Executive Summary

2010 User Comparative Database

In response to requests from hospitals interested in comparing their results to other hospitals on the Hospital Survey on Patient Safety Culture (hospital survey), 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 included data from 382 U.S. hospitals. Subsequent reports in 2008 and 2009 included data from more hospitals and respondents.

The Hospital Survey on Patient Safety Culture 2010 User Comparative Database Report includes more data than any previous report, displaying results from 885 hospitals and 338,607 hospital staff respondents. The 2010 report also includes a chapter on trending that presents results showing change over time for 321 hospitals that administered the survey and submitted data more than once.

Hospitals do not necessarily administer the hospital patient safety culture survey every year. They may administer it on an 18-month, 24-month, or other cycle. Therefore, the comparative database is a "rolling" indicator. It retains data from prior years when a hospital does not have new data to submit, replaces older data with more recent data when available, and adds data from hospitals submitting for the first time. The user comparative database report will be produced yearly through at least 2012.

This comparative database report was developed as a tool for the following purposes:

  • Comparison. To allow hospitals to compare their patient safety culture survey results to 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 was pilot tested and revised and then released in November 2004 (AHRQ, 2004). It was designed to assess hospital staff opinions about patient safety issues, medical error, and event reporting. The survey includes 42 items that measure 12 areas or composites of patient safety culture, including:

  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.

The survey also includes two questions that ask respondents to provide an overall grade on patient safety for their work area/unit and to indicate the number of events they have reported over the past 12 months.

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2010 Database Hospitals

The 885 hospitals in the 2010 database fall into two categories:

  • 347 hospitals from the previous database report that are still included in the 2010 report.
  • 538 hospitals that submitted data for the 2010 report.

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Survey Administration Statistics

  • The average hospital response rate was 56 percent, with an average of 383 completed surveys per hospital.
  • Most hospitals (45 percent) administered Web surveys, which resulted in lower response rates (50 percent) compared with response rates from paper (63 percent) or mixed-mode surveys (56 percent).
  • Most hospitals (75 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 nonteaching (68 percent) and non-government owned (voluntary/nonprofit or proprietary/investor owned) (81 percent).
  • Overall, the characteristics of the 885 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 were 338,607 hospital staff respondents from 885 hospitals.
  • One-third of respondents (33 percent) selected "Other" as their work area, followed by "Medicine" (10 percent), and "Surgery" (9 percent).
  • More than 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" (21 percent), and "Technician (e.g., EKG, Lab, Radiology)" (11 percent).
  • Most respondents (76 percent) indicated that they had direct interaction with patients.

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Areas of Strength for Most Hospitals

Two areas emerged as areas of strength. Results are expressed in terms of percent positive response. Percent positive is the percentage of positive responses (e.g., Agree, Strongly agree) to positively worded items (e.g., "People support one another in this unit") or negative response (e.g., Disagree) to negatively worded items (e.g., "We have safety problems in this unit").

Teamwork Within Units—This is an area of strength for most hospitals, with the highest average percent positive response (80 percent). This composite is defined as the extent to which staff support each other, treat each other with respect, and work together as a team. The survey items with the highest average percent positive response (86 percent) were: "People support one another in this unit," and, "When a lot of work needs to be done quickly, we work together as a team to get the work done."

Supervisor/Manager Expectations & Actions Promoting Patient Safety—This is also an area of strength for most hospitals, with a high average percent positive response (75 percent). This composite is defined as the extent to which supervisors/managers consider staff suggestions for improving patient safety, praise staff for following patient safety procedures, and do not overlook patient safety problems. The survey items with the highest average percent positive response (77 percent) were: "My supervisor/manger seriously considers staff suggestions for improving patient safety," and, "My supervisor/manager overlooks patient safety problems that happen over and over."

Patient Safety Grade—On average, most respondents within hospitals (74 percent) gave their work area or unit a grade of either "A-Excellent" (27 percent) or "B-Very Good" (47 percent) on patient safety. However, the grades varied widely, from at least one hospital where none of the respondents (0 percent) gave their unit a patient safety grade of "A-Excellent" to a hospital where 65 percent did.

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Areas With Potential for Improvement for Most Hospitals

Three areas showed potential for improvement.

Nonpunitive Response to Error—This is an area with potential for improvement for most hospitals. Nonpunitive response to error is defined as 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. This area was one of the two patient safety culture composites with the lowest average percent positive response (44 percent). The survey item with the lowest average percent positive response was: "Staff worry that mistakes they make are kept in their personnel file" (an average of only 35 percent).

Handoffs and Transitions—The extent to which important patient care information is transferred across hospital units and during shift changes was the other patient safety culture composite with the lowest average percent positive response (44 percent). The survey item with the lowest average percent positive response was: "Things 'fall between the cracks' when transferring patients from one unit to another" (an average of only 41 percent).

Number of Events Reported—On average, most respondents within hospitals (53 percent) reported no events in their hospital over the past 12 months. It is likely events were underreported. Event reporting was identified as an area for improvement for most hospitals because underreporting of events means potential patient safety problems may not be recognized or identified and therefore may not be addressed. However, responses varied widely, ranging from one hospital where 82 percent of respondents had not reported a single event over the past 12 months to a hospital where only 14 percent had not reported an event.

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Results by Hospital Characteristics

Results on the survey's patient safety culture composites, patient safety grade, and number of event reports by hospital characteristics (bed size, teaching status, ownership and control, geographic region) are highlighted. A 5 percentage point 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 percent positive response on all 12 patient safety culture composites.
  • Large hospitals (400-499 beds) scored lowest on the percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good" (70 percent positive for 400-499 beds compared with 79 percent positive for 25-49 beds).
  • There were no noticeable differences on number of events reported based on bed size (all differences were 3 percentage points or less).

Teaching Status and Ownership and Control

  • Non-teaching hospitals had a higher average percent positive response on Handoffs and Transitions than teaching hospitals (46 percent positive compared with 41 percent positive).
  • There were no noticeable differences on the patient safety culture composites based on ownership and control (all differences were 3 percentage points or less).
  • There were no noticeable differences on patient safety grade or number of events reported based on teaching status or ownership and control (all differences were 2 percentage points or less).

Geographic Region*

  • East South Central hospitals had the highest average percent positive response across the composites (66 percent positive); Mid Atlantic/New England hospitals had the lowest (60 percent positive).
  • West South Central hospitals scored highest on the percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good" (78 percent).
  • Pacific hospitals had the highest percentage of respondents who reported one or more events in the past year (53 percent); the lowest percentage of respondents reporting events was in the West South Central region (41 percent).

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

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

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Results by Respondent Characteristics

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

Work Area/Unit

  • Respondents in Rehabilitation had the highest average percent positive response across the composites (68 percent positive); Emergency had the lowest (57 percent positive).
  • Rehabilitation had the highest percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good" (84 percent); Emergency had the lowest percentage (62 percent).
  • ICU (any type) had the highest percentage of respondents reporting one or more events in the past year (65 percent); Anesthesiology had the lowest percentage of respondents reporting events (40 percent).

Staff Position

  • Respondents in Administration/Management had the highest average percent positive response across the composites (73 percent positive); Pharmacists had the lowest (58 percent positive).
  • Administration/Management had the highest percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good" (85 percent); Pharmacists had the lowest percentage (65 percent).
  • Pharmacists had the highest percentage of respondents reporting one or more events in the past year (72 percent); Unit Assistants/Clerks/Secretaries and Dietitians had the lowest percentage reporting events (19 percent).

Interaction With Patients

  • Respondents with direct patient interaction were 8 percent more positive on Handoffs and Transitions compared with those without direct patient interaction (46 percent positive compared with 38 percent positive).
  • Respondents without direct patient interaction were 6 percent more positive about Management Support for Patient Safety than those with direct patient interaction (77 percent compared with 71 percent positive).
  • Respondents without direct patient interaction had the highest percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good" (79 percent) compared with those with direct patient interaction (74 percent).
  • More respondents with direct patient interaction reported one or more events in the past year (52 percent) than respondents without direct patient interaction (31 percent).

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Trending: Comparing Results Over Time

This report highlights results regarding changes over time on the patient safety culture composites, patient safety grade, and number of events reported for the 321 hospitals (of the 885 total database hospitals) that administered the survey and submitted data more than once. When comparing results over time, a 5 percentage point 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 Hospitals

  • There were 321 trending hospitals in the 2010 database.
  • For the 321 hospitals with trending data, the average length of time between previous and most recent survey administrations was 19 months (range: 6 months to 46 months).
  • The distribution of the 321 trending hospitals by bed size, teaching status, and ownership and control is similar to the distribution of the 885 database hospitals.

Trending: Overall Summary Statistics

  • The average change in percent positive scores between administrations on the patient safety culture composites was a slight increase of 2 percentage points (ranging from 1 to 3 percentage point change).
  • There were no noticeable differences over time in the percentage of respondents who gave their work area/unit a patient safety grade of "A-Excellent" and "B-Very Good" (average percentage increased by 4 percentage points).
  • There were no noticeable differences over time in the number of events reported by respondents in the past 12 months (average percentage increased by only 1 percentage point).

Trending: Largest Increases and Decreases

  • Most hospitals changed less than 5 percentage points on the 12 composites (ranging from 46 percent to 63 percent of hospitals on each of the composites).
  • The composites with the largest percentage of hospitals that increased 5 percentage points or more were Management Support for Patient Safety and Staffing (38 percent of trending hospitals increased by at least 5 percentage points).
  • The composite with the largest percentage of hospitals that decreased 5 percentage points or more was Handoffs and Transitions (23 percent of trending hospitals decreased by at least 5 percentage points).
  • In 41 percent of trending hospitals, the percentage of respondents providing patient safety grades of "A-Excellent" or "B-Very Good" increased by 5 percentage points or more. However, almost as many (40 percent) had changes of less than 5 percentage points.
  • In 23 percent of trending hospitals, the percentage of respondents reporting one or more events increased by at least 5 percentage points. However, 29 percent of trending hospitals decreased by 5 percentage points or more.

Trending: Number of Composites that Changed Over Time

  • Most hospitals (77 percent) increased by 5 percentage points or more on at least one composite.
  • About half of the hospitals (48%) changed less than 5 percentage points on 7 or more composites.
  • About half of the hospitals (51%) decreased by 5 percentage points or more on at least one composite.

Additional Trending Analyses

This report highlights quantitative and qualitative data on changes in patient safety culture over time. Quantitative data include questionnaire data on actions taken by the trending hospitals to improve their patient safety culture. Qualitative data consist of findings from nine interviews conducted with staff of trending hospitals, who provided potential explanations for increases and decreases in their hospitals' hospital survey scores.

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Trending Results by Hospital Characteristics

Results for the 321 trending hospitals regarding changes over time by hospital characteristics (e.g., bed size, ownership, and teaching status) are highlighted. When comparing results over time, a 5 percentage point change 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. Types of hospitals with the greatest increases in scores over time are highlighted.

Trending: Bed Size

  • Large hospitals (400-499 beds) had the greatest increases in percent positive response over time on 7 of the 12 composites (average increase of 5 percentage points across these 7 composites).
  • Small hospitals (6-24 beds) had the greatest increase in percentage of respondents who gave their work area/unit a patient safety grade of "Excellent" or "Very Good" (a 7 percentage point increase, from 73 percent in the previous administration to 80 percent in the most recent administration).

Trending: Teaching Status and Ownership and Control

  • There were no noticeable changes over time on the patient safety culture composites by teaching status or ownership and control (all changes were 4 percentage points or less).

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Trending Results by Respondent Characteristics

Results for the 321 trending hospitals regarding changes over time by respondent characteristics are highlighted. When comparing results over time, a 5 percentage point 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. Groups with the greatest increases or decreases in scores over time are highlighted.

Trending: Work Area/Unit

  • Obstetrics had the greatest increase in percent positive response on 5 of the 12 patient safety culture composites (average increase of 6 percentage points across these 5 composites).
  • ICU, Pediatrics, and Pharmacy had the greatest increases over time in average percentage of respondents giving their work area/unit a patient safety grade of "Excellent" or "Very Good" (each increased by 6 percentage points).
  • There were no noticeable increases in the average percentage of respondents reporting one or more events in the past year. The largest decrease was in Anesthesiology (a 10 percentage point decrease).

Trending: Staff Position

  • Administration/Management had the greatest increase in positive response over time on 7 of the 12 patient safety culture composites (average increase across the 7 composites was 5 percentage points).
  • Therapists had the largest increase over time in average percentage of respondents giving their work area/unit a patient safety grade of "Excellent" or "Very Good" (5 percentage point increase).

Trending: Interaction With Patients

  • There were no noticeable changes over time on the patient safety culture composites by level of interaction with patients (all changes were 4 percentage points or less).

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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. Often, the perceived failure of surveys to create lasting change is actually due to faulty or nonexistent action planning or survey followup. 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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Current as of March 2010
Internet Citation: Executive Summary: 2010 User Comparative Database. March 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/2010/hospdb10summ.html