Attachment K -- HSOPS Survey Data File Specifications

Attachment B-3: AHRQ Hospital Survey on Patient Safety Culture Survey Data File Specifications

AHRQ

Hospital Survey on Patient Safety Culture

Survey Data File Specifications

AHRQ Hospital Survey on Patient Safety Culture

Survey Data File Specifications

These specifications are for preparing your respondent-level data from the Hospital Survey on Patient Safety Culture (HSOPS). The instructions below tell you how to prepare your Excel data file for submission to the HSOPS Comparative Database.

INSTRUCTIONS (Excel File Only):

Step 1: Include a header row with the variable name for each column.

Step 2: Submit individual survey response data using the response values indicated in this document (beginning on page 4).

Step 3: Check your data before for the following things:

• OUT-OF-RANGE VALUES

You should clean your data before submitting to the database to ensure that there are no out-of-range values and that the data submitted are free from error. Make sure all response values match the response value for the question.

• REVERSE CODED ITEMS

Do not submit reverse coded data on the survey’s negatively worded items—simply submit each individual’s unmodified responses to the survey items.

• For example, survey item A17, “We have patient safety problems in this unit” is negatively worded, but the data should be submitted so that 1=Strongly disagree and 5=Strongly agree, as originally indicated in the survey, as follows:

1=Strongly Disagree

2=Disagree

3=Neither

4=Agree

5=Strongly Agree

blank = MISSING

• For example, survey item C6, “Staff are afraid to ask questions when something does not seem right” is negatively worded, but the data should be submitted so that 1=Never and 5= Always, as originally indicated in the survey, as follows:

1= Never

2= Rarely

3= Sometimes

4= Most of the time

5= Always

blank = MISSING

• In addition, for survey item E1 on overall grade on patient safety, make sure your data are coded as originally indicated in the survey, as follows:

A=Excellent

B=Very Good

C=Acceptable

D=Poor

E=Failing

blank = MISSING

• An additional example, for survey item G1 “In the past 12 months, how many event reports have you filled out and submitted?” make sure your data are coded as originally indicated in the survey, as follows:

a= No event reports

b=1 to 2 event reports

c=3 to 5 event reports

d=6 to 10 event reports

e=11 to 20 event reports

f=21 event reports or more

• DO NOT submit RECODED data on ANY survey item.

The only exception to this recoding rule is noted below regarding modified work areas and staff position for survey item Ai and H4:

• If your hospital modified or added new work area or staff position categories on your survey, you MUST RECODE your specific work areas/staff positions back to the survey’s original work area/staff position categories (a through n). If you added work areas/staff positions that do not match any of the survey’s original work areas/staff positions, code your specific work areas/staff positions as “OTHER” before submitting your data. If you are unable to map them to the survey response values then please leave them blank.

• OTHER, PLEASE SPECIFY TEXT

Do not include Other-Please Specify data (questions Ai and H4, and Section I). While you may find it useful to review this text, it should not be submitted to the Database.

• SPANISH VERSION OF THE HSOPS

Please indicate which respondents (if any) completed a Spanish version of the safety culture survey, if you have this information available. You should do so by adding an ‘S’ to the Individual Unique Record ID (UNIQUEID), e.g. 001S

• OTHER LANGUAGE VERSION OF THE HSOPS

Please indicate which respondents (if any) completed the safety culture survey in a language that was not English or Spanish, if you have this information available. You should do so by adding an ‘N’ to the Individual Unique Record ID (UNIQUEID), e.g. 001N

Record Identifier

Site ID

SITEID

Column A

If you are submitting data for multiple hospitals, then each site should have a unique Site ID. If you have data for only one hospital, then its Site ID can be 1.

Individual Unique Record ID

UNIQUEID

Column B

Each individual record in the dataset should have a unique ID, e.g. 001, 002, 003. NOTE: If an individual completed a Spanish survey, add an ‘S’ at the end of the Record ID, e.g. 001S.

SECTION A: Your Work Area/Unit

What is your primary work area or unit in this hospital?

Ai

Column C

a=Many different hospital units/No specific unit b=Medicine (non-surgical) c=Surgery d=Obstetrics e=Pediatrics f=Emergency department g=Intensive care unit (any type) h=Psychiatry/mental health i=Rehabilitation j=Pharmacy k=Laboratory l=Radiology m=Anesthesiology n=Other, please specify blank = MISSING

TEXT FOR OTHER, PLEASE SPECIFY [Ai, item n]* - DO NOT SUBMIT TO DATABASE

1. People support one another in this unit

A1

Column D

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

2. We have enough staff to handle the workload

A2

Column E

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

A3

Column F

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

A4

Column G

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

A5

Column H

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

6. We are actively doing things to improve patient safety

A6

Column I

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

A7

Column J

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

8. Staff feel like their mistakes are held against them

A8

Column K

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

9. Mistakes have led to positive changes here

A9

Column L

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

A10

Column M

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

A11

Column N

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

A12

Column O

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

A13

Column P

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

14. We work in "crisis mode" trying to do too much, too quickly

A14

Column Q

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

A15

Column R

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

A16

Column S

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

17. We have patient safety problems in this unit

A17

Column T

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

A18

Column U

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

SECTION B: Your Supervisor/ Manager

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

B1

Column V

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

B2

Column W

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

B3

Column X

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

B4

Column Y

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

SECTION C: Communications

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

C1

Column Z

1=Never 2=Rarely 3=Sometimes 4=Most of the time 5=Always blank = MISSING

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

C2

Column AA

1=Never 2=Rarely 3=Sometimes 4=Most of the time 5=Always blank = MISSING

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

C3

Column AB

1=Never 2=Rarely 3=Sometimes 4=Most of the time 5=Always blank = MISSING

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

C4

Column AC

1=Never 2=Rarely 3=Sometimes 4=Most of the time 5=Always blank = MISSING

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

C5

Column AD

1=Never 2=Rarely 3=Sometimes 4=Most of the time 5=Always blank = MISSING

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

C6

Column AE

1=Never 2=Rarely 3=Sometimes 4=Most of the time 5=Always blank = MISSING

SECTION D: Frequency of Events Reported

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

D1

Column AF

1=Never 2=Rarely 3=Sometimes 4=Most of the time 5=Always blank = MISSING

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

D2

Column AG

1=Never 2=Rarely 3=Sometimes 4=Most of the time 5=Always blank = MISSING

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

D3

Column AH

1=Never 2=Rarely 3=Sometimes 4=Most of the time 5=Always blank = MISSING

SECTION E: Patient Safety Grade

Please give your work area/unit in this hospital an overall grade on patient safety.

E1

Column AI

A=Excellent B=Very Good C=Acceptable D=Poor E=Failing blank = MISSING

SECTION F: Your Hospital

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

F1

Column AJ

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

2. Hospital units do not coordinate well with each other

F2

Column AK

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

F3

Column AL

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

F4

Column AM

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

F5

Column AN

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

F6

Column AO

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

F7

Column AP

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

8. The actions of hospital management show that patient safety is a top priority

F8

Column AQ

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

9. Hospital management seems interested in patient safety only after an adverse event happens

F9

Column AR

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

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

F10

Column AS

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

11. Shift changes are problematic for patients in this hospital

F11

Column AT

1=Strongly Disagree 2=Disagree 3=Neither 4=Agree 5=Strongly Agree blank = MISSING

SECTION G: Number of Events Reported

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

G1

Column AU

a=No event reports b=1 to 2 event reports c=3 to 5 event reports d=6 to 10 event reports e=11 to 20 event reports f=21 event reports or more

SECTION H: Background Information

1. How long have you worked in this hospital?

H1

Column AV

a=Less than 1 year b=1 to 5 years c=6 to 10 years d=11 to 15 years e=16 to 20 years f=21 years or more

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

H2

Column AW

a=Less than 1 year b=1 to 5 years c=6 to 10 years d=11 to 15 years e=16 to 20 years f=21 years or more

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

H3

Column AX

a=Less than 20 hours per week b=20 to 39 hours per week c=40 to 59 hours per week d=60 to 79 hours per week e=80 to 99 hours per week f=100 hours per week or more

4. What is your staff position in this hospital?

H4

Column AY

a=Registered nurse b=Physician assistant/Nurse practitioner c=LVN/LPN d=Patient care assistant/Hospital aide/Care partner e=Attending/Staff physician f=Resident physician/Physician in training g=Pharmacist h=Dietician i=Unit assistant/Clerk/Secretary j=Respiratory therapist k=Physical, Occupational, or Speech Therapist l=Technician (e.g., EKG, Lab, Radiology) m=Administration/Management n=Other, please specify

TEXT FOR OTHER, PLEASE SPECIFY [H4, item n]* - DO NOT SUBMIT TO DATABASE

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

H5

Column AZ

a=Yes, I typically have direct interaction or contact with patients b=No, I typically do NOT have direct interaction or contact with patients

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

H6

Column BA

a=Less than 1 year b=1 to 5 years c=6 to 10 years d=11 to 15 years e=16 to 20 years f=21 years or more

Please feel free to write any comments about patient safety, error or event reporting in your hospital* - DO NOT SUBMIT ANY OPEN-ENDED COMMENTS TO DATABASE

*DO NOT SUBMIT OTHER SPECIFY TEXT OR TEXT ON COMMENTS TO THE DATABASE (ITEM IN SHADED ROW)