Executive Summary

In response to requests from hospitals interested in comparing their results against those from 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 Hospital Survey on Patient Safety Culture 2008 Comparative Database Report is an update of the 2007 report. The 2008 report includes more data, reporting results from a total of 519 hospitals and 160,176 hospital staff respondents who completed the survey. In addition, the 2008 report includes a new chapter on trending that presents results showing change over time for 98 hospitals that administered the survey and submitted data twice.

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.

• Comparison. To allow hospitals to compare their patient safety culture survey results against other hospitals.
• Assessment and learning. To provide data to hospitals to facilitate internal assessment and learning in the patient safety improvement process.
• Supplemental information. To provide supplemental information to help hospitals identify their strengths and areas with potential for improvement in patient safety culture.
• Trending. To provide data that describe changes in patient safety culture over time.

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Development of the Survey

The Hospital Survey on Patient Safety Culture was pilot tested, revised, and then released in November 2004. It is designed to assess hospital staff opinions about patient safety issues, medical error, and event reporting; it includes 42 items that measure 12 areas or composites of patient safety culture:

1. Communication openness
2. Feedback and communication about error
3. Frequency of events reported
4. Handoffs and 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 and actions promoting safety
11. Teamwork across units
12. Teamwork within units

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2008 Database Hospitals

The hospitals in the 2008 database fall into three categories:

• 284 hospitals from the 2007 report that are still included in the 2008 report;
• 98 hospitals from the 2007 report that conducted a follow-up survey of their staff; older data from these hospitals was replaced by data from their follow-up survey so the database reflects their most recent survey data; and
• 137 hospitals that submitted data for the first time.

Survey Administration Statistics

• The average hospital response rate was 54 percent, with an average of 309 completed surveys per hospital.
• Most hospitals (48 percent) administered paper surveys, which resulted in higher response rates (60 percent) compared to web (44 percent) or mixed mode surveys (52 percent).
• Most hospitals (70 percent) administered the survey to all staff or a sample of all staff from all hospital departments.

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Characteristics of Participating Hospitals

• Participating hospitals represent a range of bed sizes and geographic regions.
• Most hospitals are non-teaching (74 percent) and non-government owned (voluntary/non-profit or proprietary/investor owned) (76 percent)
• Overall, the characteristics of the 519 database hospitals are fairly consistent with the distribution of U.S. hospitals registered with the American Hospital Association (AHA).

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Characteristics of Respondents

• There are 160,176 hospital staff respondents from 519 hospitals.
• One-third of respondents (33 percent) selected "Other" as their work area, followed by "Surgery" (10 percent), "Medicine" (9 percent), and "Many different hospital units/No specific unit" (9 percent).
• Over one-third of respondents (36 percent) selected "Registered Nurse" or "Licensed Vocational Nurse/Licensed Practical Nurse (LVN/LPN)" as their staff position, followed by "Other" (22 percent), and "Technician (e.g., EKG, Lab, Radiology)" (11 percent).
• Most respondents (77 percent) indicated they had direct interaction with patients.

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Areas of Strength for Most Hospitals

Teamwork Within Units—The extent to which staff support one another, treat each other with respect, and work together as a team was the patient safety culture composite with the highest average percent positive response (79 percent), indicating this is an area of strength for most hospitals. The survey item with the highest average percent positive response (85 percent) was: "When a lot of work needs to be done quickly, we work together as a team to get the work done."

Patient Safety Grade—On average, the majority of respondents within hospitals (72 percent) gave their work area or unit a grade of either "A-Excellent" (24 percent) or "B-Very Good" (48 percent) on patient safety. However, there was a wide range of response in patient safety grades, from at least one hospital where none of the respondents (0 percent) provided their unit with a patient safety grade of "A-Excellent," to a hospital where 63 percent did.

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Areas with Potential for Improvement for Most Hospitals

Nonpunitive Response to Error—The extent to which staff feel that their mistakes and event reports are not held against them and that mistakes are not kept in their personnel file was the patient safety culture composite with the lowest average percent positive response (44 percent), indicating this is an area with potential for improvement for most hospitals. The survey item with the lowest average percent positive response (36 percent) was: "Staff worry that mistakes they make are kept in their personnel file," (an average of only 36 percent strongly disagreed or disagreed with this item).

Number of Events Reported—On average, the majority of respondents within hospitals (52 percent) reported no events in their hospital over the past 12 months. It is likely that this percentage represents under-reporting of events, and was identified as an area for improvement for most hospitals because potential patient safety problems may not be recognized or identified and therefore may not be addressed. However, there was a wide range of response in the number of events reported, from a hospital where 96 percent of respondents had not reported a single event over the past 12 months, to a hospital where only 5 percent had not reported an event.

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Overall Results by Hospital Characteristics

Results on the survey's patient safety culture composites and items by hospital characteristics (bed size, teaching status, ownership and control, region) are highlighted. A 5 percent difference in percent positive scores was used as a rule of thumb to identify meaningful differences in scores.

Bed Size

• Smaller hospitals (49 beds or fewer) had the highest average positive response on all 12 patient safety culture composites.
• The largest difference across hospitals by bed size was on Handoffs & Transitions where the smallest hospitals (6-24 beds) scored 21 percent higher than the largest hospitals (400+ beds) (56 percent positive compared to 35 percent).
• The smallest difference by bed size was 6 percent on Feedback & Communication about Error.
• Large hospitals (400+ beds) scored lowest on the percent of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very good" (64 percent for 400+ beds compared to 78 percent for 25-49 beds).
• There were no noticeable differences on number of events reported based on bed size (all differences were 3 percent or less).

Teaching Status, and Ownership and Control

• There were no noticeable differences on the composites between the teaching and non-teaching hospitals (differences were 4 percent or less).
• Government-owned hospitals had a higher percent of positive responses than nongovernment owned hospitals on Handoffs & Transitions (7 percent more positive), Staffing (5 percent more positive), and Teamwork Across Units (5 percent more positive).
• There were no noticeable differences on patient safety grade based on teaching status or ownership and control (all differences were 2 percent or less).
• There were no noticeable differences on number of events reported based on teaching status or ownership and control (all differences were 1 percent or less).

Region*

• East South Central and West North Central hospitals scored highest across the 12 patient safety culture composites; Mid-Atlantic/New England, East North Central, and Pacific hospitals scored lowest.
• The largest difference by region was on Staffing where West North Central hospitals were 13 percent more positive than Mid Atlantic/New England hospitals (62 percent positive compared to 49 percent).
• Hospitals in the Mid Atlantic/New England and Pacific regions scored lowest on the percent of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very good" (69 percent for these regions).
• Hospitals in the Pacific region had the highest percent of respondents who reported one or more events in the past year (53 percent); the lowest percent of respondents reporting events was 40 percent in the West South Central region.

*Note: States are categorized into AHA-defined regions as follows:

Region	States
Mid Atlantic/New England	NY, NJ, PA, ME, NH, VT, MA, RI, CT
South Atlantic	DE, MD, DC, VA, WV, NC, SC, GA, FL
West North Central	MN, IA, MO, ND, SD, NE, KS
West South Central	AR, LA, OK, TX
East North Central	OH, IN, IL, MI, WI
East South Central	KY, TN, AL, MS
Mountain	MT, ID, WY, CO, NM, AZ, UT, NV
Pacific	WA, OR, CA, AK, HI

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Overall Results by Respondent Characteristics

Results on the survey's patient safety culture composites and items by respondent characteristics (work area/unit, staff position, interaction with patients) are highlighted. A 5 percent difference in percent positive scores was used as a rule of thumb to identify meaningful differences in scores.

Respondent Work Area/Unit

• Respondents in Rehabilitation had the highest average positive response on 9 of the 12 patient safety culture composites.
• The largest differences by work area/unit were on Overall Perceptions of Patient Safety (21 percent) (Rehabilitation was 76 percent positive; ICU (any type) and Medicine were 55 percent positive).
• Rehabilitation had the highest percent of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very good" (82 percent); Emergency and Medicine had the lowest percent (62 percent).
• ICU (any type) had the highest percent of respondents reporting one or more events in the past year (68 percent); Anesthesiology and Rehabilitation had the lowest percent of respondents reporting events (43 percent).

Respondent Staff Position

• Respondents in Administration/Management had the highest average positive response on 11 of the 12 patient safety culture composites.
• The largest difference (27 percent) by staff position was on Nonpunitive Response to Error; Administration/Management was 62 percent positive and Patient Care Assistants Aides/Care Partners were 35 percent positive.
• Administration/Management had the highest percent of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very good" (82 percent); Registered Nurse/LVN/LPN had the lowest percent (67 percent).
• Pharmacists had the highest percent of respondents reporting one or more events in the past year (78 percent); Unit Assistants/Clerks/Secretaries had the lowest percent reporting events (23 percent).

Respondent Interaction With Patients

• Respondents with direct patient interaction were 7 percent more positive on Handoffs & Transitions compared to those without direct patient interaction (46 percent positive compared to 39 percent positive).
• Respondents without direct patient interaction were 7 percent more positive about Management Support for Patient Safety than those with direct patient interaction (76 percent positive compared with 69 percent positive).
• Respondents without direct patient interaction had the highest percent of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very good" (76 percent) compared to those with direct patient interaction (71 percent).
• More respondents with direct patient interaction reported one or more events in the past year (53 percent) than respondents those without direct patient interaction (32 percent).

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Trending: Comparing Results Over Time

Results regarding changes over time on the patient safety culture composites and items for the 98 hospitals (of the 519 total database hospitals) that administered the survey and submitted data twice are highlighted. When comparing results over time, a 5 percent difference in percent positive scores between the previous and most recent survey administrations was used as a rule of thumb to identify meaningful changes in scores over time.

• The average change in percent positive scores over time across all 12 patient safety culture composites was a slight increase of 2 percent (ranging from 0 to 3 percent change).
• 38 percent of trending hospitals increased by 5 percent or more on Overall Perceptions of Patient Safety, Frequency of Events Reported, and Nonpunitive Response to Error.
• 27 percent of trending hospitals decreased by 5 percent or more on Staffing.
• The average percent of respondents giving their work area/unit a patient safety grade of "A-Excellent" and "B-Very Good" increased over time by 7 percent.
• The average percent of respondents reporting one or more events increased slightly over time by 3 percent.

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Trending Results by Respondent Characteristics

Results for the 98 trending hospitals regarding changes over time on the patient safety culture composites and items by respondent characteristics are highlighted. When comparing results over time, a 5 percent difference in percent positive scores between the previous and most recent survey administrations was used as a rule of thumb to identify meaningful changes in scores over time.

Trending: Respondent Work Area/Unit

• Respondents in Pediatrics had the largest increases in positive response over time on 9 of the 12 patient safety culture composites (average increase across the 9 composites was 11 percent).
• Respondents in Anesthesiology had the largest decreases in positive response over time on 7 of the 12 patient safety culture composites (average decrease across the 7 composites was 13 percent).
• Pediatrics had the largest average percent of respondents who increased over time in giving their work area/unit a patient safety grade of "Excellent" or "Very good" (a 21 percent increase—from 60 to 81 percent); Anesthesiology had the largest decrease over time (a 7 percent decrease—from 89 to 82 percent).
• Anesthesiology had the largest average percent of respondents who increased over time in their reporting of one or more events in the past year (a 13 percent increase: from 35 percent to 48 percent); the largest decrease in percent reporting was in Obstetrics (an 11 percent decrease from 65 to 54 percent).

Trending: Respondent Staff Position

• Dieticians had the largest decreases in positive response over time on 7 of the 12 patient safety culture composites (average decrease across the 7 composites was 8 percent).
• Pharmacists had the largest average percent of respondents who increased over time in giving their work area/unit a patient safety grade of "Excellent" or "Very good" (a 15 percent increase—from 67 to 82 percent); Dieticians had the largest decrease over time (a 9 percent decrease—from 83 to 74 percent).
• Pharmacists had the largest average percent of respondents who increased over time in their reporting of one or more events in the past year (a 12 percent increase from 69 to 81 percent); the largest decrease in percent reporting was with Therapists (Respiratory, Physical, Occupational, Speech) (a 5 percent decrease from 43 to 38 percent).

Trending: Respondent Interaction With Patients

• There were no noticeable composite differences over time based on respondent interaction with patients (all were increases over time of 3 percent or less).
• There were no noticeable differences in patient safety grade over time based on respondent direct patient interaction (difference was 1 percent; a 7 percent increase for respondents with direct interaction and a 6 percent increase for respondents without direct interaction).
• There were no noticeable differences in the number of events reported over time based on respondent interaction with patients (difference was 3 percent; a 5 percent increase for respondents with direct interaction and a 2 percent increase for respondents without direct interaction).

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Action Planning for Improvement

The delivery of survey results is not the end point in the survey process, it is just the beginning. It is often the case that the perceived failure of surveys to create lasting change is actually due to faulty or nonexistent action planning or survey follow-up. Seven steps of action planning are provided to give hospitals guidance on next steps to take to turn their survey results into actual patient safety culture improvement.

1. Understand your survey results.
2. Communicate and discuss the survey results.
3. Develop focused action plans.
4. Communicate action plans and deliverables.
5. Implement action plans.
6. Track progress and evaluate impact.
7. Share what works.

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