Form # 2 Form # 2 Ambulatory Surgery SOPS

Form Approved

OMB No. 0935-XXXX

Exp. Date XX/XX/20XX

Attachment B - PILOT TEST

Draft Ambulatory Surgery

Survey on Patient Safety

8-30-2013

This survey asks for your opinions about patient safety in outpatient surgery/procedure/treatment facilities and takes at least 15 minutes to complete. If you work in multiple facilities, please answer only for the facility that gave you the survey.

Please review the following definitions and instructions:

• The term doctors refers to physicians (MDs or DOs) and other doctors, such as podiatrists and dentists, who perform surgeries, procedures, or treatments, including delivery of anesthesia.

• The term staff refers to all others (clinical and nonclinical) who work in your facility, whether they are employed directly by your facility or are contract/per diem/agency staff.

• “Patient Safety” is the prevention of harm resulting from the processes of health care delivery.

• A mistake is any type of error, incident, or event that contributed to patient harm or that could have caused patient harm but did not.

• If a question does not apply to you or your facility or you don’t know the answer, please check “Does Not Apply or Don’t Know.”

Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

1. Teamwork

How much do you agree or disagree with the following statements about your facility?	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
There is a good working relationship between doctors and staff	1	2	3	4	5	9
When someone in this facility gets really busy, others help out	1	2	3	4	5	9
Doctors and staff clearly understand each other’s roles and responsibilities	1	2	3	4	5	9
We work together as an effective team	1	2	3	4	5	9
We treat each other with respect	1	2	3	4	5	9
We resolve work-related disagreements in a respectful way……………………………………	1	2	3	4	5	9

2. Communication Openness

How often do the following statements apply to your facility?	Never 	Rarely 	Some- times 	Most of the time 	Always 	Does Not Apply or Don’t Know 
In this facility, we speak up when we see something that may negatively affect patient care	1	2	3	4	5	9
In this facility, we feel comfortable asking questions when something doesn’t seem right	1	2	3	4	5	9
Staff feel free to question the decisions or actions of those with more authority	1	2	3	4	5	9
Staff who see others doing something unsafe for patients tell them it is unsafe	1	2	3	4	5	9

3. Communication About Patient Information

How much do you agree or disagree with the following statements about your facility?	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
In this facility, we do a good job communicating information that affects patient care	1	2	3	4	5	9
Problems often occur in the exchange of information between doctors and staff	1	2	3	4	5	9
We share key information about patients as it becomes available	1	2	3	4	5	9
Key patient care information is clearly communicated across areas in this facility	1	2	3	4	5	9

4. Organizational Learning – Continuous Improvement

How often do the following statements apply to your facility?	Never 	Rarely 	Some- times 	Most of the time 	Always 	Does Not Apply or Don’t Know 
This facility makes improvements when someone points out patient safety problems	1	2	3	4	5	9
We are good at changing processes to make sure the same patient safety problems don’t happen again	1	2	3	4	5	9
When our efforts to improve patient safety are unsuccessful, we keep trying to find a better way to do things	1	2	3	4	5	9
We try to prevent patient harm by learning from mistakes	1	2	3	4	5	9
This facility is open to making changes to improve patient safety	1	2	3	4	5	9
Mistakes have led to improvements in patient safety in this facility	1	2	3	4	5	9

5. Response to Mistakes

How much do you agree or disagree with the following statements about your facility?	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
We are informed about errors that happen in this facility	1	2	3	4	5	9
We discuss if any of our processes contributed to mistakes that affect patient care	1	2	3	4	5	9
Management emphasizes learning rather than blame when staff make patient safety mistakes	1	2	3	4	5	9
We try to understand the factors that lead to patient safety errors	1	2	3	4	5	9
Staff feel comfortable reporting patient safety errors	1	2	3	4	5	9
Staff are treated fairly when they make patient safety mistakes	1	2	3	4	5	9
When staff take shortcuts that put patient safety at risk, managers work with them to change their behavior	1	2	3	4	5	9

6. Documenting Mistakes

	Never 	Rarely 	Some- times 	Most of the time 	Always 	Does Not Apply or Don’t Know 
When a mistake is made that could harm the patient, but does not, how often is it documented?	1	2	3	4	5	9

7. Staff Training

How much do you agree or disagree with the following statements about your facility?

Strongly Disagree 

Disagree 

Neither Agree nor Disagree 

Agree 

Strongly Agree 

Does Not Apply or Don’t Know 

Staff feel pressured to do tasks they haven’t been trained to do

1

2

3

4

5

9

Staff receive adequate training in this facility on how to manage complications with patient care

1

2

3

4

5

9

Staff who are new to this facility receive adequate orientation

1

2

3

4

5

9

This facility provides effective training on patient safety policies and procedures

1

2

3

4

5

9

Staff get the on-the-job training they need in this facility

1

2

3

4

5

9

8. Staffing, Work Pressure, and Pace

How often do the following statements apply to your facility?	Never 	Rarely 	Some- times 	Most of the time 	Always 	Does Not Apply or Don’t Know 
Pressure to move quickly from case to case gets in the way of patient safety	1	2	3	4	5	9
We feel rushed when taking care of patients	1	2	3	4	5	9
We have enough staff to handle the workload	1	2	3	4	5	9
There is enough time between procedures to properly prepare for the next one	1	2	3	4	5	9
The scheduling of patients allows enough time to safely care for them	1	2	3	4	5	9
We have enough time to safely care for patients	1	2	3	4	5	9

9. Management Support for Patient Safety

How much do you agree or disagree with the following statements about your facility?	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
Management encourages everyone to suggest ways to improve patient safety	1	2	3	4	5	9
Management makes sure staff follow patient safety rules and procedures	1	2	3	4	5	9
Management examines near misses that could have harmed patients but did not	1	2	3	4	5	9
Management provides adequate resources to improve patient care processes	1	2	3	4	5	9
The actions of management show that patient safety is a top priority	1	2	3	4	5	9
Management sends a clear message that patient safety is everyone’s responsibility	1	2	3	4	5	9

10. Overall Perceptions of Patient Safety

How much do you agree or disagree with the following statements about your facility?	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
We are well prepared to manage medical complications that occur in this facility	1	2	3	4	5	9
We have patient safety problems in this facility	1	2	3	4	5	9
This facility places more emphasis on quick turnover time than on patient safety	1	2	3	4	5	9
The way we do things in this facility reflects a strong focus on patient safety	1	2	3	4	5	9
Our work processes and procedures are good at preventing mistakes that could affect patients	1	2	3	4	5	9
This facility is good at preventing patient safety mistakes	1	2	3	4	5	9

11. Information Exchange

	Daily 	Weekly 	Monthly 	Several times in the past 6 months 	Once or twice in the past 6 months 	Not in the past 6 months 	Does Not Apply or Don’t Know 
Over the past 6 months, how often were a patient’s medical records or lab/diagnostic results not available when needed?	1	2	3	4	5	6	9

12. Overall Patient Safety Ratings

How much do you agree or disagree with the following statement about your facility?	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
I would feel safe being treated here as a patient	1	2	3	4	5	9

2. Overall, how would you rate the systems and clinical processes your facility has in place to prevent, catch, and correct problems that have the potential to affect patients?

Poor ▼	Fair ▼	Good ▼	Very good ▼	Excellent ▼
1	2	3	4	5

13. Use of a Procedure/Surgical Safety Checklist

a. Are you typically in the room during the performance of surgeries, procedures, or treatments?

1	Yes
2	No Go to Section 14
Over the past 6 months, for how many procedures did the following things happen?		No procedures 	Few procedures 	About half the procedures 	Most procedures 	All procedures 	Does Not Apply or Don’t Know 
In preparation for procedures, we confirmed patient identity and procedure details with patients or their caregivers.		1	2	3	4	5	9
Before the start of procedures, all team members stopped to discuss the overall plan of what was to be done		1	2	3	4	5	9
The doctor encouraged every team member to speak up if they had any concerns during a case		1	2	3	4	5	9
After procedures, team members discussed any problems that may have occurred or ways to improve patient safety.		1	2	3	4	5	9
After procedures, team members discussed any concerns for patient recovery		1	2	3	4	5	9
We stopped and used a procedure/surgical checklist: Before the patient entered the procedure room		1	2	3	4	5	9
In the procedure room before the procedure began		1	2	3	4	5	9
After the procedure ended		1	2	3	4	5	9
We read our procedure/surgical safety checklist out loud and did not say it from memory		1	2	3	4	5	9

How much do you agree or disagree with the following statements about your facility?	Strongly Disagree 	Disagree 	Neither Agree nor Disagree 	Agree 	Strongly Agree 	Does Not Apply or Don’t Know 
The procedure/surgical safety checklist has improved teamwork	1	2	3	4	5	9
The procedure/surgical safety checklist has improved communication	1	2	3	4	5	9

14. Background Questions

1. What is your position in this facility? Check ONE category that best applies to your job.

a. Doctor (non-anesthesia)/Physician/Surgeon

b. Anesthesiologist

c. Certified Registered Nurse Anesthetist (CRNA)

d. Physician Assistant or Nurse Practitioner

e. Management

Medical Director	Nurse Manager
Center Director Clinical Director/Administrator	Materials Manager Office Manager
Business Manager	Other Manager

f. Nurse

Registered Nurse (RN)

Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN)

g. Technician

Surgical/Scrub Technician	X-Ray Technician
Sterile Processing Technician	Other Technician

h. Other clinical staff or clinical support staff

Anesthesiologist Assistant

Medical Assistant

Nurse Assistant

Other clinical staff or clinical support staff

i. Administrative, Clerical Staff, or Business staff

Billing Staff	Medical Records
Front Desk	Scheduler (appointments, surgery, etc.)
Receptionist	Other administrative or clerical staff position
Insurance Processor

j. Other position; please specify:

2. Indicate all the areas in this facility where you typically work:

Mark all that apply

a. Admission/Check-in

b. Office/business/administrative area

c. Holding/Pre-op

d. Surgery or procedure rooms

e. PACU/Post-op/Recovery

f. Sterile processing

g. Other area, please specify ___________________

3. Typically, how many hours per week do you work in this facility?

a. 1 to 16 hours per week

b. 17 to 31 hours per week

c. 32 to 40 hours per week

d. More than 40 hours per week

15. Your Comments

Please feel free to write any comments about how things are done or could be done in your facility that might affect patient safety.

Thank you for completing this survey.

AMBUALTORY SURGERY SURVEY ON PATIENT SAFETY, DRAFT 8-30-13 DO NOT DISTRIBUTE 12