Chapter 1. Introduction
The safety of patient care is critical to the quality of care provided in medical offices. As medical offices continually strive to improve, there is growing recognition of the importance of establishing a culture of patient safety. Achieving such a culture requires an understanding of the values, beliefs, and norms about what is important in the organization and what attitudes and behaviors related to patient safety are expected and appropriate. A definition of safety culture applicable to all health care settings is provided below.
Safety Culture Definition
The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures.
Source: Study Group on Human Factors. Organising for Safety: Third Report of the ACSNI (Advisory Committee on the Safety of Nuclear Installations). Sudbury, England: HSE Books, 1993.
In November 2004, the Agency for Healthcare Research and Quality (AHRQ) made available to the public the Hospital Survey on Patient Safety Culture (HSOPS). The hospital survey has been well received and administered in hundreds of hospitals. In response to medical offices interested in a survey that focuses on patient safety culture in their offices, AHRQ sponsored the development of the Medical Office Survey on Patient Safety Culture. The new survey is designed specifically for outpatient medical office providers and staff and asks for their opinions about the culture of patient safety and health care quality in their medical offices. The survey can be used:
- As a diagnostic tool to assess the status of patient safety culture in a medical office.
- As an intervention to raise staff awareness about patient safety issues.
- As a mechanism to evaluate the impact of patient safety improvement initiatives.
- As a way to track changes in patient safety culture over time.
Survey Development and Pilot Test
To develop the medical office survey, researchers reviewed the literature pertaining to patient safety, health care quality, ambulatory medicine, medical errors, error reporting, safety climate and culture, and organizational climate and culture. In addition, they reviewed existing medical office surveys. The researchers also consulted more than two dozen experts in the field of medical office practice and patient safety and many medical office providers and staff for help in identifying key topics and issues. On the basis of all those activities, the researchers identified a potential list of dimensions to include in the survey.
Researchers then developed draft survey items to measure the key dimensions. The survey draft was iteratively pretested with medical office providers and staff to ensure that the items were easy to understand and answer and relevant to patient safety and health care quality in medical offices. The pretest findings were used to revise the survey for the pilot study.
In cooperation with two practice-based research networks, five health care systems, and one health care management association, the Medical Office Survey on Patient Safety Culture was pilot tested in late 2007 in more than 200 medical offices across the United States. Participating medical offices varied by number of staff, specialty (primary care, other specialty, or multispecialty), and geographic location. All staff within each medical office, including physicians and other providers, were asked to complete the survey.
At the end of data collection, more than 4,100 surveys were received. Analysts examined item statistics and the reliability and validity of the safety culture dimensions. Exploratory and confirmatory factor analyses were conducted to examine the factor structure of the survey. Based on these analyses, the survey was revised so that the final items and dimensions in the Medical Office Survey on Patient Safety Culture have sound psychometric properties.
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The purpose of the Medical Office Survey on Patient Safety Culture is to measure the culture of patient safety in a single medical office in a specific location. Medical offices meeting this definition have the following characteristics:
- The medical office should be an outpatient facility in one geographic location. A medical practice or health care system may have multiple medical offices in different locations, but each unique location would be considered a separate medical office for the purposes of the survey and for feedback.
In addition, a medical office could be located in a building containing multiple medical offices, but each office in the building would be considered a separate medical office for the purposes of the survey.
- Providers in the medical office should share some or all administrative staff, such as receptionists and schedulers, and share some or all clinical support staff.
These characteristics are essential because the survey is designed to measure the culture of patient safety in a single medical office. You may, of course, choose to administer the survey to multiple medical offices in your practice, health care system, or building. If so, each medical office has to be identified as a separate office rather than being surveyed as one entity.
Size. We recommend restricting administration of the medical office survey to offices with at least three providers. We define providers as physicians (M.D. or D.O.), physician assistants, nurse practitioners, and other providers licensed to diagnose medical problems, treat patients, and prescribe medications. Solo practitioners or offices with only two providers are so small that conducting a survey is probably not an effective way to obtain staff opinions about patient safety culture. Staff in small offices will not feel that their answers are anonymous and may not be willing to complete the survey or answer honestly.
We recommend that there be at least five respondents in an office before feedback reports are created, to protect anonymity. Therefore, offices have to survey more than five providers and staff because it is unlikely that all of them will respond to the survey. In small offices, rather than administering the survey, you can use it as a tool to initiate open dialogue or discussion about patient safety and quality issues among providers and staff. You will be the best judge, however, of whether your office is large enough for staff to be willing respondents to the survey.
The survey was designed to be appropriate for any specialty. Your office may provide primary care services only, other specialty care services only, or a mix of primary and specialty care services.
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The survey is designed to be administered to all providers and staff in your medical office—from billing staff and receptionists to nurses and physicians. It is expected, though, that some staff may not be informed enough to answer all the questions. The survey includes a "Does Not Apply or Don't Know" response option. Also, you may need to consider the following issues when identifying whom to survey.
Part-Time Providers and Staff. The survey is best suited for medical office providers and staff who spend enough time in the office to know the office and report on the topics assessed in the survey. Use your best judgment in deciding which part-time providers and staff should receive the survey. For example, a part-time specialist who practices in the office one full day a week may know enough about your medical office to respond. On the other hand, a physician who has worked only on Saturday mornings once a month for the past 6 months might not be familiar enough with typical office processes and staff to answer many of the survey items. Similarly, staff who help with administrative tasks a few hours a week may not be knowledgeable respondents.
Providers and Staff Working in Multiple Participating Medical Offices. Medical practices or systems with more than one location may have some providers and staff who work in more than one medical office that is participating in the survey. In such cases, distribute the survey to them in the participating office where they spend most of their time and instruct them to answer about that office location only. If they spend an equal amount of time in multiple participating medical offices, choose one office for them to receive the survey in and instruct them to answer the survey only for that medical office.
Staff Working Away From the Main Office. Some of your office staff, such as billing staff, insurance processors, and appointment schedulers, may be located in an area away from the main office area. Again, you will need to decide if they interact enough with others in your main office area and are familiar enough with activities in the main office area to answer the survey items.
New Employees. You may want to set a criterion of a minimum number of weeks that a provider or staff member has worked in the office to be included in the survey. The goal is to make sure new employees know enough about the office to provide informed answers.
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The Medical Office Survey on Patient Safety Culture emphasizes patient safety and health care quality issues. The survey includes 51 items measuring 12 dimensions. Six of the survey dimensions (Communication Openness, Communication About Error, Organizational Learning, Overall Perceptions of Patient Safety and Quality, Owner/Managing Partner/Leadership Support for Patient Safety, and Teamwork) are similar to dimensions in the Hospital Survey on Patient Safety Culture (HSOPS), although the items are different in the two surveys. The remaining six survey dimensions are unique to the medical office survey with items that focus specifically on issues related to patient safety or quality of care in medical offices.
The dimensions in the medical office survey include:
- Communication Openness (4 items)
- Communication About Error (4 items)
- Information Exchange With Other Settings (4 items)
- Office Processes and Standardization (4 items)
- Organizational Learning (3 items)
- Overall Perceptions of Patient Safety and Quality (4 items)
- Owner/Managing Partner/Leadership Support for Patient Safety (4 items)
- Patient Care Tracking/Followup (4 items)
- Patient Safety and Quality Issues (9 items)
- Staff Training (3 items)
- Teamwork (4 items)
- Work Pressure and Pace (4 items)
In addition, the medical office survey includes three items about respondent background characteristics and two overall rating questions:
- How they would rate this medical office on five different areas of health care quality (patient centered, effective, timely, efficient, and equitable) (5 items)
- How they would rate this medical office on patient safety (1 item)
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The survey was developed to be general enough for use in most medical offices. You may find that the survey uses terms that are different from those used in your medical office. It is also possible that your medical office's management would like to ask additional questions about patient safety and health care quality. Anticipating the need for some modification or customization of the survey, we have included the survey and feedback report templates as modifiable electronic files on the AHRQ Web site (http://www.ahrq.gov/qual/hospculture). We recommend making changes to the survey only when they are absolutely necessary, because any changes may affect the reliability and validity of the survey and make comparisons with other medical offices difficult. We provide the following suggestions regarding modifications to the survey.
Adding or Removing Items
Adding items. If your medical office decides to add items to the survey, we recommend that you add these items toward the end of the survey (just before the Background Questions section).
Removing items. Although the survey takes about 10 to 15 minutes to complete, you may want to administer a shorter survey with fewer items. The best way to shorten the survey is to refer to Part Two of this document to see the safety culture dimensions assessed in the survey. Delete certain dimensions that your medical office is not interested in assessing (that means deleting all the items in those dimensions). In this way, your medical office's results on the remaining safety culture dimensions can still be compared with results from other medical offices using the survey. We do not recommend selectively removing items within the various dimensions.
Web-Based Data Collection
We strongly recommend using paper-based survey data collection methods to make sure you obtain the highest possible response rate in your medical office. Because some medical office staff may have limited access to email and the Internet, as well as limited computer skills, it is best to administer the survey on paper only. In addition, recent research and evidence shows that, generally, Web-based surveys have lower response rates than paper surveys do (Groves, 2002; Shih and Fan, 2008). However, your medical office, practice, or health care system may decide to use a Web-based survey to collect the data because you have done so successfully on other surveys. Web-based surveys have a wide range of design features and can involve different data collection procedures. Please go to Chapter 5, "Conducting a Web-Based Survey" for guidelines on how to use the Medical Office Survey on Patient Safety Culture with this method of data collection.
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The survey, this user guide, and the survey dimension descriptions are available on the AHRQ Web site (http://www.ahrq.gov/qual/hospculture). They are designed to provide medical offices with the basic knowledge and tools needed to conduct a safety culture assessment, along with ideas for using the data. This guide provides a general overview of the issues and major decisions involved in conducting a survey and reporting the results. The guide presents information about data collection and how to organize and plan your survey and includes the following chapters:
Chapter 2—Getting Started. Chapter 2 provides information on planning the project, outlines major decisions and tasks in a task timeline, and discusses hiring a vendor and forming a project team.
Chapter 3—Determining Your Data Collection Methods. Chapter 3 outlines decisions about how surveys will be distributed and returned and discusses the importance of establishing a point of contact within the medical office.
Chapter 4—Establishing Data Collection Procedures. Chapter 4 describes techniques for publicizing and promoting the survey, describes recommended data collection steps, discusses the importance of protecting confidentiality, and describes the content and assembly of survey materials.
Chapter 5—Conducting a Web-Based Survey. Chapter 5 presents the pros and cons of using a Web-based survey approach to data collection and outlines special considerations that must be taken into account.
Chapter 6—Preparing and Analyzing Data and Producing Reports. Chapter 6 discusses the steps needed to prepare the data and analyze the responses and provides suggestions for producing feedback reports.
The end of the guide includes the medical office survey form, followed by an overview of the survey items, grouped according to the safety culture dimensions they are intended to measure, and reliability statistics from the pilot test. A sample page from the Microsoft PowerPoint® Survey Feedback Template (part of the toolkit downloadable from the AHRQ Web site) that can be used to summarize the survey results is also provided.
Appendix A includes a sample data collection protocol for medical offices to use during survey administration. Appendix B includes questions about medical office background characteristics that should be completed for every medical office surveyed.
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