PSafety Questionnaire _ 3.28.2018

DEPARTMENT OF DEFENSE
2019 TRI-SERVICE SURVEY ON PATIENT SAFETY

Thank you for participating in this survey! Your perspective on patient safety matters is important to the Military Health System (MHS).

Description of this Survey

The 2019 Tri-Service Survey on Patient Safety (Culture Survey) is sponsored by the Department of Defense Patient Safety Program. Military and civilian staff with email access in MHS facilities, including Military Treatment Facilities (MTFs) and DENTACs (Dental Activities/DTFs) are being asked to complete this survey. Survey questions ask for your opinions about patient safety issues, error, and event reporting in your MHS facility.

For more information on the background and purpose of this survey, please click here.

Pop-up box content:

What is the purpose of the survey?

The purpose of this survey is to gather honest staff opinions regarding the culture of safety across our MHS facilities. The survey will assist in raising awareness about patient safety matters and prioritize efforts to provide safe care.

What is the survey about?

The survey asks for your opinions about areas deemed essential for maintaining a culture of patient safety, which includes: reporting errors, communicating feedback on an error, learning from errors, working with teams, handling care transitions and ensuring management support for patient safety.

How will information from this survey be used?

Survey results will be used to identify areas where we shine as well as areas that may need improvement. The results will help prioritize activities promoting patient safety.

Why was I selected for the survey?

All staff – military, civilian, and contractors – working in direct care facilities are invited to participate.

Who determined the questions?
The Agency for Healthcare Research and Quality (AHRQ) developed the survey instrument in conjunction with national experts in patient safety, pilot-tested, and validated the questions. For more information on the development of the survey instrument: http://www.ahrq.gov/qual/patientsafetyculture. The Tri-Service Survey on Patient Safety utilizes the AHRQ instrument with minor modifications, reflective of our MHS environment, mainly around demographics collected.

I am retiring or I am new to this facility. Do you still want me to take this survey?

Yes, your experiences and opinions are highly valued.

Why should I participate?

Every individual working within an MTF provides a unique perspective on how we can deliver safe care to our patients. Your responses will help provide a comprehensive picture to help us continue delivering safe care to our patients.

When will the survey results be ready?

Results are expected in TBD.

How will the results be reported?

Reports will be produced at various levels, for example, overall, by Service, and work area.

IF YOU HAVE QUESTIONS

For questions about this survey, click here for Service points of contact.

Pop-up box content:

Army: Col. Kimberly Kesling, email: [email protected]
Navy: Ms. Carmen Birk, email: [email protected]
Air Force: Col. Allen Kidd, email: [email protected]

NCR: Ms. Lisa Lewis, email: [email protected]
DOD: Mr. Mike Datena, email: [email protected]

PRIVACY ADVISORY

Your responses are voluntary and your decision to participate or not will not affect your employment or any opportunity to receive future benefits. Your responses to this Survey about your opinions about patient safety issues, medical errors, and event reporting will allow us to maintain or improve the quality of the patient care provided to all receiving treatment at your facility. If you do not wish to answer a question, or if a question does not apply to you, you may leave your answer blank.

OMB CLEARANCE

This survey has been approved by the Office of Management and Budget (OMB Number 0720-0034, Expiration Date X/XX/XXXX). It is estimated that it takes 10 minutes to complete. If you have comments about the survey, its length, or any other aspects of this collection of information, send them to: Dr. Kimberley Marshall, Senior Health Care Research Analyst, Defense Health Agency Decision Support (DHADS); email: [email protected].

For more information on the confidentiality associated with your survey responses, please click here.

Pop-up box content:

Will anyone be able to link my survey responses to me?

This is a confidential and anonymous survey. Responses will not be tracked to specific individuals nor will responses be reported that may breach confidentiality. Only group statistics will be prepared from the survey results, such as “70 percent of staff gave their work area an overall patient safety grade of B, or very good.”

Will my answers be reported to my commanding officer or be put in my personnel file?

Because the survey is anonymous, none of your survey answers can be tracked to you. Therefore, your survey answers will not be reported to your commanding officer, nor will they be put in your personnel file.

How will demographic data be used in reporting survey results?

Survey results will only be reported in terms of group statistics, such as “70 percent of staff gave their work area an overall patient safety grade of B or very good.” Because the survey is anonymous, no one will match your survey responses to you. If you do not wish to answer a demographic question, you may leave it blank.

What authority do you have to ask me to provide you with demographic data?

This is a voluntary survey. We have authority to conduct the survey under 10 U.S.C., Chapter 55, Public Law 102- 484, E.O. 9397. The survey has been approved by the Office of Management and Budget (OMB Number 0720-0034, Expiration Date 9/30/2018).

In accordance with the Privacy Act of 1974 (Public Law 93-579), the providing of personal information is completely voluntary. If you do not wish to answer a question, or if a question does not apply to you, you may leave your answer blank.

1. What is YOUR Service affiliation?

• For more information about reporting your Service information, click here.

Pop-up box content:

I work at a facility that isn’t commanded by my Service. Should I report my Service or the Service that commands the facility in which I work?

For this question, you should report the Service with which you are affiliated—NOT the Service that commands your work facility (which will be reported in a separate question.)

I am in the Army, but my facility is commanded by the Navy. Should I report my Service affiliation as Army or Navy?

For this question, you should report the Service affiliation as Army. A separate question will ask about the Service which commands your facility.

The survey will not let me go further without choosing my Service. Do I have to answer this question to complete the survey?

Yes. To provide information that can be used to improve patient safety at a particular facility, we need to know which facility a particular respondent is from. This information is not used to identify individuals and individual respondents will still remain anonymous. Survey feedback will only be provided at the group level if 20 or more responses are received from a particular facility.

• \\

1. Air Force

2. Army

3. Navy

• National Capital Region Medical Directorate (NCR MD)

[Question is mandatory—survey respondents cannot proceed without answering this question.

2. Which Service commands the facility in which you work?

• For more information about reporting which Service commands your work facility, click here.

Pop-up box content:

I work at a facility that isn’t commanded by my Service. Should I report my Service or the Service that commands the facility in which I work?

For this question, you should report the Service that commands your work facility—NOT the Service with which you are affiliated (which should have been reported in the previous question.)

I am in the Army, but my facility is commanded by the Navy. Should I report Army or Navy for this question?

For this question, you should report Navy since it commands the facility in which you work. The previous question asks about your Service affiliation.

I’m not sure if my work facility is a National Capital Region Medical Directorate (NCR MD) facility. What should I report?

The email that accompanied the link to this survey should specify whether your work facility is commanded by NCR MD. If you are unsure, contact your patient safety manager.

The survey will not let me go further without choosing my Service. Do I have to answer this question to complete the survey?

Yes. To provide information that can be used to improve patient safety at a particular facility, we need to know which facility a particular respondent is from. This information is not used to identify individuals and individual respondents will still remain anonymous. Survey feedback will only be provided at the group level if 20 or more responses are received from a particular facility.

1. Air Force

2. Army

3. Navy

4. NCR MD  Go to NCR MD facility list.

[Question is mandatory—survey respondents cannot proceed without answering this question.]

3. What is the region of your work facility?

For more information about reporting your region information, click here.

Pop-up box content:

I’m not sure which region I’m in. What should I report?

The email that accompanied the link to this survey should specify your facility’s region. If you are unsure, contact your patient safety manager.

The survey will not let me go further without answering which region I am from. Do I have to answer this question to complete the survey?

Yes. To provide information that can be used to improve patient safety at a particular facility, we need to know which region and facility a particular respondent is from. This information is not used to identify individuals and individual respondents will still remain anonymous. Survey feedback will only be provided at the group level if 20 or more responses are received from a particular facility.

[Please create drop-down list of MTF/DENTAC regions by Service using the lists from the “Zogby Patient Safety Drop Down List” Excel spreadsheet. Respondents should only see those facilities that correspond to their answers from Q2.]

[Question is mandatory—survey respondents cannot proceed without answering this question. If respondent does not answer this question, please input the following message:

“Please answer this question in order to move forward with the rest of the survey.”]

4. Please select your Parent Facility.

[NOTE: This question should only appear for Army and Navy. If a respondent selects Air Force in Q2, the survey should skip to Q5.]

• [Please create drop-down list of MTF/DENTAC Parent Facility by Service and Region using the lists from the “Drop Downs” Excel spreadsheet. Respondents should only see those facilities that correspond to their answers from Q2 and Q3.]

• [Question is mandatory—survey respondents cannot proceed without answering this question. If respondent does not answer this question, please input the following message:

“Please answer this question in order to move forward with the rest of the survey.”]

5. Please select your Facility.

• [Please create drop-down list of MTF/DENTAC Parent Facility by Service, Region, and Parent Facility using the lists from the “Drop Downs” Excel spreadsheet. Respondents should only see those facilities that correspond to their answers from Q2, Q3, and Q4.]

• [Question is mandatory—survey respondents cannot proceed without answering this question. If respondent does not answer this question, please input the following message:

• “Please answer this question in order to move forward with the rest of the survey.”]

[“Drop Downs” Excel spreadsheet lists whether each facility is a hospital, clinic, or DENTAC/Dental Clinic. Based on the respective type, skip to the appropriate question as designated below:

If MTF Hospital  Go to question 6

If Army/Navy & Clinic  Go to question Ai, Clinic work area drop-down list

If Air Force & Clinic  Go to “Clinic Area Survey” instrument

If DENTAC or Dental Clinic  Go to question Ai, DENTAC/Dental Clinic work area drop-

down list]

6. In what area of your Military Treatment Facility (MTF) do you work?

1. Hospital  Go to question Ai, Hospital work area drop-drop down list

2. Ambulatory/outpatient clinic

Army and Navy  Go to question Ai, Clinic work area drop-down list

Air Force  Go to “Clinic Area Survey” instrument

3. DENTAC or Dental Clinic  Go to question Ai, DENTAC/Dental Clinic work area drop-

• down list

[Question is mandatory for those who select an MTF hospital. If respondent does not answer this question, please input the following message: “Please answer this question in order to move forward with the rest of the survey.”]

SECTION A: Your Work Area/Duty Area

For the purposes of this survey, please consider the following definitions of key terms:

• Your work area or duty area as the section, department, clinical unit, or area of the Military Health System (MHS) facility where you spend most of your work time or provide most of your clinical services.

• An event is defined as any type of error, mistake, incident, accident, or deviation, regardless of whether or not it results in patient harm.

• Patient safety is defined as the avoidance and prevention of patient injuries or adverse events resulting from the processes of health care delivery.

Ai. What is your primary work area/duty area in your MHS facility?

For more information on selecting your primary work area/duty, please click here. [Clicking on link will open a pop-up box with the following content:]

Pop-up box content:

My primary work area is not listed. How should I answer this question?

You should check "Other" and type in the name of your specific work area in the text box.

I am not sure if someone in my work area or type of staff position should answer the survey. Can you tell me?

Every individual who works in an MTF is invited to participate in the survey. Individuals from different work areas within a military treatment facility provide unique perspectives and can help provide a comprehensive picture of the culture of patient safety to help us continue delivering safe care to our patients. If some questions do not appear applicable, individuals may choose not to respond to those.

All staff in MHS facilities with email access are being asked to complete the survey. This includes Military Treatment Facilities and Dental Treatment Facilities. It includes clinical and house staff (interns, residents, fellows); non-clinical staff; active duty and reservist military; GS and civilian contractors; volunteers; and local nationals.

The survey will not let me go further without answering which work area I am from. Do I have to answer this question to complete the survey?

Yes. To provide information that can be used to improve patient safety at a particular facility, we need to know which facility a particular respondent is from. This information is not used to identify individuals and individual respondents will still remain anonymous. Survey feedback will only be provided at the group level if 20 or more responses are received from a particular facility.

[Please create separate drop-down lists of work areas depending on whether the respondent works in the hospital, an outpatient clinic, or a dental clinic (Respondents should only see the drop down list that corresponds to their answers in questions 2 and 3). In this way, only relevant work areas will be listed. Please use work areas listed in tab titled “Q Ai-Primary Work Area” of the “Patient Safety Survey Instrument Drop Downs” Excel spreadsheet.]

[Question is mandatory—survey respondents cannot proceed without answering this question. If

respondent does not answer this question, please input the following message: “Please answer this question in order to move forward with the rest of the survey.”]

Question Ai Drop-down menu (Respondent will see a particular list based on their answer to the previous question)

[Before the following rating scale questions, please display this message: “From this point forward, if you do not wish to answer a question, or if a question does not apply to you, you may leave your answer blank.”]

Please indicate your agreement or disagreement with the following statements about your work area.

[All rating scale questions should contain a box for each category (5 boxes per question) in which an “x” appears when participants select it]

	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
People support one another in this work area…….
We have enough staff to handle the workload…….
When a lot of work needs to be done quickly, we work together as a team to get the work done..
In this work area, people treat each other with respect……………………………………………..
Staff in this work area work longer hours than is best for patient care………………………………..
We are actively doing things to improve patient safety………………………………………………
We use more agency/temporary staff than is best for patient care……………………………………..
Staff feel like their mistakes are held against them….
Mistakes have led to positive changes here………...
It is just by chance that more serious mistakes don’t happen around here…………………………...........
When one section in this work area gets really busy, others help out……………………………………..
When an event is reported, it feels like the person is being written up, not the problem……………….....
After we make changes to improve patient safety, we evaluate their effectiveness…...................................
We work in "crisis mode" trying to do too much, too quickly………………………………………..
Patient safety is never sacrificed to get more work done………………………………………………
Staff worry that mistakes they make are kept in their personnel file………………………………………
We have patient safety problems in this work area…
Our procedures and systems are good at preventing errors from happening……………………………..

SECTION B: Your Supervisor/Manager

Please indicate your agreement or disagreement with the following statements about your immediate supervisor/manager or person to whom you directly report.

	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
My supervisor/manager says a good word when he/she sees a job done according to established patient safety procedures…………………………
My supervisor/manager seriously considers staff suggestions for improving patient safety…………..
Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it means taking shortcuts…………………………..
My supervisor/manager overlooks patient safety problems that happen over and over.………………

SECTION C: Communications

How often do the following things happen in your work area?

	Never	Rarely	Sometimes	Most of the time	Always
We are given feedback about changes put into place based on event reports……………………………..
Staff will freely speak up if they see something that may negatively affect patient care…………………..
We are informed about errors that happen in this work area…………………………………………
Staff feel free to question the decisions or actions of those with more authority…………………………
In this work area, we discuss ways to prevent errors from happening again……………………….............
Staff are afraid to ask questions when something does not seem right………………………………..

SECTION D: Frequency of Events Reported

In your work area, when the following mistakes happen, how often are they reported?

	Never	Rarely	Sometimes	Most of the time	Always
G2-1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?
G2-2. When a mistake is made, but has no potential to harm the patient, how often is this reported?
G2-3. When a mistake is made that could harm the patient, but does not, how often is this reported?

SECTION E: Patient Safety Grade

Please give your work area an overall grade on patient safety.

A Excellent	B Very Good	C Acceptable	D Poor	E Failing

SECTION F: Your Military Health System (MHS) Facility

Please indicate your agreement or disagreement with the following statements about your MHS facility.

	Strongly Disagree	Disagree	Neither	Agree	Strongly Agree
Management in this facility provides a work climate that promotes patient safety………………………
Work areas in this facility do not coordinate well with each other…………………………………...
Things “fall between the cracks” when transferring patients from one work area to another..……….....
There is good cooperation among areas that need to work together…………………………….…….
Important patient care information is often lost during shift changes………………………………
It is often unpleasant to work with staff from other work areas in this facility…………………………
Problems often occur in the exchange of information across work areas in this facility……...
The actions of management in this facility show that patient safety is a top priority...……………….
Management in this facility seems interested in patient safety only after an adverse event happens...…………………………………………
Work areas in this facility work well together to provide the best care for patients……....………….
Shift changes are problematic for patients in this facility…………………………….………………

SECTION G: Number of Events Reported

In the past 12 months, how many event reports have you filled out and submitted?

	No event reports
	1 to 2 event reports
	3 to 5 event reports
	6 to 10 event reports
	11 to 20 event reports
	21 event reports or more

SECTION H: Workplace Burnout

1. Using your own definition of “burnout,” please select one of the answers below:

a. I enjoy my work. I have no symptoms of burnout.

b. I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out.

c. I am definitely burning out and have one or more symptoms of burnout, e.g., emotional exhaustion.

d. The symptoms of burnout that I am experiencing won’t go away. I think about work frustrations a lot. 


e. I feel completely burned out. I am at the point where I may need to seek help.

2. Which number best describes the atmosphere in your primary work area?

a. 1 - Calm

b. 2

c. 3 - Busy, but reasonable

d. 4

e. 5 - Hectic, chaotic

3. To what extent do you agree or disagree with the following: “Burnout” has a negative impact on patient safety in my work area.

1. Strongly disagree

2. Disagree

3. Neutral

4. Agree

5. Strongly agree

4. [IF AGREE OR STRONGLY AGREE] How has “burnout” impacted patient safety?

NOTE: Verbatim comments will be shared at the respective Service Headquarters level.

4. [IF AGREE OR STRONGLY AGREE] What can be done to minimize “burnout” among hospital staff?

NOTE: Verbatim comments will be shared at the respective Service Headquarters level.

SECTION I: Background Information

[All respondents, including Air Force clinic respondents, should be directed here after completing Section G from their respective survey.]

This background information will help in the analysis of the survey results.

1. How long have you worked in this Military Health System (MHS) facility?

	Less than 1 year
	1 to 5 years
	6 to 10 years
	11 to 15 years
	16 to 20 years
	21 years or more

2. How long have you worked in your current work/clinic area?

	Less than 1 year
	1 to 5 years
	6 to 10 years
	11 to 15 years
	16 to 20 years
	21 years or more

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

	Less than 20 hours per week
	20 to 39 hours per week
	40 to 59 hours per week
	60 to 79 hours per week
	80 to 99 hours per week
	100 hours per week or more

4. What is your staff position in this MHS facility?

Select ONE answer that best describes your staff position.

For questions related to being a local national, please click here.
[Clicking on link will open a pop-up box with the following content:]

Pop-up box content:

I am a local national and don’t see my staff type listed. How should I answer?

You should check “Other” and specify your staff type in the text box.

[Please create a drop down menu using list in tab titled, “Q H4 Staff Position” of “Patient Safety Survey Instrument Drop Downs” Excel spreadsheet.]

5. In your staff position, do you typically have direct interaction or contact with patients?

	YES, I typically have direct interaction or contact with patients.
	NO, I typically do NOT have direct interaction or contact with patients.

6. How long have you worked in your current specialty or profession?

	Less than 1 year
	1 to 5 years
	6 to 10 years
	11 to 15 years
	16 to 20 years
	21 years or more

7. Please select your staff type below:

	Military—Active duty
	Military—Reservist
	Civilian—Government employee
	Civilian—Contractor
	Volunteer
	Other, please specify: _____________

SECTION I: Your Comments

Please share with us any thoughts or comments about patient safety that were not covered in this survey or that would benefit patient safety improvement efforts. Do not include any comments that identify individuals (patient, staff, providers, etc.) or events.

NOTE: Verbatim comments will be shared at the respective Service Headquarters level.

Closing:

Thank you for completing this survey. Click the submit survey button below to complete the survey process.

Then redirect to patient safety survey Web site:

http://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Quality-And-Safety-of-Healthcare/Patient-Safety

[Clinic area Survey: ONLY for survey respondents who are Air Force and the respondent-selected MTF is designated as a ‘clinic’ by the AF mapping file.]

SURVEY INSTRUCTIONS

Think about the way things are done in your clinic area (primary care clinic, internal medicine clinic, etc) and provide your opinions on issues that affect the overall safety and quality of the care provided to patients in your clinic area.

In this survey, the term provider refers to physicians, physician assistants, pharmacists and nurse practitioners who diagnose, treat patients, and prescribe medications. The term staff refers to all others who work in the clinic area.

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

• If you work in more than one clinic area, when answering this survey answer only about the clinic area where you received this survey—do not answer about the entire facility.

• If your clinic area is in a building with other clinic areas, answer only about the specific clinic area where you work—do not answer about any other clinic areas in the building.

8. In which clinic area of your Military Treatment Facility (MTF) do you work?

For more information on selecting your primary work area/duty, please click here.

• 

  Pop-up box content:

  
  

  My primary Clinic Area is not listed. How should I answer this question?

  You may not notice the exact name of your specific work area. Please review the list of options available and choose the one that best describes the area where you spend most of your work day.

  
  

  I am not sure if someone in my Clinic Area or type of staff position should answer the survey. Can you tell me?

  Every individual who works in an MTF is invited to participate in the survey. Individuals from different work areas within a military treatment facility provide unique perspectives and can help provide a comprehensive picture of the culture of patient safety to help us continue delivering safe care to our patients. If some questions do not appear applicable, individuals may choose not to respond to those.

  
  

  All staff in MHS facilities with email access are being asked to complete the survey. This includes Military Treatment Facilities and Dental Treatment Facilities. It includes clinical and house staff (interns, residents, fellows); non-clinical staff; active duty and reservist military; GS and civilian contractors; volunteers; and local nationals.

  
  

  The survey will not let me go further without answering which clinic area I am from. Do I have to answer this question to complete the survey?

  Yes. To provide information that can be used to improve patient safety at a particular facility, we need to know which facility a particular respondent is from. This information is not used to identify individuals and individual respondents will still remain anonymous. Survey feedback will only be provided at the group level if 20 or more responses are received from a particular facility.

[Please create drop-down list of clinic areas from “Clinic” column listed in “Q Ai Primary Work Area” of the “Drop Downs” Excel spreadsheet.]

[Question is mandatory—survey respondents cannot proceed without answering this question. If respondent does not answer this question, please input the following message: “Please answer this question in order to move forward with the rest of the survey.”]

SECTION J: List of Patient Safety and Quality Issues

The following items describe things that can happen in clinics that affect patient safety and quality of care. In your best estimate, how often did the following things happen in your clinic area OVER THE PAST 12 MONTHS?

[Before the following rating scale questions, please display this message:

“From this point forward, if you do not wish to answer a question, or if a question does not apply to you, you may leave your answer blank.”]

[All rating scale questions should contain a box for each category in which an “x” appears when participants select it]

	Daily	Weekly	Monthly	Several times in the past 12 months	Once or twice in the past 12 months	Not in the past 12 months	Does Not Apply or Don’t Know
Access to Care
A patient was unable to get an appointment within 48 hours for an acute/serious problem
Patient Identification
The wrong chart/medical record was used for a patient
Charts/Medical Records
A patient’s chart/medical record was not available when needed
Medical information was filed, scanned, or entered into the wrong patient’s chart/medical record
Medical Equipment
Medical equipment was not working properly or was in need of repair or replacement

SECTION K: List of Patient Safety and Quality Issues (continued) How often did the following things happen in your clinic area OVER THE PAST 12 MONTHS?
	Daily	Weekly		Monthly		Several times in the past 12 months	Once or twice in the past 12 months	Not in the past 12 months	Does Not Apply or Don’t Know
Medication
A pharmacy contacted our clinic area to clarify or correct a prescription
A patient’s medication list was not updated during his or her visit
Diagnostics & Tests
The results from a lab or imaging test were not available when needed
A critical abnormal result from a lab or imaging test was not followed up within 1 business day

SECTION L: Information Exchange With Other Settings

Over the past 12 months, how often has your clinic area had problems exchanging accurate, complete, and timely information with:

	Problems daily	Problems weekly	Problems monthly	Problems several times in the past 12 months	Problems once or twice in the past 12 months	No problems in the past 12 months	Does Not Apply or Don’t Know
Outside labs/imaging centers?
Other clinic areas/ outside physicians? .
Pharmacies?
Hospitals?
Other ? (Specify):______

SECTION M: Working in Your Clinic Area

How much do you agree or disagree with the following statements?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
When someone in this Clinic Area gets really busy, others help out
In this Clinic Area, there is a good working relationship between staff and providers
In this Clinic Area, we often feel rushed when taking care of patients
This Clinic Area trains staff when new processes are put into place
In this Clinic Area, we treat each other with respect
We have too many patients for the number of providers in this Clinic Area
This Clinic Area makes sure staff get the on-the-job training they need
This Clinic Area is more disorganized than it should be
We have good procedures for checking that work in this Clinic Area was done correctly
Staff in this Clinic Area are asked to do tasks they haven’t been trained to do
We have enough staff to handle our patient load
We have problems with workflow in this Clinic Area
This Clinic Area emphasizes teamwork in taking care of patients
This Clinic Area has too many patients to be able to handle everything effectively
Staff in this Clinic Area follow standardized processes to get tasks done

SECTION N: Communication and Follow-up

How often do the following things happen in your Clinic Area?	Never	Rarely	Some- times	Most of the time	Always	Does Not Apply or Don’t Know
Providers in this Clinic Area are open to staff ideas about how to improve Clinic Area processes .
Staff are encouraged to express alternative viewpoints in this Clinic Area
This Clinic Area reminds patients when they need to schedule an appointment for preventive or routine care
Staff are afraid to ask questions when something does not seem right
This Clinic Area documents how well our chronic-care patients follow their treatment plans
Our Clinic Area follows up when we do not receive a report we are expecting from an outside provider
Staff feel like their mistakes are held against them. .
Providers and staff talk openly about office problems.
This Clinic Area follows up with patients who need monitoring
It is difficult to voice disagreement in this Clinic Area
In this Clinic Area, we discuss ways to prevent errors from happening again
Staff are willing to report mistakes they observe in this Clinic Area

SECTION O: Leadership Support

A. Are you in a leadership position with responsibility for making financial decisions for your Clinic Area? 1 Yes  Skip to Section F 2 No  Answer items 1-4 below
How much do you agree or disagree with the following statements about the leadership of your Clinic Area?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
They aren’t investing enough resources to improve the quality of care in this Clinic Area
They overlook patient care mistakes that happen over and over
They place a high priority on improving patient care processes .
They make decisions too often based on what is best for the facility area rather than what is best for patients

SECTION P: Your Clinic area

How much do you agree or disagree with the following statements?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
When there is a problem in our Clinic Area, we see if we need to change the way we do things
Our Clinic Area processes are good at preventing mistakes that could affect patients
Mistakes happen more than they should in this Clinic Area
It is just by chance that we don’t make more mistakes that affect our patients
This Clinic Area is good at changing clinic area processes to make sure the same problems don’t happen again
In this Clinic Area, getting more work done is more important than quality of care
After this Clinic Area makes changes to improve the patient care process, we check to see if the changes worked

SECTION Q: Overall Ratings

Overall, how would you rate your Clinic Area on each of the following areas of health care quality?

		Poor	Fair	Good	Very good	Excellent
a. Patient centered	Is responsive to individual patient preferences, needs, and values
b. Effective	Is based on scientific knowledge
c. Timely	Minimizes waits and potentially harmful delays
d. Efficient	Ensures cost-effective care (avoids waste, overuse, and misuse of services)
e. Equitable	Provides the same quality of care to all individuals regardless of gender, race, ethnicity, socioeconomic status, language, etc.

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

Poor	Fair	Good	Very good	Excellent

SECTION R: Frequency of Events Reported

In your Clinic Area, when the following mistakes happen, how often are they reported?

Never Rarely Sometimes Most of Always

the time

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?

SECTION S: Number of Events Reported

In the past 12 months, how many event reports have you filled out and submitted?

	No event reports
	1 to 2 event reports
	3 to 5 event reports
	6 to 10 event reports
	11 to 20 event reports
	21 event reports or more

SECTION H: Workplace Burnout

1. Using your own definition of “burnout,” please select one of the answers below:

a. I enjoy my work. I have no symptoms of burnout.

b. I am under stress, and don’t always have as much energy as I did, but I don’t feel burned out.

c. I am definitely burning out and have one or more symptoms of burnout, e.g., emotional exhaustion.

d. The symptoms of burnout that I am experiencing won’t go away. I think about work frustrations a lot. 


e. I feel completely burned out. I am at the point where I may need to seek help.

2. Which number best describes the atmosphere in your primary work area?

a. 1 - Calm

b. 2

c. 3 - Busy, but reasonable

d. 4

e. 5 - Hectic, chaotic

3. To what extent do you agree or disagree with the following: “burnout” has a negative impact on patient safety in my work area.

6. Strongly disagree

7. Disagree

8. Neutral

9. Agree

10. Strongly agree

4. [IF AGREE OR STRONGLY AGREE] How has “burnout” impacted patient safety?

NOTE: Verbatim comments will be shared at the respective Service Headquarters level.

4. [IF AGREE OR STRONGLY AGREE] What can be done to minimize “burnout” and its impact on patient safety?

NOTE: Verbatim comments will be shared at the respective Service Headquarters level.

[All respondentsGo to Section I of main survey.]

33