Chapter 1. Introduction

Patient safety is a critical component of health care quality. As healthcare organizations continually strive to improve, there is growing recognition of the importance of establishing a culture of patient safety. Achieving a culture of patient safety requires an understanding of the values, beliefs, and norms about what is important in an organization and what attitudes and behaviors related to patient safety are supported, rewarded, and expected.

Development of the Survey

Recognizing the need for a measurement tool to assess the culture of patient safety in healthcare organizations, the Medical Errors Workgroup of the Quality Interagency Coordination Task Force (QuIC) sponsored the development of a hospital survey focusing on patient safety culture. The Agency for Healthcare Research and Quality (AHRQ) funded and supervised development of the Hospital Survey on Patient Safety Culture (hospital survey). Developers reviewed research pertaining to safety, patient safety, error and accidents, and error reporting. They also examined existing published and unpublished safety culture assessment tools. In addition, hospital employees and administrators were interviewed to identify key patient safety and error-reporting issues.

The survey was pilot tested and revised and then released by AHRQ in November 2004. It was designed to assess hospital staff opinions about patient safety issues, medical error, and event reporting and includes 42 items that measure 12 areas or composites of patient safety culture. Each of the 12 patient safety culture composites is listed and defined in Table 1-1.

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. In addition, respondents are asked to provide limited background demographic information about themselves (their work area/unit, staff position, whether they have direct interaction with patients, etc). The survey's toolkit materials are available at the AHRQ Web site (http://www.ahrq.gov/qual/patientsafetyculture/) and include the survey, survey items and dimensions, user's guide, feedback report template, information about acquiring the Microsoft® Excel® Data Entry and Analysis Tool, an article about safety culture assessment, and a series of three national technical assistance conference calls. The toolkit provides hospitals with the basic knowledge and tools needed to conduct a patient safety culture assessment and ideas regarding how to use the data.

The 2009 Comparative Database and Report

Since its release, the hospital survey has been widely implemented across the United States. Hospitals administering the survey have expressed interest in comparing their results with other hospitals as an additional source of information to help them identify areas of strength and areas for improvement. In response to these requests, AHRQ funded the Hospital Survey on Patient Safety Culture Comparative Database to enable hospitals to compare their most recent survey results with other hospitals and to examine trends in patient safety culture over time. Hospitals interested in submitting to the database should go to the AHRQ Web site for more information (http://www.ahrq.gov/qual/patientsafetyculture/).

What Is New in the 2009 Comparative Database Report?

The Hospital Survey on Patient Safety Culture 2009 Comparative Database Report is an update of the 2008 report, presenting the most current survey data and trending data available. The 2009 report includes 204 hospitals that submitted data to the comparative database more than once, which provides substantially more data to analyze trends in patient safety culture over time. On average, hospitals show small increases in the patient safety culture composites and survey items over time. The average increase in composite scores across the 204 trending hospitals is 2 percent (ranging from 1 percent to 3 percent).

In addition to being an update of the 2008 report, the 2009 report contains several new types of data not previously reported. Chapter 7 presents quantitative and qualitative data on changes in patient safety culture over time. The quantitative data include questionnaire data on actions taken by the 2009 trending hospitals to improve their patient safety culture and correlations between improvement efforts and changes in hospital survey scores. The qualitative data consist of findings from nine interviews conducted with staff in trending hospitals and suggest explanations for increases and decreases in hospitals' hospital survey scores.

Finally, there are now enough trending hospitals to present trending results by hospital characteristics (bed size, teaching status, ownership and control), as well as respondent characteristics (work area/unit, staff position, interaction with patients). These breakouts are presented in Appendixes C and D.

Data Limitations

The survey results presented in this report represent the largest compilation of hospital patient safety survey data currently available and therefore provide a useful reference for comparison. However, there are several limitations to these data that should be kept in mind.

First, the hospitals that submitted data to the database are not a statistically selected sample of all U.S. hospitals since only hospitals that administered the survey on their own and were willing to submit their data for inclusion in the database are represented. However, the characteristics of the database hospitals are fairly consistent with the distribution of U.S. hospitals registered with the American Hospital Association (AHA) and are described further in Chapter 3.

Second, hospitals that administered the survey were not required to undergo any training and administered it in different ways. Some hospitals used a paper-only survey, others used Web-only surveys, and others used a combination of these two methods to collect the data. It is possible that these different modes could lead to differences in survey responses; further research is needed to determine whether mode effects affect the results. In addition, some hospitals conducted a census, surveying all hospital staff, while others administered the survey to a sample of staff. In cases in which a sample was drawn, no data were obtained to determine the methodology used to draw the sample. Survey administration statistics that were obtained about the database hospitals, such as survey administration modes and response rates, are provided in Chapter 2.

Finally, the data hospitals submitted have been cleaned for out-of-range values (e.g., invalid response values due to data entry errors) and blank records (where responses to all survey items were missing). In addition, logic checks were made. Otherwise, data are presented as submitted. No additional attempts were made to verify or audit the accuracy of the data submitted.

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