or more
Did Not Change (<5%)
Note: Based on 204 hospitals that repeated survey administration and data submission.
March 2009 Trending Report for ABC Hospital, Page 40
Chart 4-2. Trending: Percentage of Hospitals that Increased, Decreased, or
Did Not Change by 5 Percent on Work Area/Unit Patient Safety Grade
Patient Safety Grade
21%
38%
41%
Most Trending Hospitals: Did not change
Your Hospital: Did Not Change
Percentage of Hospitals that:
Increased 5% or more
Decreased 5% or more
Did Not Change (<5%)
Note: When determining change over time, percentages for patient safety grades
“Excellent” and “Very Good” were combined.
Chart 4-3. Trending: Percentage of Hospitals that Increased, Decreased, or
Did Not Change by 5 Percent on Number of Events Reported
Number of Events Reported
22%
31%
47%
Most Trending Hospitals: Did not change
Your Hospital: Did Not Change
Percentage of Hospitals that:
Increased 5% or more
Decreased 5% or more
Did Not Change (<5%)
Note: When determining change over time, percentages of respondents who
reported 1 or more events over the past 12 months were combined.
March 2009 Trending Report for ABC Hospital, Page 41
Chapter 5. What’s Next? Action Planning for
Improvement
After the initial release of the Hospital Survey on Patient Safety Culture in November of
2004, AHRQ held a series of national conference calls to provide technical assistance and
guidance to hospitals interested in administering the survey. The seven steps of action planning
outlined in this chapter are primarily based on the third conference call presentation by an
organizational psychologist (Church, 2005; available on the AHRQ web site at
(www.ahrq.gov/qual/hospculture), and based on the book “Designing and Using Organizational
Surveys: A Seven-Step Process” (Church & Waclawski, 1998).
Seven Steps of Action Planning
While administering the Hospital Survey on Patient Safety Culture can be considered an
“intervention”—a means of educating hospital staff and building awareness about issues of
concern related to patient safety—this should not be the only goal of conducting the survey.
Administering the survey is not enough. Keep in mind that the delivery of survey results is not
the end point in the survey process, it is actually just the beginning. It is often the case that the
perceived failure of surveys as a means for creating lasting change is actually due to faulty or
nonexistent action planning or survey follow-up. Seven steps of action planning are provided to
help your hospital go beyond simply conducting a survey to realizing patient safety culture
change.
Step # 1: Understand Your Survey Results
It is important to review the survey results and interpret them before you develop action
plans. Develop an understanding of your hospital’s key strengths and areas for improvement.
Examine your hospital’s overall percent positive scores on the patient safety culture composites
and items:
•
•
Which areas were most and least positive?
How do your hospital’s results compare to the results from the database hospitals?
Next, consider examining your survey data broken down by work area/unit or staff
position.
•
•
•
•
Are there different areas for improvement for different hospital units?
Are there different areas for improvement for different hospital staff?
Do any patterns emerge?
How do your hospital’s results for these breakouts compare to the results from the
database hospitals?
Finally, if your hospital administered the survey more than once, compare your most recent
results to your previous results to examine change over time.
•
Did your hospital have an increase in its scores on any of the survey composites or items?
March 2009 Trending Report for ABC Hospital, Page 42
•
•
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 2 to 3 areas for improvement at the
hospital level. While your hospital may want to improve in almost all areas, it is better to
avoid focusing on too many issues at one time.
Step # 2: Communicate and Discuss the Survey Results
Common complaints among survey respondents are that they never get any feedback about
survey results and have no idea whether anything ever happens as a result of a survey. It is
therefore important to thank your staff for taking the time to complete the survey and let them
know that you value their input. Sharing results from the survey throughout the hospital shows
your commitment to the survey and improvement process.
Use survey feedback as an impetus for change. Feedback can be provided at the hospital
level and/or at the department or unit level. However, to ensure respondent anonymity/
confidentiality, it is important to only report data if there are enough respondents in a particular
category or group. One common rule-of-thumb recommends not reporting data if there are fewer
than 10 respondents in a category. For example, if there are only 4 respondents from a
department, that department’s data should not be reported separately because there are too few
respondents to provide complete assurance of anonymity/confidentiality.
Summaries of the survey results should be distributed throughout the hospital in a top-down
manner beginning with senior management, administrators, medical and senior leaders, and
committees, followed by department or unit managers and then staff. Managers at all levels
should be expected to carefully review the findings. Summarize key findings, but also encourage
discussion about the results throughout the hospital. What do others see in the data and how do
they interpret the results?
In some cases, it may not be completely clear why an area of patient safety culture was
particularly low. Keep in mind that surveys are only one way of examining culture, so strive for
a deeper understanding when needed, by conducting follow-up activities such as focus groups or
interviews with staff to find out more about an issue, why it is problematic, and how it can be
improved.
Step # 3: Develop Focused Action Plans
Once areas for patient safety culture improvement have been identified, formal, written
action plans need to be developed to ensure progress toward change. Hospital-wide and
department- or unit-based action plans can be developed. Major goals can be established as
hospital-wide action plans. Unit-specific goals can be fostered by encouraging and empowering
staff to develop action plans at the unit level.
Encourage action plans that are “SMART”:
• Specific
March 2009 Trending Report for ABC Hospital, Page 43
•
•
•
•
Measurable
Achievable
Relevant
Time-bound
Identify funding or other resources needed to implement action plans. It is also important
to identify quantitative and qualitative measures that can be used to evaluate progress and
the impact of changes implemented.
Step # 4: Communicate Action Plans and Deliverables
Once action plans have been developed, the plans, deliverables and expected outcomes of
the plans need to be communicated. Those directly involved or affected will need to know
their roles, responsibilities, and the time frame for implementation. Action plans and goals
should also be shared widely so that their transparency encourages further accountability
and demonstrates the hospital-wide commitments being made in response to the survey
results.
At this step it is important for senior hospital managers and leaders to understand that they
are the primary owners of the change process and that success depends on their full
commitment and support. Senior-level commitment to taking action must be strong;
without buy-in from the top, including medical leadership, improvement efforts are likely
to fail.
Step # 5: Implement Action Plans
Implementing action plans is one of the hardest steps. Taking action requires the provision
of necessary resources and support. It requires tracking quantitative and qualitative
measures of progress and success that have already been identified. It requires publicly
recognizing those individuals and units that take action to drive improvement. And it
requires adjustments along the way.
This step is critical to realizing patient safety culture improvement. While communicating
the survey results is important, taking action makes the real difference. However, as the
Institute for Healthcare Improvement (IHI, 2006) suggests, actions do not have to be major,
permanent changes that are enacted. In fact, it is worthwhile to strive to implement easier,
smaller changes that are likely to have a positive impact rather than big changes with
unknown probability of success.
The “Plan-Do-Study-Act” cycle (Langley et al, 1996) is a pilot-study approach to change
that involves first developing a small-scale plan to test a proposed change (Plan), carrying
out the plan (Do), observing and learning from the consequences (Study), and determining
what modifications should be made to the plan (Act). Implementation of action plans can
occur on a small scale, within a single unit, to examine impact and refine plans before
rolling out the changes on a larger scale to other units or hospitals.
March 2009 Trending Report for ABC Hospital, Page 44
Step # 6: Track Progress and Evaluate Impact
Use quantitative and qualitative measures to review progress and evaluate whether a
specific change actually leads to improvement. Ensure that there is timely communication
of progress toward action plans on a regular basis. If you determine that a change has
worked, communicate that success to staff by telling them what was changed, and that it
was done in response to the safety culture survey results. Be sure to make the connection to
the survey so that the next time the survey is administered, staff will know that it will be
worthwhile to participate again because actions were taken based on the prior survey’s
results. Alternatively, your evaluation may discover that a change is not working as
expected or has failed to reach its goals and will need to be modified or replaced by another
approach. Before dropping the effort completely, try to determine why it failed and whether
adjustments might be worth trying.
Keep in mind that it is important not to reassess culture too frequently because lasting
culture change will be slow and may take years. Frequent assessments of culture are likely
to find temporary shifts or improvements that may come back down to baseline levels in
the longer term if changes are not sustained. When planning to reassess culture, it is also
very important to obtain high survey response rates. Otherwise, it will not be clear whether
changes in survey results over time are due to true changes in attitudes, or due to the fact
that you may be surveying different staff each time.
Step # 7: Share What Works
In step six, you tracked measures to be able to identify which changes result in
improvement. Once your hospital has found effective ways to address a particular area, the
changes can be implemented on a broader scale to other departments within the hospital
and to other hospitals. Be sure to share your successes with outside hospitals and healthcare
systems as well.
March 2009 Trending Report for ABC Hospital, Page 45
References
Church, A.H. The Importance of Taking Action, Not Just Sharing Survey Feedback.
Powerpoint presentation for the Third Technical Assistance Conference Call: Hospital
Survey on Patient Safety Culture (http://www.ahrq.gov/qual/hospculture), April 2005.
Church, A.H. and Waclawski, J. Designing and Using Organizational Surveys: A SevenStep Process. San Francisco: Jossey-Bass, 1998.
Hospital Survey on Patient Safety Culture. Rockville, MD: Agency for Healthcare
Research and Quality (http://www.ahrq.gov/qual/hospculture), 2004.
Institute for Healthcare Improvement (IHI). Improvement methods: The Plan-Do-Study-Act
(PDSA) cycle.
(http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove),
2006.
Langley, C., Nolan, K., Nolan, T., Norman, C., and Provost, L. The Improvement Guide: A
Practical Approach to Improving Organizational Performance. San Francisco: JosseyBass, 1996.
March 2009 Trending Report for ABC Hospital, Page 46
Notes: Description of Data Cleaning and Calculations
This notes section provides additional detail regarding how various statistics presented in
this report were calculated.
Data Cleaning
Each participating hospital was asked to submit cleaned, individual-level survey data.
However, as an additional check, once the data were submitted, response frequencies were
run on each hospital’s data to look for out-of-range values, missing variables, or other data
anomalies. In instances where data problems were found, hospitals were contacted, asked
to make corrections and resubmit their data. In addition, each participating hospital was
sent a copy of their data frequencies as an additional way for the hospitals to verify that the
dataset received was correct.
Response Rates
As part of the data submission process, hospitals were asked to provide their response rate
numerator and denominator. Response rates were calculated using the formula below.
Response Rate =
Number of complete, returned surveys
Number of surveys distributed – Ineligibles
Numerator = Number of complete, returned surveys. The numerator equals the number of
individual survey records submitted to the database. It should exclude surveys that were
returned blank on all non-demographic survey items, but include surveys where at least one
non-demographic survey item was answered.
Denominator = The total number of surveys distributed minus ineligibles. Ineligibles
include deceased individuals or those who were not employed at the hospital during data
collection.
As a data cleaning step, we examined whether any individual survey records submitted to
the database were missing responses on all of the non-demographic survey items
(indicating the respondent did not answer any of the main survey questions). Records
where all non-demographic survey items were missing 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
To calculate your hospital’s composite score, simply average the percent of positive
response on each item that is in the composite. Here is an example of computing a
composite score for Overall Perceptions of Patient Safety:
March 2009 Trending Report for ABC Hospital, Page 47
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 percent of positive response at the item level (see example in Table 1).
Table 1. Example of Computing Item and Composite Percent Positive Scores
For positively
worded items,
count the # of
“Strongly agree” or
“Agree” responses
For negatively worded
items, count the # of
“Strongly disagree” or
“Disagree” responses
Total # of
responses
to the item
Percent
positive
response on
item
“Patient safety is never
sacrificed to get more work
done”
Item A18-positively worded
120
NA*
260
120/260=46%
“Our procedures and systems
are good at preventing errors
from happening”
Item A10-negatively worded
130
NA*
250
130/250=52%
“It is just by chance that more
serious mistakes don’t
happen around here”
Item A17-negatively worded
NA*
110
240
110/240=46%
“We have patient safety
problems in this unit”
NA*
140
250
140/250= 56%
Four items measuring
"Overall Perceptions of
Patient Safety"
Item A15-positively worded
* NA = Not applicable
Composite Score % Positive = (46% + 52% + 46% + 56%) / 4 = 50%
In this example, there were 4 items with percent positive response scores of 46%, 52%,
46%, and 56%. Averaging these item-level percent positive scores results in a composite
score of .50 or 50% on Overall Perceptions of Patient Safety. In this example, an average of
about 50% of the respondents responded positively on the survey items in this composite.
Once you have calculated your hospital’s percent positive response on each of the 12 safety
culture composites, you can compare your results with the composite-level results from the
622 database hospitals.
Note that the method described above for calculating composite scores is slightly different
than the method described in the September 2004 Survey User’s Guide that is part of the
original survey toolkit materials on the AHRQ web site. The Guide advises computing
composites by calculating the overall percent positive across all the items within a
composite. The updated recommendation included in this report is to compute item percent
positive scores first, and then average the item percent positive scores to obtain the
composite score, which gives equal weight to each item in a composite. The Survey User’s
Guide will eventually be updated to reflect this slight change in methodology.
March 2009 Trending Report for ABC Hospital, Page 48
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.
For example, to calculate the 10th percentile, one would multiply 622 (the total number of
hospitals) by .10 (10th percentile). The product of n x p is equal to “j+g” where “j” is the
integer and “g” is the number after the decimal. If “g” equals 0, the percentile is equal to
the percent positive value of the hospital in the jth position plus the percent positive value of
the hospital in the jth +1 position, all divided by two [(X(j) + X(j+1))/2]. If “g” is not equal to
0, the percentile is equal to the percent positive value of the hospital in the jth +1 position.
The following examples show how the 10th and 50th percentiles would be computed using a
sample of percent positive scores from 12 hospitals (using fake data shown in Table 2).
First, the percent positive scores are sorted from low to high on Composite “A.”
Table 2. Data Table for Example of How to Compute Percentiles
Composite “A”
Hospital
% Positive Score
1
33%
2
48%
Å10th percentile score = 48%
3
52%
4
60%
5
63%
6
64%
Å50th percentile score = 65%
7
66%
8
70%
9
72%
10
75%
11
75%
12
78%
10th percentile
1. For the 10th percentile, we would first multiply the number of hospitals by .10 (n x p =
12 x .10 = 1.2).
2. The product of n x p = 1.2, where “j” = 1 and “g” = 2. Since “g” is not equal to 0, the 10th
percentile score is equal to the percent positive value of the hospital in the jth +1 position:
a. “j” equals 1
b. The 10th percentile equals the value for the hospital in the 2nd position = 48%
50th Percentile
1. For the 50th percentile, we would first multiply the number of hospitals by .50 (n x p =
12 x .50 = 6.0).
2. The product of n x p = 6.0, where “j” = 6 and “g” = 0. Since “g” = 0, the 50th percentile
score is equal to the percent positive value of the hospital in the jth position plus the percent
positive value of the hospital in the jth +1 position, all divided by two:
a. “j” equals 6
b. The 50th percentile equals the average of the hospitals in the 6th and 7th position
(64%+66%)/2 = 65%
March 2009 Trending Report for ABC Hospital, Page 49
Hospital Survey on Patient Safety Culture
2009 Comparative Database
Report for Trending Hospitals
ABC Hospital
Nowhere, USA
Part II: Appendix A— Overall Results by Respondent
Characteristics
Appendix B— Trending Results by Respondent
Characteristics
March 2009
Report prepared by:
Westat
1650 Research Blvd.
Rockville, MD 20850
Email: [email protected]
Funded by:
Agency for Healthcare Research and Quality (AHRQ)
U.S. Department of Health and Human Services (HHS)
540 Gaither Road
Rockville, MD 20850
http://www.ahrq.gov
List of Tables
Page
Appendix A: Overall Results by Respondent Characteristics—.............................................. 1
Table A-1. Composite-level Average % Positive Response by Respondent Work Area/Unit....... 2
Table A-2. Item-level Average % Positive Response by Respondent Work Area/Unit................. 4
Table A-3. Average % Distribution of Work Area/Unit Patient Safety Grade by Respondent
Work Area/Unit ....................................................................................................... 10
Table A-4. Average % Distribution of Number of Events Reported in the Past 12 Months by
Respondent Work Area/Unit................................................................................... 11
Table A-5. Composite-level Average % Positive Response by Respondent Staff Position......... 13
Table A-6. Item-level Average % Positive Response by Respondent Staff Position................... 15
Table A-7. Average % Distribution of Work Area/Unit Patient Safety Grade by Respondent
Staff Position.............................................................................................................21
Table A-8. Average % Distribution of Number of Events Reported in the Past 12 Months by
Respondent Staff Position....................................................................................... 22
Table A-9. Composite-level Average % Positive Response by Respondent Interaction with
Patients..................................................................................................................... 24
Table A-10. Item-level Average % Positive Response by Respondent Interaction
with Patients............................................................................................................. 25
Table A-11. Average % Distribution of Work Area/Unit Patient Safety Grade by Respondent
Interaction With Patients.......................................................................................... 29
Table A-12. Average % Distribution of Number of Events Reported in the Past 12 Months by
Respondent Interaction With Patients...................................................................... 29
Appendix B: Trending Results by Respondent Characteristics— ......................................... 30
Table B-1. Trending: Composite-level Average % Positive Response by Respondent Work
Area/Unit.................................................................................................................. 31
Table B-2. Trending: Item-level % Positive Response by Respondent Work Area/Unit............ 33
Table B-3. Trending: Average % Distribution of Work Area/Unit Patient Safety Grade by
Respondent Work Area/Unit.................................................................................... 39
Table B-4. Trending: Average % Distribution of Number of Events Reported in the Past
12 Months by Respondent Work Area/Unit ............................................................ 40
Table B-5. Trending: Composite-level Average % Positive Response by Respondent Staff
Position .................................................................................................................... 42
Table B-6. Trending: Item-level % Positive Response by Respondent Staff Position................. 44
Table B-7. Trending: Average % Distribution of Work Area/Unit Patient Safety Grade by
Respondent Staff Position........................................................................................ 50
Table B-8. Trending: Average % Distribution of Number of Events Reported in the Past
12 Months by Respondent Staff Position................................................................. 51
Table B-9. Trending: Composite-level Average % Positive Response by Respondent Interaction
with Patients............................................................................................................. 53
Table B-10. Trending: Item-level Average % Positive Response by Respondent Interaction
with Patients............................................................................................................. 55
Table B-11. Trending: Average % Distribution of Work Area/Unit Patient Safety Grade by
Respondent Interaction With Patients...................................................................... 61
Table B-12. Trending: Average % Distribution of Number of Events Reported in the Past 12
Months by Respondent Interaction With Patients ................................................... 62
Appendix A: Overall Results by Respondent
Characteristics
Appendix A presents data tables that show average percent positive scores on the survey
composites and items across database hospitals compared to percent positive scores from your
hospital, broken down by the following respondent characteristics:
Appendix A: Overall Results by Respondent Characteristics
¾ Work area/unit
¾ Staff position
¾ Interaction with patients
In the bottom row of the composite-level tables, an overall average across composite scores
is shown as a summary statistic when comparing across breakout categories.
To ensure hospital confidentiality, a rule was established requiring at least 20 hospitals to be
in a particular breakout category before data would be displayed by that category.
You can compare your hospital’s percent positive scores against the averages shown in
Appendix A by respondent work areas, staff positions, and respondent interaction with patients.
You can use a 5% difference as a rule of thumb for determining what differences to pay attention
to.
Hospitals that did not ask respondents for their work area/unit, staff position, or about
interaction with patients will have a hyphen (-) in Appendix A showing that no data are
available. In addition, a rule was established requiring at least 10 respondents to be in a particular
breakout category before data would be displayed by that category. Therefore, in Appendix A,
work areas, staff positions, and respondent interaction levels may have a hyphen (-) if there were
9 or fewer respondents in a category. Furthermore, respondents who selected “Many different
work areas/No specific work area” (for their work area), “Other” (for their work area or staff
position), or did not answer (missing) were not included in the breakout tables in Appendix A.
Appendix B: Trending Results by Respondent
Characteristics
Appendix B, shows trends over time for the 204 hospitals (of the 622 total database
hospitals) that administered the survey and submitted data twice. Average percent positive scores
across hospitals from the most recent and previous administrations are shown on the survey
composites and items, broken down by the following respondent characteristics:
Appendix B: Trending Results by Respondent Characteristics
¾ Work area/unit
¾ Staff position
¾ Interaction with patients
Tables 1 and 2 below show examples of the statistics shown in this appendix. The tables
show the average percent of respondents who answered positively among the trending hospitals
for the hospitals’ most recent survey administration (top row) and their previous administration
(middle row). The change over time is shown in the bottom row as a negative number if the most
recent administration showed a decline, or is shown as a positive number if the most recent
administration showed an increase. Changes in scores of 5% or greater, whether positive or
negative, are bolded.
Table 1: Example of Decrease in Average Score Over Time (Negative Change)
Most Recent
Previous
Change
85%
90%
-5%
Table 2: Example of Increase in Average Score Over Time (Positive Change)
Most Recent
Previous
Change
70%
60%
10%
Hospitals that did not ask respondents for their work area/unit, staff position, or about
interaction with patients will have a hyphen (-) in Appendix B showing that no data are
available. In addition, a rule was established requiring at least 10 respondents to be in a particular
breakout category before data would be displayed by that category. Therefore, in Appendix B,
work areas, staff positions, and respondent interaction levels may have a hyphen (-) if there were
9 or fewer respondents in a category. Furthermore, respondents who selected “Many different
work areas/No specific work area” (for their work area), “Other” (for their work area or staff
position), or did not answer (missing) were not included in the breakout tables in Appendix B.
Appendix A: Overall Results by Respondent Characteristics—
(1) Work Area/Unit
NOTE 1: Hospitals that did not ask respondents to indicate their work area/unit were excluded from these breakout tables. In addition,
respondents who selected “Many different work areas/No specific work area,” “Other,” or did not answer (missing) were not included.
NOTE 2: The number of database respondents in each work area/unit is shown. However, the precise number of database respondents
corresponding to each data cell in the tables will vary because hospitals may have omitted a specific survey item and because of individual
non-response/missing data.
NOTE 3: Your hospital’s number of respondents in each work area/unit is shown. However, the precise number of respondents
corresponding to each of your hospital’s data cells in the tables will vary because of individual non-response/missing data.
Your hospital’s results are shown in the second row underneath the average results for the database hospitals but are only displayed if
there were at least 10 respondents in a particular work area/unit (to protect individual respondent confidentiality in these areas). If there
were 9 or fewer respondents in a particular work area/unit, a hyphen (-) is shown.
March 2009 Trending Report for ABC Hospital, Appendix Page 1
Table A-1. Composite-level Average Percent Positive Response by Work Area/Unit (Page 1 of 2)
Work Area/Unit
Patient Safety Culture Composites
Database: # Respondents
Your Hospital: # Respondents
1. Teamwork Within Units
2. Supv/Mgr Expectations &
Actions Promoting Patient
Safety
3. Org Learning-Continuous Improvement
4. Mgmt Support for Patient
Safety
5. Overall Perceptions of
Patient Safety
6. Feedback &
Communication About
Error
7. Communication
Openness
Pharmacy
Psych/
Mental
Health
Radiology
Rehabilitation
Surgery
4,534
5,226
4,298
10,528
7,429
17,393
0
10
6
4
25
8
0
74%
80%
80%
78%
79%
79%
86%
78%
-
-
-
100%
-
-
89%
-
-
72%
75%
72%
73%
75%
77%
76%
76%
81%
74%
64%
91%
-
-
-
98%
-
-
78%
-
-
71%
65%
69%
72%
69%
69%
72%
75%
70%
69%
74%
74%
Your
Hospital
-
66%
80%
-
-
-
93%
-
-
80%
-
-
Database
65%
62%
59%
71%
65%
66%
67%
70%
67%
72%
75%
68%
Your
Hospital
-
76%
97%
-
-
-
97%
-
-
95%
-
-
Database
64%
55%
56%
70%
55%
61%
65%
65%
59%
72%
76%
67%
Your
Hospital
-
72%
93%
-
-
98%
-
-
78%
-
-
Database
64%
56%
56%
65%
57%
60%
61%
67%
66%
63%
70%
64%
Your
Hospital
-
60%
77%
-
-
-
100%
-
-
82%
-
-
Database
66%
61%
61%
63%
56%
63%
63%
70%
63%
64%
72%
64%
Your
Hospital
-
53%
76%
-
-
-
93%
-
-
69%
-
-
Anesthesiology
Emergency
Medicine
Obstetrics
Pediatrics
ICU
Lab
106,839
91
1,184
9,703
12,040
9,273
17,143
8,088
0
22
11
2
3
Database
79%
79%
83%
79%
Your
Hospital
-
77%
89%
Database
74%
72%
Your
Hospital
-
Database
Dataset
-
NOTE: Respondents who selected "Many different work areas/No specific work area," "Other," and missing are not shown.
March 2009 Trending Report for ABC Hospital, Appendix Page 2
Table A-1. Composite-level Average Percent Positive Response by Work Area/Unit (Page 2 of 2)
Work Area/Unit
Patient Safety Culture Composites
Database: # Respondents
Your Hospital: # Respondents
8. Frequency of Events
Reported
9. Teamwork Across Units
10. Staffing
11. Handoffs & Transitions
12. Nonpunitive Response to
Error
Average Across Composites
Pharmacy
Psych/
Mental
Health
Radiology
Rehabilitation
Surgery
4,534
5,226
4,298
10,528
7,429
17,393
0
10
6
4
25
8
0
61%
60%
60%
59%
63%
54%
61%
64%
-
-
-
100%
-
-
84%
-
-
53%
56%
56%
54%
53%
55%
53%
56%
61%
53%
67%
67%
-
-
-
93%
-
-
78%
-
-
58%
49%
52%
54%
50%
56%
58%
56%
55%
62%
62%
56%
Your
Hospital
-
56%
63%
-
-
-
95%
-
-
55%
-
-
Database
41%
48%
47%
37%
47%
53%
46%
32%
39%
41%
40%
40%
Your
Hospital
-
62%
40%
-
-
-
95%
-
-
56%
-
-
Database
44%
37%
39%
43%
39%
42%
41%
56%
46%
46%
59%
45%
Your
Hospital
-
35%
74%
-
-
-
90%
-
-
62%
-
-
Database
62%
57%
59%
62%
58%
61%
62%
63%
61%
63%
68%
62%
Your
Hospital
-
62%
77%
-
-
-
96%
-
-
75%
-
-
Anesthesiology
Emergency
Medicine
Obstetrics
Pediatrics
ICU
Lab
106,839
91
1,184
9,703
12,040
9,273
17,143
8,088
0
22
11
2
3
Database
58%
56%
56%
64%
Your
Hospital
-
54%
79%
Database
54%
48%
Your
Hospital
-
Database
Dataset
NOTE: Respondents who selected "Many different work areas/No specific work area," "Other," and missing are not shown.
March 2009 Trending Report for ABC Hospital, Appendix Page 3
Table A-2. Item-level Average Percent Positive Response by Work Area/Unit (Page 1 of 6)
Work Area/Unit
Item
Survey Items by Composite
Database: # Respondents
Your Hospital: # Respondents
1.
Teamwork Within Units
A1
1. People support one another
in this unit.
A3
2. When a lot of work needs to
be done quickly, we work
together as a team to get the
work done.
A4
3. In this unit, people treat each
other with respect.
A11
2.
B1
B2
4. When one area in this unit
gets really busy, others help
out.
Supv/Mgr 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.
B3
R
3. Whenever pressure builds
up, my supv/mgr wants us to
work faster, even if it means
taking shortcuts.
B4
R
4. My supv/mgr overlooks
patient safety problems that
happen over and over.
Anesthesiology
Dataset
Emergency
ICU
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mental
Health
Radiology
Rehabilitation
Surgery
91
1,184
0
9,703 12,040
22
11
9,273
2
17,143
3
8,088
0
4,534
10
5,226
6
4,298
4
10,528
25
7,429
8
17,393
0
Database
85%
85%
88%
83%
83%
87%
86%
85%
84%
85%
91%
83%
-
77%
100%
-
-
-
100%
-
-
96%
-
-
87%
87%
88%
85%
80%
88%
87%
84%
84%
87%
90%
87%
Your
Hospital
-
86%
82%
-
-
-
100%
-
-
96%
-
-
Database
78%
75%
80%
76%
74%
77%
80%
78%
79%
77%
88%
74%
Your
Hospital
-
73%
100%
-
-
-
100%
-
-
88%
-
-
Database
65%
70%
74%
70%
61%
68%
67%
67%
70%
66%
76%
65%
Your
Hospital
-
73%
73%
-
-
-
100%
-
-
75%
-
-
Database
70%
69%
68%
69%
70%
70%
71%
71%
74%
69%
77%
71%
Your
Hospital
-
45%
91%
-
-
-
90%
-
-
83%
-
-
Database
76%
73%
73%
74%
73%
74%
76%
80%
77%
77%
84%
76%
Your
Hospital
-
59%
100%
-
-
-
100%
-
-
83%
-
-
Database
74%
72%
70%
80%
72%
72%
75%
78%
73%
78%
80%
71%
Your
Hospital
-
73%
82%
-
-
-
100%
-
-
75%
-
-
Database
76%
75%
75%
77%
74%
76%
78%
79%
78%
80%
84%
77%
106,839
Your
Hospital
Database
Your
77% 91%
100%
71%
Hospital
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 4
-
Table A-2. Item-level Average Percent Positive Response by Work Area/Unit (Page 2 of 6)
Work Area/Unit
Item
3.
A6
A9
A13
Surgery
4,534
10
5,226
6
4,298
4
10,528
25
7,429
8
17,393
0
80%
84%
87%
81%
80%
88%
86%
-
-
100%
-
-
88%
-
-
69%
59%
61%
60%
73%
60%
62%
62%
64%
50%
-
-
-
90%
-
-
70%
-
-
62%
67%
66%
68%
67%
71%
66%
69%
65%
73%
71%
-
64%
91%
-
-
-
90%
-
-
83%
-
-
Pediatrics
ICU
Lab
91
1,184
0
9,703
22
12,040
11
9,273
2
17,143
3
8,088
0
Database
85%
77%
83%
80%
81%
Your
Hospital
-
86%
100%
-
Database
63%
56%
57%
Your
Hospital
-
50%
Database
64%
Your
Hospital
Database: # Respondents
Your Hospital: # Respondents
Organizational Learning—
Continuous Improvement
106,839
3. After we make changes to
improve patient safety, we
evaluate their effectiveness.
Rehabilitation
Medicine
Obstetrics
Dataset
2. Mistakes have led to positive
changes here.
Radiology
Emergency
Survey Items by Composite
1. We are actively doing things
to improve patient safety.
Pharmacy
Psych/
Mental
Health
Anesthesiology
4.
Mgmt Support for Patient
Safety
1. Hospital mgmt provides a
work climate that promotes
patient safety.
Database
75%
70%
68%
81%
73%
76%
76%
77%
75%
83%
84%
78%
F1
Your
Hospital
-
86%
100%
-
-
-
100%
-
-
96%
-
-
2. The actions of hospital mgmt
show that patient safety is a top
priority.
Database
67%
63%
61%
73%
67%
68%
68%
71%
68%
74%
77%
69%
Your
Hospital
-
77%
100%
-
-
-
100%
-
-
100%
-
-
Database
54%
52%
49%
60%
55%
54%
55%
61%
58%
60%
63%
58%
F8
F9
R
3. Hospital mgmt seems
interested in patient safety only
after an adverse event
happens.
Your
64%
90%
90%
88%
Hospital
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 5
-
Table A-2. Item-level Average Percent Positive Response by Work Area/Unit (Page 3 of 6)
Work Area/Unit
Item
5.
Survey Items by Composite
Database: # Respondents
Your Hospital: # Respondents
Overall Perceptions of
Patient Safety
Anesthesiology
Emergency
ICU
Lab
91
1,184
0
9,703
22
12,040
11
Dataset
106,839
Pharmacy
Psych/
Mental
Health
Radiology
Rehabilitation
Surgery
4,534
10
5,226
6
4,298
4
10,528
25
7,429
8
17,393
0
Medicine
Obstetrics
Pediatrics
9,273
2
17,143
3
8,088
0
A10
R
1. It is just by chance that
more serious mistakes don’t
happen around here.
Database
63%
52%
54%
64%
53%
60%
62%
62%
58%
67%
74%
63%
Your
Hospital
-
64%
91%
-
-
-
100
%
-
-
76%
-
-
2. Patient safety is never
sacrificed to get more work
done.
Database
58%
55%
51%
70%
54%
55%
64%
63%
62%
74%
76%
64%
A15
Your
Hospital
-
64%
91%
-
-
-
100
%
-
-
80%
-
-
Database
64%
51%
55%
70%
50%
60%
62%
62%
50%
72%
74%
66%
Your
Hospital
-
73%
100
%
-
-
-
90%
-
-
88%
-
-
Database
72%
61%
63%
78%
63%
68%
71%
72%
68%
75%
79%
75%
Your
Hospital
-
86%
90%
-
-
-
100
%
-
-
67%
-
-
Database
55%
48%
47%
52%
50%
53%
52%
53%
59%
51%
61%
53%
Your
Hospital
-
48%
70%
-
-
-
100
%
-
-
70%
-
-
Database
61%
57%
55%
69%
55%
59%
62%
73%
67%
69%
70%
65%
Your
Hospital
-
71%
80%
-
-
-
100
%
-
-
88%
-
-
Database
74%
63%
64%
72%
65%
68%
68%
75%
73%
70%
79%
73%
Your
Hospital
-
62%
82%
-
-
-
100
%
-
-
88%
-
-
A17
R
3. We have patient safety
problems in this unit.
A18
4. Our procedures and
systems are good at
preventing errors from
happening.
6.
Feedback and
Communication About Error
C1
1. We are given feedback
about changes put into place
based on event reports.
C3
C5
2. We are informed about
errors that happen in this unit.
3. In this unit, we discuss
ways to prevent errors from
happening again.
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 6
Table A-2. Item-level Average Percent Positive Response by Work Area/Unit (Page 4 of 6)
Work Area/Unit
Item
Survey Items by Composite
Database: # Respondents
Your Hospital: # Respondents
Anesthesiology
Emergency
ICU
Lab
91
1,184
0
9,703
22
12,040
11
Dataset
106,839
Pharmacy
Psych/
Mental
Health
Radiology
Rehabilitation
Surgery
4,534
10
5,226
6
4,298
4
10,528
25
7,429
8
17,393
0
Medicine
Obstetrics
Pediatrics
9,273
2
17,143
3
8,088
0
7.
Communication Openness
1. Staff will freely speak up if
they see something that may
negatively affect patient care.
Database
76%
74%
75%
76%
71%
78%
78%
79%
77%
79%
84%
80%
C2
Your
Hospital
-
67%
100%
-
-
-
100%
-
-
92%
-
-
2. Staff feel free to question
the decisions or actions of
those with more authority.
Database
53%
48%
44%
47%
40%
48%
49%
58%
50%
47%
57%
48%
Your
Hospital
-
50%
45%
-
-
-
90%
-
-
48%
-
-
3. Staff are afraid to ask
questions when something
does not seem right.
Database
68%
63%
63%
66%
56%
63%
63%
72%
63%
67%
73%
63%
Your
Hospital
-
43%
82%
-
-
-
90%
-
-
68%
-
-
1. When a mistake is made,
but is caught and corrected
before affecting the patient,
how often is this reported?
Database
53%
44%
44%
55%
50%
50%
50%
46%
55%
44%
54%
57%
Your
Hospital
-
38%
70%
-
-
-
100%
-
-
78%
-
-
2. When a mistake is made,
but has no potential to harm
the patient, how often is this
reported?
Database
52%
53%
52%
58%
58%
56%
56%
57%
59%
48%
56%
60%
Your
Hospital
-
48%
78%
-
-
-
100%
-
-
77%
-
-
3. When a mistake is made
that could harm the patient,
but does not, how often is this
reported?
Database
70%
71%
71%
80%
74%
74%
74%
75%
74%
69%
73%
75%
Your
Hospital
-
76%
89%
-
-
-
100
%
-
-
95%
-
-
C4
C6
R
8.
D1
D2
D3
Frequency of Events
Reported
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 7
Table A-2. Item-level Average Percent Positive Response by Work Area/Unit (Page 5 of 6)
Work Area/Unit
Item
Survey Items by Composite
Database: # Respondents
Your Hospital: # Respondents
Anesthesiology
Emergency
ICU
Lab
91
1,184
0
9,703
22
12,040
11
Dataset
106,839
Pharmacy
Psych/
Ment
Health
Radiology
Rehabilitation
Surgery
4,534
10
5,226
6
4,298
4
10,528
25
7,429
8
17,393
0
Medicine
Obstetrics
Pediatrics
9,273
2
17,143
3
8,088
0
9.
Teamwork Across Units
F2
R
1. Hospital units do not
coordinate well with each
other.
Database
39%
38%
39%
43%
43%
39%
41%
43%
39%
43%
47%
40%
Your
Hospital
-
50%
55%
-
-
-
80%
-
-
63%
-
-
2. There is good cooperation
among hospital units that
need to work together.
Database
53%
48%
52%
58%
56%
56%
54%
55%
52%
58%
61%
53%
F4
Your
Hospital
-
68%
50%
-
-
-
90%
-
-
83%
-
-
F6
R
3. It is often unpleasant to
work with staff from other
hospital units.
Database
58%
51%
60%
56%
60%
57%
60%
56%
65%
55%
-
77%
73%
-
-
-
56%
100
%
58%
Your
Hospital
-
-
79%
-
-
4. Hospital units work well
together to provide the best
care for patients.
Database
64%
57%
60%
66%
64%
65%
61%
66%
70%
62%
Your
Hospital
-
73%
90%
-
-
-
62%
100
%
65%
F10
-
-
88%
-
-
Database
62%
43%
48%
49%
44%
53%
57%
51%
51%
60%
56%
55%
Your
Hospital
-
36%
18%
-
-
-
90%
-
-
44%
-
-
10.
Staffing
A2
1. We have enough staff to
handle the workload.
A5
R
2. Staff in this unit work longer
hours than is best for patient
care.
Database
49%
51%
51%
55%
48%
52%
54%
56%
53%
58%
60%
49%
Your
Hospital
-
55%
80%
-
-
-
90%
-
-
48%
-
-
A7
R
3. We use more
agency/temporary staff than is
best for patient care.
Database
68%
63%
64%
66%
64%
73%
69%
67%
73%
70%
70%
Your
Hospital
-
77%
70%
-
-
-
73%
100
%
-
-
75%
-
-
A14
R
4. We work in “crisis mode”
trying to do too much, too
quickly.
Database
54%
40%
46%
48%
43%
47%
51%
55%
62%
49%
-
57%
82%
-
-
-
51%
100
%
48%
Your
Hospital
-
-
52%
-
-
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 8
Table A-2. Item-level Average Percent Positive Response by Work Area/Unit (Page 6 of 6)
Work Area/Unit
Item
Survey Items by Composite
Database: # Respondents
Your Hospital: # Respondents
Anesthesiology
Emergency
ICU
Lab
91
1,184
0
9,703
22
12,040
11
Database
39%
46%
Your
Hospital
-
Dataset
106,839
Pharmacy
Psych/
Mental
Health
Radiology
Rehabilitation
Surgery
4,534
10
5,226
6
4,298
4
10,528
25
7,429
8
17,393
0
44%
41%
26%
33%
40%
38%
40%
-
-
90%
-
-
57%
-
-
Medicine
Obstetrics
Pediatrics
9,273
2
17,143
3
8,088
0
37%
29%
42%
52%
20%
-
11.
Handoffs & Transitions
F3
R
1. Things “fall between the
cracks” when transferring
patients from one unit to
another.
F5
R
2. Important patient care
information is often lost
during shift changes.
Database
45%
57%
58%
44%
51%
63%
52%
36%
46%
46%
42%
45%
Your
Hospital
-
82%
50%
-
-
-
90%
-
-
48%
-
-
F7
R
3. Problems often occur in
the exchange of information
across hospital units.
Database
40%
45%
41%
36%
44%
46%
35%
39%
41%
39%
-
36%
50%
-
-
-
40%
100
%
33%
Your
Hospital
-
-
64%
-
-
F11
R
4. Shift changes are
problematic for patients in
this hospital.
Database
37%
46%
53%
40%
48%
59%
34%
42%
41%
37%
36%
Your
Hospital
-
77%
40%
-
-
-
48%
100
%
-
-
57%
-
-
Database
54%
45%
47%
51%
46%
49%
50%
63%
52%
52%
65%
51%
Your
Hospital
-
36%
91%
-
-
-
90%
-
-
72%
-
-
Database
42%
38%
41%
44%
42%
44%
45%
57%
51%
46%
59%
47%
Your
Hospital
-
36%
70%
-
-
-
90%
-
-
75%
-
-
Database
36%
29%
30%
33%
30%
31%
29%
49%
37%
39%
53%
37%
12.
Nonpunitive Response to
Error
A8
R
1. Staff feel like their
mistakes are held against
them.
A12
R
2. When an event is reported,
it feels like the person is
being written up, not the
problem.
A16
R
3. Staff worry that mistakes
they make are kept in their
personnel file.
Your
32%
60%
90%
38%
Hospital
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 9
Table A-3. Average Percent Distribution of Work Area/Unit Patient Safety Grades by Work Area/Unit
Work Area/Unit
Work Area/Unit
Patient Safety
Grade
Database:
# Respondents
Your Hospital:
# Respondents
A
B
C
D
E
Excellent
Very Good
Acceptable
Poor
Failing
Pharmacy
Psych/
Mental
Health
Radiology
Rehabilitation
Surgery
4,534
5,226
4,298
10,528
7,429
17,393
0
10
6
4
25
8
0
15%
21%
24%
25%
23%
28%
35%
32%
-
-
-
100%
-
-
27%
-
-
49%
51%
47%
47%
49%
49%
44%
49%
46%
45%
71%
50%
-
-
-
0%
-
-
59%
-
-
19%
30%
26%
20%
31%
25%
22%
20%
22%
19%
16%
18%
Your
Hospital
-
6%
0%
-
-
-
0%
-
-
14%
-
-
Database
3%
7%
6%
3%
6%
6%
5%
5%
9%
3%
2%
4%
Your
Hospital
-
6%
0%
-
-
-
0%
-
-
0%
-
-
Database
1%
1%
1%
0%
1%
1%
0%
1%
1%
0%
1%
1%
Your
Hospital
-
0%
0%
-
-
-
0%
-
-
0%
-
-
Dataset
Anesthesiology
Emergency
Medicine
Obstetrics
Pediatrics
ICU
Lab
106,839
1,184
9,703
12,040
9,273
17,143
8,088
91
0
22
11
2
3
Database
35%
16%
18%
26%
Your
Hospital
-
18%
50%
Database
42%
46%
Your
Hospital
-
Database
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
March 2009 Trending Report for ABC Hospital, Appendix Page 10
Table A-4. Average Percent Distribution of Number of Events Reported in the Past 12 Months by Work Area/Unit
Work Area/Unit
Number of Events
Reported by
Respondents
Database:
# Respondents
Your Hospital:
# Respondents
No events
1 to 2 events
3 to 5 events
6 to 10 events
11 to 20 events
21 event reports or
more
Pharmacy
Psych/
Mental
Health
Radiology
Rehabilitation
Surgery
4,534
5,226
4,298
10,528
7,429
17,393
0
10
6
4
25
8
0
38%
43%
44%
42%
51%
55%
55%
46%
-
-
-
20%
-
-
57%
-
-
38%
29%
33%
36%
34%
18%
26%
31%
33%
32%
56%
18%
-
-
-
50%
-
-
14%
-
-
7%
13%
20%
12%
20%
15%
16%
15%
14%
10%
8%
14%
Your
Hospital
-
17%
9%
-
-
-
20%
-
-
19%
-
-
Database
4%
5%
6%
5%
6%
4%
4%
10%
6%
2%
3%
5%
Your
Hospital
-
0%
0%
-
-
-
10%
-
-
5%
-
-
Database
1%
2%
2%
3%
2%
1%
2%
8%
2%
1%
0%
1%
Your
Hospital
-
0%
0%
-
-
-
0%
-
-
0%
-
-
Database
1%
2%
0%
3%
1%
0%
0%
8%
1%
0%
0%
1%
Your
Hospital
-
0%
0%
-
-
-
0%
-
-
5%
-
-
Dataset
Anesthesiology
Emergency
Medicine
Obstetrics
Pediatrics
ICU
Lab
106,839
1,184
9,703
12,040
9,273
17,143
8,088
91
0
22
11
2
3
Database
56%
46%
34%
49%
Your
Hospital
-
28%
73%
Database
30%
32%
Your
Hospital
-
Database
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
March 2009 Trending Report for ABC Hospital, Appendix Page 11
Appendix A: Overall Results by Respondent Characteristics—
(2) Staff Position
NOTE 1: Hospitals that did not ask respondents to indicate their staff position were excluded from these breakout tables. In addition,
respondents who selected “Other,” or did not answer (missing) were not included.
NOTE 2: The number of database respondents in each staff position is shown. However, the precise number of database respondents
corresponding to each data cell in the tables will vary because hospitals may have omitted a specific survey item and because of individual
non-response/missing data.
NOTE 3: Your hospital’s number of respondents in each staff position is shown. However, the precise number of respondents corresponding
to each of your hospital’s data cells in the tables will vary because of individual non-response/missing data.
Your hospital’s percent positive results are shown in the second row underneath the average results for the database hospitals but are only
displayed if there were at least 10 respondents in a particular staff position (to protect individual respondent confidentiality in these areas). If
there were 9 or fewer respondents in a particular staff position, a hyphen (-) is shown.
March 2009 Trending Report for ABC Hospital, Appendix Page 12
Table A-5. Composite-level Average Percent Positive Response by Staff Position (Page 1 of 2)
Staff Position
Patient Safety Culture Composites
Database: # Respondents
Your Hospital: # Respondents
1. Teamwork Within Units
2. Supervisor/Manager
Expectations & Actions
Promoting Patient Safety
3. Org Learning--Continuous
Improvement
4. Management Support for
Patient Safety
5. Overall Perceptions of
Patient Safety
6. Feedback & Communication
About Error
Dataset
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
Pharmacist
RN/LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Unit Asst/
Clerk/
Secretary
142,969
92
13,750
0
8,084
32
1,195
0
10,386
26
3,123
0
66,261
34
19,230
0
9,026
0
11,914
0
Database
88%
82%
81%
74%
80%
79%
77%
84%
77%
Your
Hospital
-
84%
-
91%
-
91%
-
-
-
Database
84%
71%
77%
75%
77%
73%
75%
77%
76%
Your
Hospital
-
69%
-
74%
-
87%
-
-
-
Database
81%
71%
69%
73%
74%
70%
69%
70%
70%
Your
Hospital
-
68%
-
78%
-
86%
-
-
-
Database
83%
69%
75%
73%
68%
64%
70%
71%
73%
Your
Hospital
-
84%
-
83%
-
91%
-
-
-
Database
73%
63%
66%
61%
61%
59%
70%
69%
65%
Your
Hospital
-
77%
-
78%
-
85%
-
-
-
Database
74%
61%
68%
64%
64%
58%
63%
65%
65%
Your
Hospital
-
81%
-
55%
-
79%
-
-
-
March 2009 Trending Report for ABC Hospital, Appendix Page 13
Table A-5. Composite-level Average Percent Positive Response by Staff Position (Page 2 of 2)
Staff Position
Patient Safety Culture Composites
Database: # Respondents
Your Hospital: # Respondents
7. Communication Openness
8. Frequency of Events
Reported
9. Teamwork Across Units
10. Staffing
11. Handoffs & Transitions
12. Nonpunitive Response to
Error
Average Across Composites
Dataset
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
Pharmacist
RN/LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Unit Asst/
Clerk/
Secretary
142,969
92
13,750
0
8,084
32
1,195
0
10,386
26
3,123
0
66,261
34
19,230
0
9,026
0
11,914
0
Database
75%
63%
65%
57%
71%
61%
62%
67%
60%
Your
Hospital
-
64%
-
67%
-
78%
-
-
-
Database
66%
55%
57%
65%
52%
61%
59%
55%
65%
Your
Hospital
-
82%
-
60%
-
73%
-
-
-
Database
63%
59%
61%
59%
55%
54%
54%
61%
57%
Your
Hospital
-
67%
-
61%
-
84%
-
-
-
Database
63%
55%
55%
49%
56%
56%
56%
58%
51%
Your
Hospital
-
55%
-
67%
-
77%
-
-
-
Database
45%
44%
37%
49%
30%
47%
39%
41%
45%
Your
Hospital
-
58%
-
42%
-
77%
-
-
-
Database
62%
42%
45%
36%
60%
43%
43%
50%
39%
Your
Hospital
-
48%
-
63%
-
72%
-
-
-
Database
71%
61%
63%
61%
62%
60%
61%
64%
62%
Your
Hospital
-
70%
-
68%
-
82%
-
-
-
March 2009 Trending Report for ABC Hospital, Appendix Page 14
Table A-6. Item-level Average Percent Positive Response by Staff Position (Page 1 of 6)
Staff Position
Item
Patient Safety Culture Composites
Database: # Respondents
Your Hospital: # Respondents
1.
Teamwork Within Units
A1
1. People support one
another in this unit.
A3
2. When a lot of work needs
to be done quickly, we work
together as a team to get the
work done.
A4
A11
2.
B1
B2
B3
R
3. In this unit, people treat
each other with respect.
4. When one area in this unit
gets really busy, others help
out.
Supv/Mgr 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.
Dataset
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Pharmacist
Unit Asst/
Clerk/
Secretary
142,969
92
13,750
0
8,084
32
1,195
0
10,386
26
3,123
0
66,261
34
19,230
0
9,026
0
11,914
0
Database
Your
Hospital
93%
88%
86%
80%
87%
86%
83%
89%
82%
-
84%
-
96%
-
94%
-
-
-
Database
93%
87%
86%
80%
85%
86%
85%
87%
83%
Your
Hospital
-
94%
-
88%
-
97%
-
-
-
Database
Your
Hospital
Database
Your
Hospital
88%
84%
80%
72%
80%
78%
75%
84%
75%
-
84%
-
96%
-
88%
-
-
-
77%
70%
73%
65%
68%
67%
67%
75%
68%
-
74%
-
85%
-
85%
-
-
-
Database
82%
69%
78%
73%
70%
70%
68%
74%
74%
Your
Hospital
-
67%
-
69%
-
74%
-
-
-
Database
87%
75%
81%
76%
79%
75%
75%
81%
76%
Your
Hospital
-
68%
-
73%
-
88%
-
-
-
Database
84%
66%
75%
74%
78%
73%
77%
76%
77%
Your
Hospital
-
71%
-
77%
-
91%
-
-
-
Database
85%
72%
76%
76%
79%
76%
78%
78%
77%
Your
71%
77%
94%
Hospital
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).
B4
R
March 2009 Trending Report for ABC Hospital, Appendix Page 15
Table A-6. Item-level Average Percent Positive Response by Staff Position (Page 2 of 6)
Staff Position
Item
Patient Safety Culture Composites
Database: # Respondents
Your Hospital: # Respondents
Dataset
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
142,969
92
13,750
0
8,084
32
Dietician
Pat Care
Asst/Aide/
Care
Partner
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Pharmacist
Unit Asst/
Clerk/
Secretary
1,195
0
10,386
26
3,123
0
66,261
34
19,230
0
9,026
0
11,914
0
3.
Organizational Learning—
Continuous Improvement
1. We are actively doing
things to improve patient
safety.
Database
88%
79%
81%
85%
86%
83%
80%
83%
81%
A6
Your
Hospital
-
94%
-
88%
-
88%
-
-
-
2. Mistakes have led to
positive changes here.
Database
80%
68%
62%
60%
76%
60%
63%
59%
62%
Your
Hospital
-
52%
-
68%
-
76%
-
-
-
3. After we make changes to
improve patient safety, we
evaluate their effectiveness.
Database
76%
66%
64%
73%
61%
68%
65%
68%
68%
Your
Hospital
-
60%
-
77%
-
94%
-
-
-
1. Hospital mgmt provides a
work climate that promotes
patient safety.
Database
89%
77%
86%
82%
74%
73%
81%
81%
83%
Your
Hospital
-
94%
-
88%
-
97%
-
-
-
2. The actions of hospital
mgmt show that patient
safety is a top priority.
Database
84%
71%
78%
77%
69%
65%
72%
71%
75%
Your
Hospital
-
87%
-
84%
-
94%
-
-
-
Database
75%
59%
61%
59%
60%
55%
58%
59%
61%
Your
Hospital
-
72%
-
76%
-
82%
-
-
-
A9
A13
4.
F1
F8
F9
R
Mgmt Support for Patient
Safety
3. Hospital mgmt seems
interested in patient safety
only after an adverse event
happens.
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 16
Table A-6. Item-level Average Percent Positive Response by Staff Position (Page 3 of 6)
Staff Position
Item
Patient Safety Culture Composites
Database: # Respondents
Your Hospital: # Respondents
5.
Dataset
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
142,969
92
13,750
0
8,084
32
Dietician
Pat Care
Asst/Aide/
Care
Partner
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Pharmacist
Unit Asst/
Clerk/
Secretary
1,195
0
10,386
26
3,123
0
66,261
34
19,230
0
9,026
0
11,914
0
Overall Perceptions of
Patient Safety
A10
R
1. It is just by chance that
more serious mistakes don’t
happen around here.
Database
72%
62%
58%
51%
61%
59%
64%
67%
56%
Your
Hospital
-
69%
-
77%
-
85%
-
-
-
2. Patient safety is never
sacrificed to get more work
done.
Database
72%
63%
65%
63%
56%
56%
70%
68%
69%
A15
Your
Hospital
-
81%
-
81%
-
79%
-
-
-
3. We have patient safety
problems in this unit.
Database
70%
60%
66%
60%
57%
56%
70%
69%
65%
Your
Hospital
-
84%
-
85%
-
85%
-
-
-
Database
77%
68%
74%
69%
71%
66%
74%
74%
71%
Your
Hospital
-
74%
-
68%
-
91%
-
-
-
1. We are given feedback
about changes put into place
based on event reports.
Database
64%
54%
60%
55%
51%
51%
51%
56%
55%
Your
Hospital
-
66%
-
44%
-
79%
-
-
-
2. We are informed about
errors that happen in this
unit.
Database
77%
62%
67%
66%
69%
57%
68%
65%
68%
Your
Hospital
-
90%
-
56%
-
79%
-
-
-
3. In this unit, we discuss
ways to prevent errors from
happening again.
Database
82%
69%
76%
71%
73%
66%
70%
73%
71%
A17
R
A18
6.
C1
C3
C5
4. Our procedures and
systems are good at
preventing errors from
happening.
Feedback and
Communication About
Error
Your
87%
65%
79%
Hospital
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 17
Table A-6. Item-level Average Percent Positive Response by Staff Position (Page 4 of 6)
Staff Position
Item
Patient Safety Culture Composites
Database: # Respondents
Your Hospital: # Respondents
Dataset
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
142,969
92
13,750
0
8,084
32
Dietician
Pat Care
Asst/Aide/
Care
Partner
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Pharmacist
Unit Asst/
Clerk/
Secretary
1,195
0
10,386
26
3,123
0
66,261
34
19,230
0
9,026
0
11,914
0
7.
Communication Openness
1. Staff will freely speak up if
they see something that may
negatively affect patient care.
Database
83%
72%
76%
74%
79%
75%
77%
80%
76%
C2
Your
Hospital
-
87%
-
88%
-
91%
-
-
-
2. Staff feel free to question
the decisions or actions of
those with more authority.
Database
68%
55%
56%
41%
61%
45%
46%
53%
42%
Your
Hospital
-
41%
-
46%
-
71%
-
-
-
3. Staff are afraid to ask
questions when something
does not seem right.
Database
74%
63%
62%
57%
74%
62%
64%
69%
61%
Your
Hospital
-
65%
-
65%
-
74%
-
-
-
Database
58%
48%
53%
62%
35%
48%
51%
48%
61%
Your
Hospital
-
76%
-
56%
-
59%
-
-
-
Database
62%
50%
50%
61%
50%
59%
52%
49%
60%
Your
Hospital
-
79%
-
54%
-
68%
-
-
-
Database
78%
69%
69%
74%
72%
76%
74%
67%
75%
Your
Hospital
-
93%
-
71%
-
91%
-
-
-
C4
C6
R
8.
D1
D2
D3
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?
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 18
Table A-6. Item-level Average Percent Positive Response by Staff Position (Page 5 of 6)
Staff Position
Item
Patient Safety Culture Composites
Database: # Respondents
Your Hospital: # Respondents
Dataset
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
142,969
92
13,750
0
8,084
32
Database
Your
Hospital
52%
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Pharmacist
Unit Asst/
Clerk/
Secretary
1,195
0
10,386
26
3,123
0
66,261
34
19,230
0
9,026
0
11,914
0
48%
50%
46%
43%
41%
42%
48%
46%
-
45%
-
46%
-
79%
-
-
-
9.
Teamwork Across Units
F2
R
1. Hospital units do not
coordinate well with each other.
2. There is good cooperation
among hospital units that need
to work together.
Database
65%
60%
62%
60%
55%
55%
56%
62%
58%
F4
Your
Hospital
-
74%
-
52%
-
82%
-
-
-
F6
R
3. It is often unpleasant to work
with staff from other hospital
units.
Database
63%
61%
61%
59%
61%
58%
54%
67%
55%
F10
4. Hospital units work well
together to provide the best care
for patients.
10.
Staffing
A2
1. We have enough staff to
handle the workload.
A5
R
2. Staff in this unit work longer
hours than is best for patient care.
Your
Hospital
Database
Your
Hospital
-
71%
-
68%
-
88%
-
-
-
74%
67%
71%
72%
63%
63%
65%
69%
68%
-
77%
-
76%
-
85%
-
-
-
Database
67%
57%
57%
44%
49%
52%
53%
53%
49%
Your
Hospital
-
34%
-
50%
-
71%
-
-
-
Database
59%
51%
53%
44%
59%
54%
54%
56%
48%
Your
Hospital
-
47%
-
75%
-
76%
-
-
-
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.
Database
69%
61%
58%
62%
71%
71%
67%
69%
59%
Your
74%
80%
88%
Hospital
Database
56%
51%
52%
47%
46%
47%
49%
55%
50%
A14
Your
R
63%
62%
73%
Hospital
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).
A7
R
March 2009 Trending Report for ABC Hospital, Appendix Page 19
Table A-6. Item-level Average Percent Positive Response by Staff Position (Page 6 of 6)
Staff Position
Item
Patient Safety Culture Composites
Database: # Respondents
Your Hospital: # Respondents
Dataset
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
142,969
92
13,750
0
8,084
32
Dietician
Pat Care
Asst/Aide/
Care
Partner
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Pharmacist
Unit Asst/
Clerk/
Secretary
1,195
0
10,386
26
3,123
0
66,261
34
19,230
0
9,026
0
11,914
0
11.
Handoffs & Transitions
F3
R
Database
1. Things “fall between the
cracks” when transferring patients
Your
from one unit to another.
Hospital
41%
43%
32%
46%
25%
43%
34%
36%
44%
-
55%
-
21%
-
69%
-
-
-
F5
R
2. Important patient care
information is often lost during
shift changes.
Database
Your
Hospital
49%
46%
40%
57%
33%
53%
45%
44%
51%
-
61%
-
50%
-
79%
-
-
-
F7
R
3. Problems often occur in the
exchange of information across
hospital units.
Database
44%
44%
39%
43%
31%
44%
37%
42%
43%
Your
Hospital
-
55%
-
36%
-
72%
-
-
-
F11
R
4. Shift changes are problematic
for patients in this hospital.
Database
46%
40%
37%
50%
31%
49%
40%
41%
44%
Your
Hospital
-
61%
-
63%
-
88%
-
-
-
12.
Nonpunitive Response to
Error
A8
R
1. Staff feel like their mistakes
are held against them.
Database
Your
Hospital
69%
48%
53%
43%
65%
50%
50%
57%
45%
-
56%
-
73%
-
74%
-
-
-
A12
R
2. When an event is reported, it
feels like the person is being
written up, not the problem.
Database
68%
45%
47%
37%
62%
46%
43%
51%
39%
Your
Hospital
-
52%
-
64%
-
79%
-
-
-
A16
AR
3. Staff worry that mistakes they
make are kept in their personnel
file.
Database
50%
31%
35%
28%
54%
33%
35%
43%
32%
Your
35%
52%
62%
Hospital
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 20
Table A-7. Average Percent Distribution of Work Area/Unit Patient Safety Grades by Staff Position
Staff Position
Work Area/Unit
Patient Safety Grade
Database: # Respondents
Your Hospital: # Respondents
A
B
C
D
E
Excellent
Very Good
Acceptable
Poor
Therapist
(Respiratory,
Phys,
Occup,
Speech)
Unit
Asst/
Clerk/
Secretary
Dataset
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
Pharmacist
RN/LVN/LPN
Technician
(EKG, Lab,
Radiology)
142,969
92
13,750
0
8,084
32
1,195
0
10,386
26
3,123
0
66,261
34
19,230
0
9,026
0
11,914
0
Database
30%
25%
27%
24%
21%
19%
27%
29%
27%
Your
Hospital
-
32%
-
35%
-
48%
-
-
-
Database
52%
47%
48%
46%
49%
47%
49%
46%
47%
Your
Hospital
-
54%
-
57%
-
52%
-
-
-
Database
16%
22%
21%
24%
23%
26%
20%
20%
22%
Your
Hospital
-
14%
-
9%
-
0%
-
-
-
Database
2%
5%
3%
5%
6%
6%
3%
4%
3%
Your
Hospital
-
0%
-
0%
-
0%
-
-
-
Database
1%
1%
0%
1%
1%
1%
1%
1%
1%
-
0%
-
-
-
Failing
Your
0%
0%
Hospital
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
March 2009 Trending Report for ABC Hospital, Appendix Page 21
Table A-8. Average Percent Distribution of Number of Events Reported in the Past 12 Months by Staff Position
Staff Position
Therapist
(Respiratory,
Phys,
Occup,
Speech)
Unit
Asst/
Clerk/
Secretary
Dataset
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
Pharmacist
RN/LVN/LPN
Technician
(EKG, Lab,
Radiology)
142,969
92
Your Hospital: # Respondents
13,750
0
8,084
32
1,195
0
10,386
26
3,123
0
66,261
34
19,230
0
9,026
0
11,914
0
Database
45%
59%
75%
75%
25%
29%
57%
59%
77%
Your
Hospital
-
50%
-
55%
-
28%
-
-
-
Database
24%
27%
16%
19%
22%
38%
29%
31%
17%
Your
Hospital
-
25%
-
23%
-
52%
-
-
-
Database
16%
9%
6%
4%
20%
22%
9%
7%
4%
Your
Hospital
-
21%
-
14%
-
14%
-
-
-
Database
8%
3%
2%
1%
13%
7%
3%
2%
1%
Your
Hospital
-
4%
-
9%
-
3%
-
-
-
Database
4%
1%
0%
0%
10%
3%
1%
0%
0%
Your
Hospital
-
0%
-
0%
-
0%
-
-
-
Database
3%
1%
0%
0%
10%
1%
1%
0%
0%
-
3%
-
-
-
Number of Events
Reported by Respondents
Database: # Respondents
No events
1 to 2 events
3 to 5 events
6 to 10 events
11 to 20 events
21 event reports or
more
Your
0%
0%
Hospital
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
March 2009 Trending Report for ABC Hospital, Appendix Page 22
Appendix A: Overall Results by Respondent Characteristics-(3) Interaction With Patients
NOTE 1: Hospitals that did not ask respondents to indicate their interaction with patients were excluded from these breakout tables. In
addition, respondents who did not answer (missing) were not included.
NOTE 2: The number of database respondents is shown in each table. However, the precise number of database respondents corresponding to
each data cell in the tables will vary because hospitals may have omitted a specific survey item and because of individual nonresponse/missing data.
NOTE 3: Your hospital’s number of respondents by interaction with patients is shown. However, the precise number of your hospital’s
respondents corresponding to each of your hospital’s data cells in the tables will vary because of individual non-response/missing data.
Database averages by interaction with patients are displayed; your hospital’s percent positive results are shown in two columns to the right
but are only displayed if there were at least 10 respondents (to protect individual respondent confidentiality in these areas). If there were 9 or
fewer respondents with or without direct interaction with patients, a hyphen (-) is shown..
March 2009 Trending Report for ABC Hospital, Appendix Page 23
Table A-9. Composite-level Average Percent Positive Response by Interaction with Patients
Database Hospital Average
Your Hospital
Interaction with Patients
WITH
direct interaction
143,052
WITHOUT
direct interaction
43,658
WITH
direct interaction
85
WITHOUT
direct interaction
15
1. Teamwork Within Units
79%
81%
86%
95%
2. Supervisor/Manager Expectations & Actions
Promoting Patient Safety
75%
76%
75%
75%
3. Org Learning--Continuous Improvement
71%
72%
73%
86%
4. Management Support for Patient Safety
69%
76%
83%
95%
5. Overall Perceptions of Patient Safety
64%
66%
78%
80%
6. Feedback & Communication About Error
62%
66%
71%
90%
7. Communication Openness
62%
64%
65%
87%
8. Frequency of Events Reported
60%
62%
69%
86%
9. Teamwork Across Units
57%
58%
67%
82%
10. Staffing
56%
53%
64%
64%
11. Handoffs & Transitions
45%
38%
57%
68%
12. Nonpunitive Response to Error
43%
47%
55%
79%
62%
63%
70%
82%
Patient Safety Culture Composites
# Respondents
Average Across Composites
March 2009 Trending Report for ABC Hospital, Appendix Page 24
Table A-10. Item-level Average Percent Positive Response by Interaction with Patients (Page 1 of 4)
Database Hospital Average
Your Hospital
Interaction with Patients
Item
Survey Items By Composite
# Respondents
WITH
direct interaction
143,052
WITHOUT
direct interaction
43,658
WITH
direct interaction
85
WITHOUT
direct interaction
15
85%
86%
88%
100%
1.
A1
Teamwork Within Units
1. People support one another in this unit.
A3
2. When a lot of work needs to be done quickly, we work
together as a team to get the work done.
86%
87%
92%
100%
A4
3. In this unit, people treat each other with respect.
77%
80%
87%
100%
A11
4. When one area in this unit gets really busy, others help out.
68%
69%
79%
79%
2.
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.
71%
75%
69%
79%
B1
B2
2. My supv/mgr seriously considers staff suggestions for
improving patient safety.
76%
78%
73%
79%
B3
R
3. Whenever pressure builds up, my supv/mgr wants us to
work faster, even if it means taking shortcuts.
74%
76%
79%
71%
B4
R
4. My supv/mgr overlooks patient safety problems that happen
over and over.
77%
77%
81%
71%
3.
Organizational Learning— Continuous Improvement
A6
1. We are actively doing things to improve patient safety.
82%
80%
88%
87%
A9
2. Mistakes have led to positive changes here.
62%
69%
58%
86%
A13
3. After we make changes to improve patient safety, we
evaluate their effectiveness.
68%
68%
74%
85%
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 25
Table A-10. Item-level Average Percent Positive Response by Interaction with Patients (Page 2 of 4)
Database Hospital Average
Your Hospital
Interaction with Patients
Item
Survey Items By Composite
# Respondents
3.
F1
F8
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.
WITH
direct interaction
143,052
WITHOUT
direct interaction
43,658
WITH
direct interaction
85
WITHOUT
direct interaction
15
78%
85%
90%
100%
70%
78%
86%
93%
58%
66%
72%
93%
60%
61%
73%
80%
F9
R
3. Hospital mgmt seems interested in patient safety only after
an adverse event happens.
5.
A10
R
Overall Perceptions of Patient Safety
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.
64%
66%
81%
60%
A17
R
3. We have patient safety problems in this unit.
62%
65%
81%
93%
A18
4. Our procedures and systems are good at preventing errors
from happening.
70%
72%
79%
86%
53%
56%
65%
79%
6.
C1
Feedback and Communication About Error
1. We are given feedback about changes put into place based
on event reports.
C3
2. We are informed about errors that happen in this unit.
63%
69%
75%
93%
C5
3. In this unit, we discuss ways to prevent errors from
happening again.
70%
74%
73%
100%
Note: The item’s survey location is shown to the left. An “R” indicates a negatively worded item, where the percent positive response is based on those who responded
“Strongly disagree” or “Disagree,” or “Never” or “Rarely” (depending on the response category used for the item).
March 2009 Trending Report for ABC Hospital, Appendix Page 26
Table A-10. Item-level Average Percent Positive Response by Interaction with Patients (Page 3 of 4)
Database Hospital Average
Your Hospital
Interaction with Patients
Item
Survey Items By Composite
# Respondents
7.
C2
Communication Openness
1. Staff will freely speak up if they see something that may
negatively affect patient care.
WITH
direct interaction
143,052
WITHOUT
direct interaction
43,658
WITH
direct interaction
85
WITHOUT
direct interaction
15
76%
76%
85%
100%
C4
2. Staff feel free to question the decisions or actions of those
with more authority.
46%
51%
46%
73%
C6
R
3. Staff are afraid to ask questions when something does not
seem right.
63%
66%
63%
87%
8.
Frequency of Events Reported
1. When a mistake is made, but is caught and corrected before
affecting the patient, how often is this reported?
51%
56%
60%
93%
D1
D2
2. When a mistake is made, but has no potential to harm the
patient, how often is this reported?
56%
57%
66%
71%
D3
3. When a mistake is made that could harm the patient, but
does not, how often is this reported?
73%
73%
81%
93%
1. Hospital units do not coordinate well with each other.
44%
47%
52%
79%
F4
2. There is good cooperation among hospital units that need to
work together.
58%
59%
65%
79%
F6
R
3. It is often unpleasant to work with staff from other hospital
units.
59%
57%
75%
86%
F10
4. Hospital units work well together to provide the best care for
patients.
66%
70%
77%
86%
9.
F2
R
Teamwork Across Units
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 27
Table A-10. Item-level Average Percent Positive Response by Interaction with Patients (Page 4 of 4)
Database Hospital Average
Your Hospital
Interaction with Patients
Item
Survey Items By Composite
# Respondents
WITH
direct interaction
143,052
WITHOUT
direct interaction
43,658
WITH
direct interaction
85
WITHOUT
direct interaction
15
10.
Staffing
A2
1. We have enough staff to handle the workload.
53%
57%
49%
40%
A5
R
2. Staff in this unit work longer hours than is best for patient
care.
53%
49%
68%
57%
A7
R
3. We use more agency/temporary staff than is best for patient
care.
67%
57%
80%
64%
A14
R
4. We work in “crisis mode” trying to do too much, too quickly.
49%
48%
59%
93%
11.
F3
R
Handoffs & Transitions
1. Things “fall between the cracks” when transferring patients
from one unit to another.
42%
35%
44%
79%
F5
R
2. Important patient care information is often lost during shift
changes.
51%
43%
64%
57%
F7
R
3. Problems often occur in the exchange of information across
hospital units.
43%
38%
49%
71%
F11
R
4. Shift changes are problematic for patients in this hospital.
46%
39%
69%
64%
1. Staff feel like their mistakes are held against them.
50%
55%
62%
80%
A12
R
2. When an event is reported, it feels like the person is being
written up, not the problem.
45%
49%
57%
93%
A16
R
3. Staff worry that mistakes they make are kept in their
personnel file.
35%
38%
45%
64%
12.
A8
R
Nonpunitive Response to Error
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 28
Table A-11. Average Percent Distribution of Work Area/Unit Patient Safety Grades by Interaction with Patients
Database Hospital Average
Your Hospital
Interaction with Patients
Work Area/Unit
Patient Safety Grade
# Respondents
WITH
direct interaction
143,052
WITHOUT
direct interaction
43,658
WITH
direct interaction
85
WITHOUT
direct interaction
15
A
Excellent
24%
28%
43%
36%
B
Very Good
48%
49%
48%
57%
C
Acceptable
23%
20%
8%
7%
D
Poor
5%
3%
1%
0%
E
Failing
1%
0%
0%
0%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
Table A-12. Average Percent Distribution of Number of Events Reported in the Past 12 Months by Interaction with Patients
Database Hospital Average
Your Hospital
Interaction with Patients
Number of Events Reported
by Respondents
# Respondents
WITH
direct interaction
143,052
WITHOUT
direct interaction
43,658
WITH
direct interaction
85
WITHOUT
direct interaction
15
No events
48%
68%
40%
93%
1 to 2 events
31%
16%
38%
0%
3 to 5 events
14%
8%
16%
7%
6 to 10 events
5%
4%
4%
0%
11 to 20 events
2%
2%
0%
0%
21 event reports or more
1%
2%
1%
0%
Note: Average percent totals in the table may not sum to exactly 100% due to rounding of decimals.
March 2009 Trending Report for ABC Hospital, Appendix Page 29
Appendix B: Trending Results by—
(1) Work Area/Unit
NOTE 1: Respondents who selected “Many different work areas/No specific work area,” “Other,” or did not answer (missing) were not
included.
NOTE 2: Your hospital’s number of respondents in each work area/unit is shown. However, the precise number of respondents
corresponding to each of your hospital’s data cells in the tables will vary because of individual non-response/missing data.
NOTE 3: Changes in scores of 5% or greater, whether positive or negative, are bolded.
Your hospital’s results are only displayed if there were at least 10 respondents in a particular work area/unit (to protect individual
respondent confidentiality in these areas). If there were 9 or fewer respondents in a particular work area/unit, a hyphen (-) is shown.
March 2009 Trending Report for ABC Hospital, Appendix Page 30
Table B-1. Trending: Composite-level Average Percent Positive Response by Work Area/Unit (Page 1 of 2)
Work Area/Unit
Patient Safety
Culture Composites
# Respondents
1. Teamwork
Within Units
2. Supv/Mgr
Expectations &
Actions Promoting
Patient Safety
3. Mgmt Support
for Patient Safety
4. Org Learning-Continuous
Improvement
5. Overall
Perceptions of
Patient Safety
6. Feedback &
Communication
About Error
Pharmacy
Psych/
Mental
Health
Radiology
Rehabilitation
Surgery
10
3
6
1
4
6
25
26
8
10
0
0
-
100%
-
-
89%
-
-
-
-
-
-
-
80%
95%
-
-
-
-
-
-
-
9%
-
-
91%
-
-
-
98%
-
-
78%
-
-
-
-
-
-
-
-
-
-
90%
86%
-
-
-
-
-
-
-
-
-
-
-12%
-
-
Most Recent
-
76%
97%
-
-
-
97%
-
-
95%
-
-
Previous
-
-
-
-
-
-
-
-
-
86%
79%
-
Change
-
-
-
-
-
-
-
-
-
9%
-
-
Most Recent
-
66%
80%
-
-
-
93%
-
-
80%
-
-
Previous
-
-
-
-
-
-
-
-
-
90%
81%
-
Change
-
-
-
-
-
-
-
-
-
-10%
-
-
Most Recent
-
72%
93%
-
-
-
98%
-
-
78%
-
-
Previous
-
-
-
-
-
-
-
-
-
76%
84%
-
Change
-
-
-
-
-
-
-
-
-
2%
-
-
Most Recent
-
60%
77%
-
-
-
100%
-
-
82%
-
-
Previous
-
-
-
-
-
-
-
-
-
86%
58%
-
Change
-
-
-
-
-
-
-
-
-
-4%
-
-
Database Year
Anesthesiology
Emergency
Medicine
Obstetrics
Pediatrics
ICU
Lab
Most Recent
Previous
0
0
22
0
11
7
2
7
3
4
0
4
Most Recent
-
77%
89%
-
-
Previous
-
-
-
-
Change
-
-
-
Most Recent
-
64%
Previous
-
Change
March 2009 Trending Report for ABC Hospital, Appendix Page 31
Table B-1. Trending: Composite-level Average Percent Positive Response by Work Area/Unit (Page 2 of 2)
Work Area/Unit
Patient Safety
Culture Composites
# Respondents
7. Communication
Openness
8. Frequency of
Events Reported
9. Teamwork
Across Units
10. Staffing
11. Handoffs &
Transitions
12. Nonpunitive
Response to Error
Pharmacy
Psych/
Mental
Health
Radiology
Rehabilitation
Surgery
10
3
6
1
4
6
25
26
8
10
0
0
-
93%
-
-
69%
-
-
-
-
-
-
-
70%
77%
-
-
-
-
-
-
-
-1%
-
-
79%
-
-
-
100%
-
-
84%
-
-
-
-
-
-
-
-
-
88%
62%
-
-
-
-
-
-
-
-
-
-
-4%
-
-
Most Recent
-
67%
67%
-
-
-
93%
-
-
78%
-
-
Previous
-
-
-
-
-
-
-
-
-
73%
70%
-
Change
-
-
-
-
-
-
-
-
-
5%
-
-
Most Recent
-
56%
63%
-
-
-
95%
-
-
55%
-
-
Previous
-
-
-
-
-
-
-
-
-
49%
40%
-
Change
-
-
-
-
-
-
-
-
-
6%
-
-
Most Recent
-
62%
40%
-
-
-
95%
-
-
56%
-
-
Previous
-
-
-
-
-
-
-
-
-
55%
26%
-
Change
-
-
-
-
-
-
-
-
-
1%
-
-
Most Recent
-
35%
74%
-
-
-
90%
-
-
62%
-
-
Previous
-
-
-
-
-
-
-
-
-
52%
56%
-
Change
-
-
-
-
-
-
-
-
-
10%
-
-
Database Year
Anesthesiology
Emergency
Medicine
Obstetrics
Pediatrics
ICU
Lab
Most Recent
Previous
0
0
22
0
11
7
2
7
3
4
0
4
Most Recent
-
53%
76%
-
-
Previous
-
-
-
-
Change
-
-
-
Most Recent
-
54%
Previous
-
Change
March 2009 Trending Report for ABC Hospital, Appendix Page 32
-
Table B-2. Trending: Item-level Percent Positive Response by Work Area/Unit (Page 1 of 6)
Work Area/Unit
Item
Survey Items by Composite
Database
Year
Pediatrics
Pharmacy
Psych/
Mental
Health
Radiology
Rehabilitation
Surgery
0
10
6
4
25
8
0
4
4
3
1
6
26
10
0
-
-
-
100%
100%
-
-
96%
81%
15%
96%
100%
-
-
-
-
-
-
-
-
-
85%
90%
-
100%
73%
-
-
-
-
100%
100%
-
-
-
11%
88%
80%
8%
75%
76%
-1%
100%
90%
-
-
91%
-
-
-
90%
-
-
83%
-
-
Anesthesiology
Emergency
ICU
Lab
Medicine
Most Recent
0
22
11
2
3
Previous
0
0
7
7
Most Recent
Previous
Change
Most Recent
-
77%
86%
100%
82%
Previous
-
-
Obstetrics
# Respondents
1.
Teamwork Within Units
A1
1. People support one another
in this unit.
A3
2. When a lot of work needs to
be done quickly, we work
together as a team to get the
work done.
A4
A11
2.
B1
B2
B3
R
B4
R
73%
3. In this unit, people treat each
other with respect.
73%
4. When one area in this unit
gets really busy, others help
out.
Supv/Mgr Expectations & Actions Promoting Patient Safety
1. My supv/mgr says a good
Most Recent
45%
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
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.
Previous
-
-
-
-
-
-
-
-
-
91%
89%
-
Change
Most Recent
-
59%
73%
100%
82%
-
-
-
100%
100%
-
-
-8%
83%
91%
-8%
75%
78%
-
-
Previous
-
-
-
-
-
-
-
-
-
87%
89%
-
Change
-
77%
-
91%
-
-
-
-
100%
-
-
-
-12%
71%
91%
-20%
89%
-
-
Most Recent
Previous
Change
Most Recent
Previous
Change
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 33
Table B-2. Trending: Item-level Percent Positive Response by Work Area/Unit (Page 2 of 6)
Work Area/Unit
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mental
Health
Radiology
11
7
2
7
3
4
0
4
10
3
6
1
4
6
25
26
8
10
0
0
86%
50%
64%
-
100%
50%
91%
-
-
-
-
100%
90%
90%
-
-
-
88%
92%
-4%
70%
85%
-15%
83%
92%
-9%
100%
67%
78%
-
-
Previous
-
86%
77%
64%
-
100%
100%
90%
-
-
-
-
100%
100%
90%
-
-
-
96%
92%
4%
100%
88%
12%
88%
77%
100%
75%
63%
-
Change
-
-
-
-
-
-
-
-
-
11%
-
-
Database
Year
Item
Survey Items by Composite
3.
Most Recent
Previous
Organizational Learning— Continuous
Improvement
# Respondents
A6
A9
1. We are actively doing
things to improve patient
safety.
2. Mistakes have led to
positive changes here.
Most Recent
Previous
Change
Most Recent
Previous
Change
A13
4.
F1
F8
F9
R
3. After we make changes to
improve patient safety, we
evaluate their effectiveness.
Most Recent
Previous
Change
Anesthesiology
Emergency
ICU
(any
type)
0
0
22
0
-
Rehabilitation Surgery
Management Support for Patient Safety
1. Hospital mgmt provides a
work climate that promotes
patient safety.
Most Recent
2. The actions of hospital
mgmt show that patient
safety is a top priority.
Most Recent
3. Hospital mgmt seems
interested in patient safety
only after an adverse event
happens.
Most Recent
Previous
Change
Previous
Change
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 34
Table B-2. Trending: Item-level Percent Positive Response by Work Area/Unit (Page 3 of 6)
Work Area/Unit
Database
Year
Item
Survey Items by Composite
5.
Most Recent
Previous
Overall Perceptions of Patient Safety
# Respondents
A10
R
A15
A17
R
A18
6.
C1
C3
C5
1. It is just by chance that
more serious mistakes don’t
happen around here.
Most Recent
2. Patient safety is never
sacrificed to get more work
done.
Most Recent
3. We have patient safety
problems in this unit.
Previous
Change
Previous
Change
Most Recent
Previous
Change
4. Our procedures and
Most Recent
systems are good at
Previous
preventing errors from
Change
happening.
Feedback and Communication About Error
1. We are given feedback
about changes put into place
based on event reports.
Most Recent
2. We are informed about
errors that happen in this
unit.
Most Recent
3. In this unit, we discuss
ways to prevent errors from
happening again.
Most Recent
Previous
Change
Previous
Change
Previous
Change
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mental
Health
Radiology
11
7
2
7
3
4
0
4
10
3
6
1
4
6
25
26
8
10
0
0
64%
64%
73%
86%
-
91%
91%
100%
90%
-
-
-
-
100%
100%
90%
100%
-
-
-
76%
68%
8%
80%
84%
-4%
88%
75%
13%
67%
76%
78%
90%
80%
89%
-
-
-
-
-
-
-
-
-
-
-9%
-
-
-
48%
71%
62%
-
70%
80%
82%
-
-
-
-
100%
100%
100%
-
-
-
70%
71%
-1%
88%
96%
-8%
88%
92%
-4%
33%
50%
90%
-
-
Anesthesiology
Emergency
ICU
0
0
22
0
-
Rehabilitation Surgery
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 35
Table B-2. Trending: Item-level Percent Positive Response by Work Area/Unit (Page 4 of 6)
Work Area/Unit
Item
Survey Items by Composite
# Respondents
7.
C2
C4
C6
R
8.
D1
D2
D3
Communication Openness
1. Staff will freely speak up if
they see something that may
negatively affect patient
care.
Database
Year
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mental
Health
Radiology
11
7
2
7
3
4
0
4
10
3
6
1
4
6
25
26
8
10
0
0
67%
-
100%
-
-
-
-
100%
-
-
-
92%
80%
100%
-
-
50%
43%
-
45%
82%
-
-
-
-
90%
90%
-
-
-
12%
48%
54%
-6%
68%
76%
-8%
40%
90%
-
-
-
38%
-
70%
-
-
-
-
100%
-
-
-
78%
80%
43%
-
-
48%
-
78%
-
-
-
-
100%
-
-
-
-2%
77%
85%
71%
-
-
76%
-
89%
-
-
-
-
100%
-
-
-
-8%
95%
100%
71%
-
-
-
-
-
-
-
-
-
-
-5%
-
-
Anesthesiology
Emergency
ICU
Most Recent
Previous
0
0
22
0
Most Recent
-
Previous
Change
2. Staff feel free to question
the decisions or actions of
those with more authority.
Most Recent
3. Staff are afraid to ask
questions when something
does not seem right.
Most Recent
Previous
Change
Previous
Change
Frequency of Events Reported
1. When a mistake is made,
Most Recent
but is caught and corrected
Previous
before affecting the patient,
Change
how often is this reported?
2. When a mistake is made,
Most Recent
but has no potential to harm
Previous
the patient, how often is this
Change
reported?
3. When a mistake is made
Most Recent
that could harm the patient,
Previous
but does not, how often is
Change
this reported?
Rehabilitation Surgery
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 36
Table B-2. Trending: Item-level Percent Positive Response by Work Area/Unit (Page 5 of 6)
Work Area/Unit
Item
Survey Items by Composite
# Respondents
9.
F2
R
Teamwork Across Units
1. Hospital units do not
coordinate well with each
other.
F4
2. There is good cooperation
among hospital units that
need to work together.
F6
R
3. It is often unpleasant to
work with staff from other
hospital units.
F10
4. Hospital units work well
together to provide the best
care for patients.
10.
Staffing
A2
1. We have enough staff to
handle the workload.
A5
R
2. Staff in this unit work
longer hours than is best for
patient care.
A7
R
3. We use more
agency/temporary staff than
is best for patient care.
A14
R
4. We work in “crisis mode”
trying to do too much, too
quickly.
Database
Year
Lab
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mental
Health
Radiology
11
7
2
7
3
4
0
4
10
3
6
1
4
6
25
26
8
10
0
0
50%
68%
77%
73%
-
55%
50%
73%
90%
-
-
-
-
80%
90%
100%
100%
-
-
-
63%
65%
-2%
83%
65%
18%
79%
84%
-5%
88%
77%
11%
50%
56%
75%
100%
-
-
36%
55%
77%
57%
-
18%
80%
70%
82%
-
-
-
-
90%
90%
100%
100%
-
-
-
44%
31%
13%
48%
40%
8%
75%
68%
7%
52%
58%
-6%
10%
38%
89%
22%
-
-
Anesthesiology
Emergency
ICU
Most Recent
Previous
0
0
22
0
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
-
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
-
Rehabilitation Surgery
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 37
Table B-2. Trending: Item-level Percent Positive Response by Work Area/Unit (Page 6 of 6)
Work Area/Unit
Item
11.
F3
R
Handoffs & Transitions
1. Things “fall between the
cracks” when transferring
patients from one unit to
another.
Pediatrics
Pharmacy
Psych/
Mental
Health
Radiology
11
7
2
7
3
4
0
4
10
3
6
1
4
6
25
26
8
10
0
0
52%
-
20%
-
-
-
-
90%
-
-
-
57%
54%
50%
-
-
82%
36%
77%
-
50%
50%
40%
-
-
-
-
90%
100%
100%
-
-
-
3%
48%
50%
-2%
64%
46%
18%
57%
70%
-13%
20%
14%
20%
-
-
-
36%
36%
-
91%
70%
-
-
-
-
90%
90%
-
-
-
72%
46%
26%
75%
59%
56%
78%
-
-
32%
-
60%
-
-
-
-
90%
-
-
-
16%
38%
52%
-14%
33%
-
-
Emergency
ICU
Most Recent
Previous
0
0
22
0
Most Recent
-
Previous
Change
F5
R
2. Important patient care
information is often lost
during shift changes.
Most Recent
F7
R
3. Problems often occur in
the exchange of information
across hospital units.
Most Recent
F11
R
4. Shift changes are
problematic for patients in
this hospital.
Most Recent
12.
Nonpunitive Response to Error
A8
R
1. Staff feel like their
mistakes are held against
them.
Most Recent
Most Recent
A12
R
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.
Most Recent
A16
R
Obstetrics
Anesthesiology
Survey Items by Composite
# Respondents
Lab
Medicine
Database
Year
Previous
Change
Previous
Change
Previous
Change
Previous
Change
Previous
Change
Previous
Change
Rehabilitation Surgery
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 38
Table B-3. Trending: Average Percent Distribution of Work Area/Unit Patient Safety Grades by Work Area/Unit
Work Area/Unit
# Respondents
Database
Year
Anesthesiology
Emergency
ICU
Lab
Most Recent
Previous
0
0
22
0
11
7
2
7
Patient Safety
Grade
A Excellent
B Very Good
C Acceptable
D Poor
E Failing
Medicine
Obstetrics
Pediatrics
3
4
0
4
10
3
Pharmacy
Psych/
Mental
Health
Radiology
Rehabilitation
Surgery
6
1
4
6
25
26
8
10
0
0
Average Percent of Respondents within Hospitals
Most Recent
-
18%
50%
-
-
-
100%
-
-
27%
-
-
Previous
-
-
-
-
-
-
-
-
-
25%
44%
-
Change
-
-
-
-
-
-
-
-
-
2%
-
-
Most Recent
-
71%
50%
-
-
-
0%
-
-
59%
-
-
Previous
-
-
-
-
-
-
-
-
-
58%
56%
-
Change
-
-
-
-
-
-
-
-
-
1%
-
-
Most Recent
-
6%
0%
-
-
-
0%
-
-
14%
-
-
Previous
-
-
-
-
-
-
-
-
-
17%
0%
-
Change
-
-
-
-
-
-
-
-
-
-3%
-
-
Most Recent
-
6%
0%
-
-
-
0%
-
-
0%
-
-
Previous
-
-
-
-
-
-
-
-
-
0%
0%
-
Change
-
-
-
-
-
-
-
-
-
0%
-
-
Most Recent
-
0%
0%
-
-
-
0%
-
-
0%
-
-
Previous
-
-
-
-
-
-
-
-
-
0%
0%
-
Change
-
-
-
-
-
-
-
-
-
0%
-
-
March 2009 Trending Report for ABC Hospital, Appendix Page 39
Table B-4. Trending: Average Percent Distribution of Number of Events Reported in the Past 12 Months by Work Area/Unit
Work Area/Unit
# Respondents
Database
Year
Anesthesiology
Emergency
ICU
Lab
Most Recent
Previous
0
0
22
0
11
7
2
7
Number of Events
Reported
No events
1 to 2 events
3 to 5 events
6 to 10 events
11 to 20 events
21 event reports
or more
Medicine
Obstetrics
Pediatrics
Pharmacy
Psych/
Mental
Health
Radiology
Rehabilitation
Surgery
3
4
0
4
10
3
6
1
4
6
25
26
8
10
0
0
Average Percent of Respondents within Hospitals
Most Recent
-
28%
73%
-
-
-
20%
-
-
57%
-
-
Previous
-
-
-
-
-
-
-
-
-
61%
56%
-
Change
-
-
-
-
-
-
-
-
-
-4%
-
-
Most Recent
-
56%
18%
-
-
-
50%
-
-
14%
-
-
Previous
-
-
-
-
-
-
-
-
-
13%
22%
-
Change
-
-
-
-
-
-
-
-
-
1%
-
-
Most Recent
-
17%
9%
-
-
-
20%
-
-
19%
-
-
Previous
-
-
-
-
-
-
-
-
-
13%
22%
-
Change
-
-
-
-
-
-
-
-
-
6%
-
-
Most Recent
-
0%
0%
-
-
-
10%
-
-
5%
-
-
Previous
-
-
-
-
-
-
-
-
-
9%
0%
-
Change
-
-
-
-
-
-
-
-
-
-4%
-
-
Most Recent
-
0%
0%
-
-
-
0%
-
-
0%
-
-
Previous
-
-
-
-
-
-
-
-
-
0%
0%
-
Change
-
-
-
-
-
-
-
-
-
0%
-
-
Most Recent
-
0%
0%
-
-
-
0%
-
-
5%
-
-
Previous
-
-
-
-
-
-
-
-
-
4%
0%
-
Change
-
-
-
-
-
-
-
-
-
1%
-
-
March 2009 Trending Report for ABC Hospital, Appendix Page 40
Appendix B: Trending Results by—
(2) Staff Position
NOTE 1: Respondents who selected "Other" or those who did not answer (missing) are not included.
NOTE 2: Your hospital’s number of respondents in each staff position is shown. However, the precise number of respondents
corresponding to each of your hospital’s data cells in the tables will vary because of individual non-response/missing data.
NOTE 3: Changes in scores of 5% or greater, whether positive or negative, are bolded.
Your hospital’s results are only displayed if there were at least 10 respondents in a particular staff position (to protect individual
respondent confidentiality in these areas). If there were 9 or fewer respondents in a particular staff position, a hyphen (-) is shown.
March 2009 Trending Report for ABC Hospital, Appendix Page 41
Table B-5. Trending: Composite-level Average Percent Positive Response by Staff Position (Page 1 of 2)
Staff Position
Patient Safety Culture Composites
# Respondents
1. Teamwork Within Units
Database
Year
Most
Recent
Previous
Most
Recent
Previous
Change
2. Supervisor/Manager
Expectations & Actions
Promoting Patient Safety
3. Org Learning--Continuous
Improvement
Most
Recent
Previous
Change
Most
Recent
Previous
Change
4. Management Support for
Patient Safety
Most
Recent
Previous
Change
5. Overall Perceptions of
Patient Safety
Most
Recent
Previous
Change
6. Feedback & Communication
About Error
Most
Recent
Previous
Change
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
RN/LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Pharmacist
0
0
32
33
0
0
26
17
0
0
34
21
0
0
0
0
0
0
-
84%
-
91%
-
91%
-
-
-
-
82%
-
94%
-
96%
-
-
-
-
2%
-
-3%
-
-5%
-
-
-
-
69%
-
74%
-
87%
-
-
-
-
89%
-
74%
-
89%
-
-
-
-
-20%
-
0%
-
-2%
-
-
-
-
68%
-
78%
-
86%
-
-
-
-
88%
-
77%
-
92%
-
-
-
-
-20%
-
1%
-
-6%
-
-
-
-
84%
-
83%
-
91%
-
-
-
-
79%
-
73%
-
88%
-
-
-
-
5%
-
10%
-
3%
-
-
-
-
77%
-
78%
-
85%
-
-
-
-
71%
-
64%
-
79%
-
-
-
-
6%
-
14%
-
6%
-
-
-
-
81%
-
55%
-
79%
-
-
-
-
77%
-
64%
-
83%
-
-
-
-
4%
-
-9%
-
-4%
-
-
-
March 2009 Trending Report for ABC Hospital, Appendix Page 42
Unit Asst/
Clerk/
Secretary
Table B-5. Trending: Composite-level Average Percent Positive Response by Staff Position (Page 2 of 2)
Staff Position
Patient Safety Culture Composites
# Respondents
7. Communication Openness
8. Frequency of Events
Reported
9. Teamwork Across Units
10. Staffing
11. Handoffs & Transitions
12. Nonpunitive Response to
Error
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
Pharmacist
Most Recent
Previous
0
0
32
33
0
0
26
17
0
0
34
21
0
0
0
0
0
0
Most Recent
-
64%
-
67%
-
78%
-
-
-
Previous
-
65%
-
66%
-
79%
-
-
-
Change
-
-1%
-
1%
-
-1%
-
-
-
Most Recent
-
82%
-
60%
-
73%
-
-
-
Previous
-
84%
-
69%
-
83%
-
-
-
Change
-
-2%
-
-9%
-
-10%
-
-
-
Most Recent
-
67%
-
61%
-
84%
-
-
-
Previous
-
69%
-
75%
-
74%
-
-
-
Change
-
-2%
-
-14%
-
10%
-
-
-
Most Recent
-
55%
-
67%
-
77%
-
-
-
Previous
-
43%
-
55%
-
68%
-
-
-
Change
-
12%
-
12%
-
9%
-
-
-
Most Recent
-
58%
-
42%
-
77%
-
-
-
Previous
-
56%
-
57%
-
73%
-
-
-
Change
-
2%
-
-15%
-
4%
-
-
-
Most Recent
-
48%
-
63%
-
72%
-
-
-
Previous
-
39%
-
56%
-
69%
-
-
-
Change
-
9%
-
7%
-
3%
-
-
-
March 2009 Trending Report for ABC Hospital, Appendix Page 43
RN/LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Unit Asst/
Clerk/
Secretary
Table B-6. Trending: Item-level Percent Positive Response by Staff Position (Page 1 of 6)
Staff Position
Item
Patient Safety Culture
Composites
# Respondents
1.
Teamwork Within Units
A1
1. People support one
another in this unit.
A3
2. When a lot of work needs
to be done quickly, we work
together as a team to get the
work done.
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
Most Recent
Previous
0
0
32
33
0
0
26
17
0
0
34
21
0
0
0
0
0
0
Most Recent
Previous
Change
Most Recent
-
84%
85%
-1%
94%
-
96%
100%
-4%
88%
-
94%
100%
-6%
97%
-
-
-
Previous
-
82%
-
94%
-
100%
-
-
-
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
-
12%
84%
81%
3%
74%
78%
-4%
-
-6%
96%
100%
-4%
85%
82%
3%
-
-3%
88%
100%
-12%
85%
86%
-1%
-
-
-
Pharmacist
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Unit Asst/
Clerk/
Secretary
A4
3. In this unit, people treat
each other with respect.
A11
4. When one area in this unit
gets really busy, others help
out.
2.
Supv/Mgr Expectations & Actions Promoting Patient Safety
Most Recent
-
67%
-
69%
-
74%
-
-
-
B1
1. My supv/mgr says a good
word when he/she sees a
job done according to
established patient safety
procedures.
Previous
-
93%
-
69%
-
76%
-
-
-
Change
-
-26%
-
0%
-
-2%
-
-
-
2. My supv/mgr seriously
considers staff suggestions
for improving patient safety.
Most Recent
-
68%
-
73%
-
88%
-
-
-
Previous
-
93%
-
69%
-
95%
-
-
-
Change
-
-25%
-
4%
-
-7%
-
-
-
3. Whenever pressure builds
up, my supv/mgr wants us to
work faster, even if it means
taking shortcuts.
Most Recent
-
71%
-
77%
-
91%
-
-
-
Previous
-
79%
-
73%
-
86%
-
-
-
Change
-
-8%
-
4%
-
5%
-
-
-
Most Recent
-
71%
-
77%
-
94%
-
-
-
Previous
-
90%
-
87%
-
100%
-
-
-
Change
-
-19%
-
-10%
-
-6%
-
-
-
B2
B3
R
B4
R
4. My supv/mgr overlooks
patient safety problems that
happen over and over.
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 44
Table B-6. Trending: Item-level Percent Positive Response by Staff Position (Page 2 of 6)
Staff Position
Item
Patient Safety Culture
Composites
Database
Year
Most Recent
# Respondents
Previous
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
0
0
32
33
Dietician
Pat Care
Asst/Aide/
Care
Partner
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Pharmacist
Unit Asst/
Clerk/
Secretary
0
0
26
17
0
0
34
21
0
0
0
0
0
0
Organizational Learning— Continuous Improvement
3.
1. We are actively
doing things to
improve patient
safety.
Most Recent
2. Mistakes have led
to positive changes
here.
Previous
-
94%
94%
-
88%
100%
-
88%
100%
-
-
-
Change
-
0%
-
-12%
-
-12%
-
-
-
Most Recent
-
52%
84%
-32%
-
68%
56%
12%
-
76%
80%
-4%
-
-
-
3. After we make
Most Recent
changes to improve
Previous
A13 patient safety, we
evaluate their
Change
effectiveness.
4.
Management Support for Patient Safety
1. Hospital mgmt
Most Recent
provides a work
Previous
F1
climate that promotes
Change
patient safety.
2. The actions of
Most Recent
hospital mgmt show
Previous
F8
that patient safety is
Change
a top priority.
3. Hospital mgmt
Most Recent
seems interested in
F9
Previous
patient safety only
R
after an adverse
Change
event happens.
60%
-
77%
-
94%
-
-
-
87%
-
73%
-
95%
-
-
-
-27%
-
4%
-
-1%
-
-
-
94%
-
88%
-
97%
-
-
-
91%
-
81%
-
95%
-
-
-
A6
A9
Previous
Change
3%
-
7%
-
2%
-
-
-
87%
88%
-
84%
69%
-
94%
90%
-
-
-
-1%
-
15%
-
4%
-
-
-
72%
-
76%
-
82%
-
-
-
59%
-
69%
-
80%
-
-
-
13%
-
7%
-
2%
-
-
-
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 45
Table B-6. Trending: Item-level Percent Positive Response by Staff Position (Page 3 of 6)
Staff Position
Item
Patient Safety Culture
Composites
# Respondents
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
Most Recent
Previous
0
0
32
33
0
0
26
17
0
0
34
21
0
0
0
0
0
0
77%
-
85%
-
-
-
Pharmacist
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Unit Asst/
Clerk/
Secretary
5.
Overall Perceptions of Patient Safety
1. It is just by chance
that more serious
mistakes don’t happen
around here.
Most Recent
-
69%
-
A10
R
Previous
-
71%
-
63%
-
81%
-
-
-
Change
-
-2%
-
14%
-
4%
-
-
-
Most Recent
-
81%
-
81%
-
79%
-
-
-
A15
2. Patient safety is
never sacrificed to get
more work done.
Previous
Change
-
75%
6%
-
63%
18%
-
60%
19%
-
-
-
3. We have patient
safety problems in this
unit.
Most Recent
-
84%
-
85%
-
85%
-
-
-
A17
R
Previous
-
65%
-
69%
-
81%
-
-
-
Change
-
19%
-
16%
-
4%
-
-
-
Most Recent
-
74%
-
68%
-
91%
-
-
-
A18
4. Our procedures and
systems are good at
preventing errors from
happening.
Previous
-
74%
-
63%
-
95%
-
-
-
Change
-
0%
-
5%
-
-4%
-
-
-
6.
C1
C3
C5
Feedback and Communication About Error
1. We are given
feedback about
changes put into place
based on event
reports.
Most Recent
-
66%
-
44%
-
79%
-
-
-
Previous
-
60%
-
53%
-
67%
-
-
-
Change
-
6%
-
-9%
-
12%
-
-
-
2. We are informed
about errors that
happen in this unit.
Most Recent
-
90%
-
56%
-
79%
-
-
-
Previous
-
81%
-
59%
-
90%
-
-
-
Change
-
9%
-
-3%
-
-11%
-
-
-
3. In this unit, we
discuss ways to
prevent errors from
happening again.
Most Recent
-
87%
-
65%
-
79%
-
-
-
Previous
-
91%
-
81%
-
90%
-
-
-
Change
-
-4%
-
-16%
-
-11%
-
-
-
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 46
Table B-6. Trending: Item-level Percent Positive Response by Staff Position (Page 4 of 6)
Staff Position
Item
7.
C2
C4
C6
R
8.
D1
D2
D3
Patient Safety Culture
Composites
Database
Year
Most Recent
# Respondents
Previous
Communication Openness
1. Staff will freely
Most Recent
speak up if they see
Previous
something that may
negatively affect
Change
patient care.
2. Staff feel free to
Most Recent
question the
Previous
decisions or actions
of those with more
Change
authority.
3. Staff are afraid to
Most Recent
ask questions when
Previous
something does not
Change
seem right.
Frequency of Events Reported
1. When a mistake is
Most Recent
made, but is caught
and corrected before
Previous
affecting the patient,
how often is this
Change
reported?
2. When a mistake is
Most Recent
made, but has no
Previous
potential to harm the
patient, how often is
Change
this reported?
3. When a mistake is
Most Recent
made that could harm
Previous
the patient, but does
not, how often is this
Change
reported?
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Pharmacist
Unit Asst/
Clerk/
Secretary
0
0
32
33
0
0
26
17
0
0
34
21
0
0
0
0
0
0
-
87%
-
88%
-
91%
-
-
-
-
84%
-
87%
-
86%
-
-
-
-
3%
-
1%
-
5%
-
-
-
-
41%
-
46%
-
71%
-
-
-
-
42%
-
38%
-
71%
-
-
-
-
-1%
-
8%
-
0%
-
-
-
-
65%
69%
-
65%
75%
-
74%
81%
-
-
-
-
-4%
-
-10%
-
-7%
-
-
-
-
76%
-
56%
-
59%
-
-
-
-
76%
-
57%
-
72%
-
-
-
-
0%
-
-1%
-
-13%
-
-
-
-
79%
-
54%
-
68%
-
-
-
-
84%
-
67%
-
82%
-
-
-
-
-5%
-
-13%
-
-14%
-
-
-
-
93%
-
71%
-
91%
-
-
-
-
92%
-
85%
-
94%
-
-
-
-
1%
-
-14%
-
-3%
-
-
-
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 47
Table B-6. Trending: Item-level Percent Positive Response by Staff Position (Page 5 of 6)
Staff Position
Item
Patient Safety Culture
Composites
# Respondents
9.
F2
R
F4
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
Most Recent
Previous
0
0
32
33
0
0
26
17
0
0
34
21
0
0
0
0
0
0
-
45%
53%
-8%
74%
-
46%
69%
-23%
52%
-
79%
76%
3%
82%
-
-
-
-
64%
-
75%
-
71%
-
-
-
-
10%
-
-23%
-
11%
-
-
-
Teamwork Across Units
Most Recent
1. Hospital units do not
Previous
coordinate well with each
other.
Change
2. There is good
Most Recent
cooperation among
Previous
hospital units that need
Change
to work together.
Pharmacist
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Unit Asst/
Clerk/
Secretary
3. It is often unpleasant
to work with staff from
other hospital units.
Most Recent
-
71%
-
68%
-
88%
-
-
-
Previous
-
80%
-
69%
-
70%
-
-
-
Change
-
-9%
-
-1%
-
18%
-
-
-
4. Hospital units work
well together to provide
F10
the best care for
patients.
10. Staffing
Most Recent
-
77%
-
76%
-
85%
-
-
-
Previous
-
78%
-
88%
-
80%
-
-
-
Change
-
-1%
-
-12%
-
5%
-
-
-
Most Recent
Previous
Change
34%
27%
7%
47%
-
50%
29%
21%
75%
-
71%
81%
-10%
76%
-
-
-
F6
R
A2
1. We have enough staff
to handle the workload.
Most Recent
A5
R
2. Staff in this unit work
longer hours than is best
for patient care.
-
Previous
-
29%
-
75%
-
50%
-
-
-
Change
-
18%
-
0%
-
26%
-
-
-
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.
Most Recent
-
74%
-
80%
-
88%
-
-
-
Previous
-
64%
-
75%
-
95%
-
-
-
Change
-
10%
-
5%
-
-7%
-
-
-
A7
R
Most Recent
63%
62%
73%
A14
Previous
50%
41%
48%
R
Change
13%
21%
25%
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 48
Table B-6. Trending: Item-level Percent Positive Response by Staff Position (Page 6 of 6)
Staff Position
Item
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Dietician
Pat Care
Asst/Aide/
Care
Partner
Most Recent
Previous
0
0
32
33
0
0
26
17
0
0
34
21
0
0
0
0
0
0
Patient Safety Culture
Composites
# Respondents
Pharmacist
RN/ LVN/
LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys, Occup,
Speech)
Unit Asst/
Clerk/
Secretary
11.
Handoffs & Transitions
Most Recent
-
55%
-
21%
-
69%
-
-
-
F3
R
1. Things “fall between
the cracks” when
transferring patients
from one unit to
another.
Previous
-
52%
-
50%
-
75%
-
-
-
Change
-
3%
-
-29%
-
-6%
-
-
-
2. Important patient
care information is often
lost during shift
changes.
Most Recent
-
61%
-
50%
-
79%
-
-
-
F5
R
Previous
-
52%
-
60%
-
76%
-
-
-
Change
-
9%
-
-10%
-
3%
-
-
-
3. Problems often occur
in the exchange of
information across
hospital units.
Most Recent
-
55%
-
36%
-
72%
-
-
-
F7
R
Previous
-
52%
-
57%
-
68%
-
-
-
Change
-
3%
-
-21%
-
4%
-
-
-
4. Shift changes are
problematic for patients
in this hospital.
Most Recent
-
61%
-
63%
-
88%
-
-
-
F11
R
Previous
-
69%
-
60%
-
71%
-
-
-
Change
-
-8%
-
3%
-
17%
-
-
-
12.
Nonpunitive Response to Error
1. Staff feel like their
mistakes are held
against them.
Most Recent
-
56%
-
73%
-
74%
-
-
-
A8
R
Previous
-
38%
-
50%
-
76%
-
-
-
Change
-
18%
-
23%
-
-2%
-
-
-
2. When an event is
reported, it feels like the
person is being written
up, not the problem.
Most Recent
-
52%
-
64%
-
79%
-
-
-
A12
R
Previous
-
45%
-
63%
-
70%
-
-
-
Change
-
7%
-
1%
-
9%
-
-
-
3. Staff worry that
mistakes they make are
kept in their personnel
file.
Most Recent
-
35%
-
52%
-
62%
-
-
-
Previous
-
35%
-
56%
-
60%
-
-
-
Change
-
0%
-
-4%
-
2%
-
-
-
A16
R
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 49
Table B-7. Trending: Average Distribution of Work Area/Unit Patient Safety Grade by Staff Position
Staff Position
# Respondents
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Most Recent
0
0
32
33
Previous
Dietician
Pat Care
Asst/Aide/
Care
Partner
Pharmacist
0
0
26
17
0
0
Patient Safety
Grade
A
B
C
D
E
Excellent
Very Good
Acceptable
Poor
Failing
RN/LVN/LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys,
Occup,
Speech)
Unit Asst/
Clerk/
Secretary
34
21
0
0
0
0
0
0
Average Percent of Respondents within Hospitals
Most Recent
-
32%
-
35%
-
48%
-
-
-
Previous
-
28%
-
19%
-
33%
-
-
-
Change
-
4%
-
16%
-
15%
-
-
-
Most Recent
-
54%
-
57%
-
52%
-
-
-
Previous
-
53%
-
75%
-
67%
-
-
-
Change
-
1%
-
-18%
-
-15%
-
-
-
Most Recent
-
14%
-
9%
-
0%
-
-
-
Previous
-
19%
-
6%
-
0%
-
-
-
Change
-
-5%
-
3%
-
0%
-
-
-
Most Recent
-
0%
-
0%
-
0%
-
-
-
Previous
-
0%
-
0%
-
0%
-
-
-
Change
-
0%
-
0%
-
0%
-
-
-
Most Recent
-
0%
-
0%
-
0%
-
-
-
Previous
-
0%
-
0%
-
0%
-
-
-
Change
-
0%
-
0%
-
0%
-
-
-
March 2009 Trending Report for ABC Hospital, Appendix Page 50
Table B-8. Trending: Average Percent Distribution of Number of Events Reported in the Past 12 Months by Staff Position
Staff Position
# Respondents
Database
Year
Admin/
Mgmt
Attending/
Physician/
Resident/
PA or NP
Most Recent
Previous
0
0
32
33
Dietician
Pat Care
Asst/Aide/
Care
Partner
Pharmacist
0
0
26
17
0
0
Number of Events
Reported
Previous
Change
Most Recent
1 to 2 events
Previous
Change
Most Recent
3 to 5 events
Previous
Change
Most Recent
6 to 10 events
Previous
Change
Most Recent
11 to 20 events
Previous
Change
21 event reports
or more
Unit Asst/
Clerk/
Secretary
34
21
0
0
0
0
0
0
-
-
-
Average Percent of Respondents within Hospitals
Most Recent
No events
RN/LVN/LPN
Technician
(EKG, Lab,
Radiology)
Therapist
(Respiratory,
Phys,
Occup,
Speech)
Most Recent
Previous
Change
-
50%
72%
-22%
25%
3%
22%
21%
10%
11%
4%
10%
-6%
0%
0%
0%
0%
3%
-3%
-
55%
38%
17%
23%
50%
-27%
14%
6%
8%
9%
6%
3%
0%
0%
0%
0%
0%
0%
-
28%
10%
18%
52%
33%
19%
14%
48%
-34%
3%
0%
3%
0%
10%
-10%
3%
0%
3%
March 2009 Trending Report for ABC Hospital, Appendix Page 51
Appendix B: Trending Results by Respondent Characteristics
(3) Interaction with Patients
NOTE 1: Respondents who did not answer (missing) are not included.
NOTE 2: Your hospital’s number of respondents in each response category (WITH or WITHOUT direct interaction with patients)
is shown. However, the precise number of respondents corresponding to each of your hospital’s data cells in the tables will vary
because of individual non-response/missing data.
NOTE 3: Changes in scores of 5% or greater, whether positive or negative, are bolded.
Your hospital’s results are only displayed if there were at least 10 respondents (to protect individual respondent confidentiality in
these areas). If there were 9 or fewer respondents in either response category (WITH or WITHOUT direct interaction with
patients), a hyphen (-) is shown.
March 2009 Trending Report for ABC Hospital, Appendix Page 52
Table B-9. Trending: Composite-level Average Percent Positive Response by Interaction with Patients (Page 1 of 2)
Patient Safety Culture Composites
# Respondents
1. Teamwork Within Units
2. Supervisor/Manager Expectations & Actions
Promoting Patient Safety
3. Management Support for Patient Safety
4. Org Learning--Continuous Improvement
5. Overall Perceptions of Patient Safety
6. Feedback & Communication About Error
Database Year
Most Recent
Previous
Interaction with Patients
WITH
WITHOUT
direct interaction
direct interaction
85
15
60
12
Most Recent
86%
95%
Previous
89%
89%
Change
-3%
6%
Most Recent
75%
75%
Previous
84%
94%
Change
-9%
-19%
Most Recent
83%
95%
Previous
82%
75%
Change
1%
20%
Most Recent
73%
86%
Previous
86%
92%
Change
-13%
-6%
Most Recent
78%
80%
Previous
72%
74%
Change
6%
6%
Most Recent
71%
90%
Previous
74%
88%
Change
-3%
2%
March 2009 Trending Report for ABC Hospital, Appendix Page 53
Table B-9. Trending: Composite-level Average Percent Positive Response by Interaction with Patients (Page 2 of 2)
Patient Safety Culture Composites
# Respondents
7. Communication Openness
8. Frequency of Events Reported
9. Teamwork Across Units
10. Staffing
11. Handoffs & Transitions
12. Nonpunitive Response to Error
Database Year
Most Recent
Previous
Interaction with Patients
WITH
WITHOUT
direct interaction
direct interaction
85
15
60
12
Most Recent
65%
87%
Previous
70%
69%
Change
-5%
18%
Most Recent
69%
86%
Previous
79%
89%
Change
-10%
-3%
Most Recent
67%
82%
Previous
74%
63%
Change
-7%
19%
Most Recent
64%
64%
Previous
56%
45%
Change
8%
19%
Most Recent
57%
68%
Previous
66%
35%
Change
-9%
33%
Most Recent
55%
79%
Previous
53%
49%
Change
2%
30%
March 2009 Trending Report for ABC Hospital, Appendix Page 54
Table B-10. Trending: Item-level Average Percent Positive Response by Interaction with Patients (Page 1 of 6)
Interaction with Patients
WITH
WITHOUT
Item
Survey Items By Composite
Database Year
direct interaction
direct interaction
Most Recent
85
15
# Respondents
60
12
Previous
1.
Teamwork Within Units
88%
100%
Most Recent
A1
1. People support one another in this unit.
93%
92%
Previous
-5%
8%
Change
92%
100%
Most Recent
2. When a lot of work needs to be done quickly, we work
90%
92%
A3
Previous
together as a team to get the work done.
2%
8%
Change
87%
100%
Most Recent
92%
91%
A4
3. In this unit, people treat each other with respect.
Previous
-5%
9%
Change
79%
79%
Most Recent
A11 4. When one area in this unit gets really busy, others help out.
82%
82%
Previous
-3%
-3%
Change
2.
B1
B2
B3
R
B4
R
Supervisor/Manager Expectations & Actions Promoting Patient Safety
Most Recent
1. My supv/mgr says a good word when he/she sees a job done
Previous
according to established patient safety procedures.
Change
Most Recent
2. My supv/mgr seriously considers staff suggestions for
Previous
improving patient safety.
Change
Most Recent
3. Whenever pressure builds up, my supv/mgr wants us to work
Previous
faster, even if it means taking shortcuts.
Change
Most Recent
4. My supv/mgr overlooks patient safety problems that happen
Previous
over and over.
Change
69%
78%
-9%
73%
85%
-12%
79%
80%
-1%
81%
93%
-12%
79%
100%
-21%
79%
100%
-21%
71%
83%
-12%
71%
92%
-21%
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 55
Table B-10. Trending: Item-level Average Percent Positive Response by Interaction with Patients (Page 2 of 6)
Item
Survey Items By Composite
# Respondents
3.
Database Year
Most Recent
Previous
Interaction with Patients
WITH
WITHOUT
direct interaction
direct interaction
85
15
60
12
Organizational Learning— Continuous Improvement
A6
1. We are actively doing things to improve patient safety.
A9
2. Mistakes have led to positive changes here.
A13
3. After we make changes to improve patient safety, we
evaluate their effectiveness.
4.
Management Support for Patient Safety
F1
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.
F9
R
3. Hospital mgmt seems interested in patient safety only after
an adverse event happens.
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
88%
97%
-9%
58%
75%
-17%
74%
86%
-12%
87%
100%
-13%
86%
83%
3%
85%
92%
-7%
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
90%
92%
-2%
86%
82%
4%
72%
72%
0%
100%
83%
17%
93%
92%
1%
93%
50%
43%
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 56
Table B-10. Trending: Item-level Average Percent Positive Response by Interaction with Patients (Page 3 of 6)
Item
Survey Items By Composite
# Respondents
5.
Overall Perceptions of Patient Safety
A10
R
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.
A17
R
3. We have patient safety problems in this unit.
A18
4. Our procedures and systems are good at preventing errors
from happening.
6.
Feedback and Communication About Error
C1
1. We are given feedback about changes put into place based
on event reports.
C3
2. We are informed about errors that happen in this unit.
C5
3. In this unit, we discuss ways to prevent errors from
happening again.
Database Year
Most Recent
Previous
Interaction with Patients
WITH
WITHOUT
direct interaction
direct interaction
85
15
60
12
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
73%
74%
-1%
81%
65%
16%
81%
71%
10%
79%
79%
0%
80%
67%
13%
60%
83%
-23%
93%
73%
20%
86%
75%
11%
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
65%
59%
6%
75%
76%
-1%
73%
86%
-13%
79%
73%
6%
93%
92%
1%
100%
100%
0%
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 57
Table B-10. Trending: Item-level Average Percent Positive Response by Interaction with Patients (Page 4 of 6)
Item
Survey Items By Composite
# Respondents
7.
Communication Openness
C2
1. Staff will freely speak up if they see something that may
negatively affect patient care.
C4
2. Staff feel free to question the decisions or actions of those
with more authority.
C6
R
3. Staff are afraid to ask questions when something does not
seem right.
8.
Frequency of Events Reported
D1
1. When a mistake is made, but is caught and corrected before
affecting the patient, how often is this reported?
D2
2. When a mistake is made, but has no potential to harm the
patient, how often is this reported?
D3
3. When a mistake is made that could harm the patient, but
does not, how often is this reported?
Database Year
Most Recent
Previous
Interaction with Patients
WITH
WITHOUT
direct interaction
direct interaction
85
15
60
12
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
85%
86%
-1%
46%
51%
-5%
63%
74%
-11%
100%
83%
17%
73%
50%
23%
87%
75%
12%
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
60%
67%
-7%
66%
78%
-12%
81%
91%
-10%
93%
89%
4%
71%
89%
-18%
93%
89%
4%
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 58
Table B-10. Trending: Item-level Average Percent Positive Response by Interaction with Patients (Page 5 of 6)
Interaction with Patients
WITH
WITHOUT
Item
Survey Items By Composite
Database Year
direct interaction
direct interaction
Most Recent
85
15
# Respondents
60
12
Previous
9.
Teamwork Across Units
52%
79%
Most Recent
F2
1. Hospital units do not coordinate well with each other.
67%
50%
Previous
R
-15%
29%
Change
65%
79%
Most Recent
2. There is good cooperation among hospital units that need to
71%
58%
F4
Previous
work together.
-6%
21%
Change
75%
86%
Most Recent
3. It is often unpleasant to work with staff from other hospital
F6
75%
70%
Previous
units.
R
0%
16%
Change
77%
86%
Most Recent
4. Hospital units work well together to provide the best care for
F10
82%
75%
Previous
patients.
-5%
11%
Change
10.
Staffing
49%
40%
Most Recent
1. We have enough staff to handle the workload.
47%
33%
A2
Previous
2%
7%
Change
68%
57%
Most Recent
2. Staff in this unit work longer hours than is best for patient
A5
47%
45%
Previous
care.
R
21%
12%
Change
80%
64%
Most Recent
3. We use more agency/temporary staff than is best for patient
A7
80%
64%
Previous
care.
R
0%
0%
Change
59%
93%
Most Recent
A14
4. We work in “crisis mode” trying to do too much, too quickly.
50%
36%
Previous
R
9%
57%
Change
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 59
Table B-10. Trending: Item-level Average Percent Positive Response by Interaction with Patients (Page 6 of 6)
Item
Survey Items By Composite
# Respondents
11.
Handoffs & Transitions
F3
R
1. Things “fall between the cracks” when transferring patients
from one unit to another.
F5
R
2. Important patient care information is often lost during shift
changes.
F7
R
3. Problems often occur in the exchange of information across
hospital units.
F11
R
4. Shift changes are problematic for patients in this hospital.
12.
Nonpunitive Response to Error
A8
R
1. Staff feel like their mistakes are held against them.
A12
R
2. When an event is reported, it feels like the person is being
written up, not the problem.
A16
R
3. Staff worry that mistakes they make are kept in their
personnel file.
Database Year
Most Recent
Previous
Interaction with Patients
WITH
WITHOUT
direct interaction
direct interaction
85
15
60
12
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
44%
62%
-18%
64%
67%
-3%
49%
64%
-15%
69%
69%
0%
79%
40%
39%
57%
22%
35%
71%
22%
49%
64%
56%
8%
Most Recent
Previous
Change
Most Recent
Previous
Change
Most Recent
Previous
Change
62%
55%
7%
57%
55%
2%
45%
49%
-4%
80%
42%
38%
93%
63%
30%
64%
42%
22%
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).
March 2009 Trending Report for ABC Hospital, Appendix Page 60
Table B-11. Trending: Average Percent Distribution of Work Area/Unit Patient Safety Grade by
Interaction With Patients
Interaction with Patients
# Respondents
Database Year
Most Recent
Previous
Patient Safety Grade
A
B
C
D
E
Excellent
Very Good
Acceptable
Poor
Failing
WITH
direct interaction
85
60
WITHOUT
direct interaction
15
12
Average Percent of Respondents within Hospitals
Most Recent
43%
36%
Previous
28%
20%
Change
15%
16%
Most Recent
48%
57%
Previous
61%
70%
Change
-13%
-13%
Most Recent
8%
7%
Previous
11%
10%
Change
-3%
-3%
Most Recent
1%
0%
Previous
0%
0%
Change
1%
0%
Most Recent
0%
0%
Previous
0%
0%
Change
0%
0%
March 2009 Trending Report for ABC Hospital, Appendix Page 61
Table B-12. Trending: Average Percent Distribution of Number of Events Reported in the Past 12
Months by Interaction With Patients
Interaction with Patients
# Respondents
Database Year
Most Recent
Previous
Number of Events Reported
No events
1 to 2 events
3 to 5 events
6 to 10 events
11 to 20 events
21 event reports or more
WITH
direct interaction
85
60
WITHOUT
direct interaction
15
12
Average Percent of Respondents within Hospitals
Most Recent
40%
93%
Previous
36%
83%
Change
4%
10%
Most Recent
38%
0%
Previous
29%
0%
Change
9%
0%
Most Recent
16%
7%
Previous
24%
8%
Change
-8%
-1%
Most Recent
4%
0%
Previous
7%
0%
Change
-3%
0%
Most Recent
0%
0%
Previous
4%
0%
Change
-4%
0%
Most Recent
1%
0%
Previous
0%
8%
Change
1%
-8%
March 2009 Trending Report for ABC Hospital, Appendix Page 62
| File Type | application/pdf |
| File Title | Microsoft Word - Individual Trending Hospital - Main-Appendix.doc |
| Author | Famolaro_t |
| File Modified | 2009-06-30 |
| File Created | 2009-06-24 |