Nursing Home Survey on Patient Safety Culture

The Nursing Home Survey on Patient Safety Culture is an expansion of AHRQ's Hospital Survey on Patient Safety Culture to the nursing home setting. The nursing home survey is designed to measure the culture of resident safety in nursing homes from the perspective of providers and staff. The Nursing Home Survey on Patient Safety Culture 2014 User Comparative Database Report consists of data from 263 nursing homes and 18,968 nursing home staff respondents who completed the survey between January 2009 and May 2014.

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

• Comparison—To allow nursing homes to compare their patient safety culture survey results to other nursing homes.
• Assessment and Learning—To provide data to nursing homes to facilitate internal assessment and learning in the patient safety improvement process.
• Supplemental Information—To provide supplemental information to help nursing homes identify their strengths and areas with potential for improvement in patient safety culture.

Survey Content

The nursing home survey includes 42 items that measure 12 composites of organizational culture pertaining to patient safety culture:

1. Communication Openness.
2. Compliance With Procedures.
3. Feedback and Communication About Incidents.
4. Handoffs.
5. Management Support for Resident Safety.
6. Nonpunitive Response to Mistakes.
7. Organizational Learning.
8. Overall Perceptions of Resident Safety.
9. Staffing.
10. Supervisor Expectations and Actions Promoting Resident Safety.
11. Teamwork.
12. Training and Skills.

The survey also includes two questions that ask respondents whether they would tell friends that this is a safe nursing home for their family (also called "willingness to recommend") and to provide an overall rating on resident safety for their nursing home.

2014 Database Nursing Homes

The 263 nursing homes in the 2014 database fall into two categories:

• 152 nursing homes from the previous report that are still included in the 2014 report.
• 111 nursing homes that submitted data for the 2014 report.

Survey Administration Statistics

• The average nursing home response rate was 65 percent, with an average of 72 completed surveys per nursing home.
• Most nursing homes (64 percent) administered paper surveys, which resulted in a higher average response rate (70 percent) compared with the average response rate from Web surveys (52 percent).

Characteristics of Participating Nursing Homes

• Just under half of the database nursing homes (46 percent) had 100-199 beds. The next largest bed size category was 50-99 beds at 32 percent.
• More than half of the database nursing homes (51 percent) were nonprofit.
• The database nursing homes were from a variety of geographic regions.
• Overall, the characteristics of the 263 database nursing homes are fairly consistent with the distribution of nursing homes in Nursing Home Compare.

Characteristics of Respondents

• The top three job titles of respondents were:
  
  • Nursing Assistant/Aide (35 percent).
  • Licensed Nurse (18 percent).
  • Support Staff (17 percent).
• Most respondents (43 percent) indicated they worked in many different units/no specific unit. Skilled Nursing was the second largest work area (23 percent).
• Most respondents (71 percent) indicated they had direct interaction with residents.
• Most respondents (69 percent) indicated they worked between 25 and 40 hours per week.
• Most respondents (69 percent) indicated they worked the day shift most often.
• Nearly one-fourth of respondents (24 percent) indicated they had worked in their current nursing home for 11 years or more.
• Most respondents (93 percent) indicated they were not paid by a staffing agency.

Areas of Strength for Most Nursing Homes

The two areas of strength, or composites with the highest average percent positive responses,ⁱ were:

1. Overall Perceptions of Resident Safety (average 87 percent positive)—This composite is defined as the extent to which residents are well cared for and safe. This composite had the highest average percent positive response.
2. Feedback and Communication About Incidents (average 84 percent positive)—This composite is defined as the extent to which staff discuss ways to keep residents safe, tell someone if they see something that might harm a resident, and talk about ways to keep incidents from happening again. This composite had the second highest average percent positive response.

Areas With Potential for Improvement for Most Nursing Homes

1. Nonpunitive Response to Error (average 51 percent positive)—This composite is defined as the extent to which staff are not blamed when a resident is harmed, are treated fairly when they make mistakes, and feel safe reporting their mistakes. This composite had the lowest average percent positive response.
2. Staffing (average 53 percent positive)—This composite is defined as the extent to which there are enough staff to handle the workload, meet residents' needs during shift changes, and keep residents safe because there is not much staff turnover. This composite had the second lowest average percent positive response.

Results by Nursing Home Characteristics

Bed Size

• Small nursing homes (49 or fewer beds) had the highest average percent positive response across the patient safety culture composites.
• The Staffing composite had the highest average percent positive difference (10 percentage points) between small nursing homes (49 or fewer beds, 60 percent) and large nursing homes (200 beds or more, 50 percent).
• Small nursing homes (49 or fewer beds) had the highest percentage of respondents (85 percent) who indicated they would tell their friends that this is a safe nursing home for their family; large nursing homes (200 beds or more) had the lowest (74 percent).
• Small nursing homes (49 or fewer beds) had the highest percentage of respondents (73 percent) who gave their nursing home an overall rating on resident safety of "Excellent" or "Very Good"; large nursing homes (200 beds or more) had the lowest (58 percent).

Ownership

• Nonprofit nursing homes had a higher average percent positive response than For Profit nursing homes on all 12 patient safety culture composites.
• Nonprofit and Government nursing homes had a higher percentage of respondents (80 percent and 82 percent, respectively) who indicated they would be willing to recommend this nursing home to friends than For Profit nursing homes (71 percent)
• Nonprofit and Government nursing homes had a higher percentage of respondents (66 percent and 71 percent, respectively) who gave their nursing home an overall rating on resident safety of "Excellent" or "Very Good" than For Profit nursing homes (54 percent).

Urban/Rural Status

• Urban nursing homes had a higher average percent positive response than Rural nursing homes on all 12 of the patient safety culture composites.
• Urban nursing homes had a higher percentage of respondents (77 percent) who were willing to recommend their nursing home than Rural nursing homes (73 percent).
• Urban nursing homes had a higher percentage of respondents (63 percent) who gave their nursing home an overall rating on resident safety of "Excellent" or "Very Good" than Rural nursing homes (56 percent).

Census Region

• Nursing homes in the South had the highest average percent positive response across the 12 patient safety culture composites (71 percent); nursing homes in the West had the lowest (60 percent).
• Midwest nursing homes had the highest percentage of respondents (81 percent) who indicated they would be willing to recommend this nursing home to friends; nursing homes in the West had the lowest (68 percent).
• Midwest nursing homes had the highest percentage of respondents (65 percent) who gave their nursing home an overall rating on resident safety of "Excellent" or "Very Good"; nursing homes in the West had the lowest (51 percent).

Results by Respondent Characteristics

Job Title

• Administrators/Managers had the highest average percent positive response across the patient safety culture composites (79 percent); Nursing Assistants/Aides and Other Providers had the lowest (64 percent).
• Administrators/Managers had the highest percentage of respondents (92 percent) who indicated they would be willing to recommend this nursing home to friends; Other Providers had the lowest (69 percent).
• Administrators/Managers had the highest percentage of respondents (80 percent) who gave their nursing home an overall rating on resident safety of "Excellent" or "Very Good"; Other Providers had the lowest (56 percent).

Work Area

• Rehabilitation units had the highest average percent positive response (82 percent) on Supervisor Expectations and Actions Promoting Resident Safety; Skilled Nursing units had the lowest (77 percent).
• Willingness to recommend this nursing home to friends did not have a large difference in results across work area/units (74 to 77 percent).
• Many different areas in this nursing home/No specific area or unit had the highest percentage of respondents (62 percent) who gave their nursing home an overall rating on resident safety of "Excellent" or "Very Good"; Alzheimer's/Dementia Unit had the lowest (57 percent).

Interaction With Residents

• Respondents without direct interaction with residents had a higher percent positive average across the composites (73 percent) than those with direct interaction with residents (66 percent) .
• Respondents without direct interaction with residents had a higher percentage of respondents (80 percent) who indicated they would be willing to recommend this nursing home to friends than respondents with direct interaction with residents (75 percent).
• Respondents without direct interaction with residents had a higher percentage of respondents (68 percent) who gave their nursing home an overall rating on resident safety of "Excellent" or "Very Good" than respondents with direct interaction with residents (59 percent).

Shift Worked Most Often

• Respondents working the day shift had the highest average percent positive response across the composites (69 percent); respondents working the night shift had the lowest (64 percent).
• Respondents working the day shift had the highest percentage (78 percent) who indicated they would be willing to recommend this nursing home to friends; respondents working the night shift had the lowest (70 percent).
• Respondents working the day shift had the highest percentage (63 percent) who gave their nursing home an overall rating on resident safety of "Excellent" or "Very Good"; respondents working the night shift had the lowest (52 percent).

Tenure in Nursing Home

• Respondents who had worked in the nursing home less than 1 year had the highest average percent positive response across the 12 composites (72 percent); respondents who had worked in the nursing home for 6 to 10 years had the lowest (66 percent).
• Respondents who had worked in the nursing home 11 years or more had the highest percentage (81 percent) who indicated they would be willing to recommend this nursing home to friends; respondents working 3 to 5 years had the lowest (74 percent)
• Respondents who had worked in their nursing home 11 years or more had the highest percentage (66 percent) who gave their nursing home an overall rating on resident safety of "Excellent" or "Very Good"; respondents who worked in their nursing home 3 to 10 years had the lowest (59 percent).

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 nursing homes 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.

Purpose and Use of This Report

In response to requests from nursing homes interested in comparing their results with those of other nursing homes on the Nursing Home Survey on Patient Safety Culture, the Agency for Healthcare Research and Quality (AHRQ) established the Nursing Home Survey on Patient Safety Culture comparative database. The first comparative database report was released in 2011.

The Nursing Home Survey on Patient Safety Culture 2014 User Comparative Database Report consists of data from 263 nursing homes and 18,968 nursing home staff respondents who completed the survey. The 263 nursing homes in the 2014 report fall into two categories:

• 152 nursing homes from the previous report that are still included in the 2014 report.
• 111 nursing homes that submitted data for the 2014 report.

Nursing homes do not necessarily administer the nursing home 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 for up to 3.5 prior years when a nursing home does not have new data to submit, replaces older data with more recent data when available, and adds data from nursing homes submitting for the first time.

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

• Comparison—To allow nursing homes to compare their patient safety culture survey results with other nursing homes.
• Assessment and Learning—To provide data to nursing homes to facilitate internal assessment and learning in the patient safety improvement process.
• Supplemental Information—To provide supplemental information to help nursing homes identify their strengths and areas for improvement in patient safety culture.

The report presents statistics (averages, standard deviations, minimum and maximum scores, and percentiles) on the patient safety culture composites and items from the survey.

Appendixes A and B present overall results by nursing home characteristics (bed size, ownership, and rural status) and respondent characteristics (job title, nursing home work area, interaction with residents, shift worked most often, hours worked, and tenure in nursing home).

 

^i. Percent positive is the percentage of positive responses (e.g., Agree, Strongly agree) to positively worded items (e.g., "Staff support one another in this nursing home") or negative responses (e.g., Disagree, Strongly disagree) to negatively worded items (e.g., "Staff use shortcuts to get their work done faster").

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