Nursing Home Survey on Patient Safety Culture Action Plan

This document contains references to Web sites that provide practical resources nursing homes can use to implement changes to improve patient safety culture and patient safety.
Nursing Home: Date: July 29, 2009
August 27, 2009

1. Date of most recent Survey—May 2009

2. Describe your organization's mission, vision and values: This organization has a Culture Statement.

"has a friendly and warm environment with the determination of providing the highest level of care and or therapy to our customers"


3. List your organization's strategic goals. 

  • To be the first name people think of when considering placing their loved one in a skilled nursing facility.
  • To be the first facility that comes to mind for all discharge planners and physicians when discussing with family members placing a loved one in a nursing home.
  • To involve the community more in our day to day activities.

4. Response Rate: 55%. A response rate of 50% or greater ensures that survey results are likely to be representative of those surveyed. A response rate of 60% or greater is ideal.

5. Identify overall strengths and weaknesses. Identify the three dimensions with the highest and the three dimensions with the lowest percent positive scores.

Top Three Dimensions (Strengths) % + Bottom Three Dimensions (Weakness) % +
Feedback and communication 79% Staffing 51%
Supervisor expectations 76% Non-punitive response to mistakes 53%
Management support for resident safety 76% Communication openness 56%

6. Rate the extent to which the practices that support safe culture are in place using the following scale:
0 = Not in place 1 = ineffective 2 = moderately effective 3 = very effective NA = not applicable

Teamwork Leadership  
   Huddles, Briefs, Debriefs to manage workload 0
Teamwork Mutual Support  
   Task Assistance Sought 0
   Task Assistance Offered 0
   CUS 0
   DESC 0
Teamwork Communication  
    SBAR 0
    Call-Out 0
    Check Back 0
    Structured Hand Off 0

7. Complete the following action plan.
Step 1: Define the problem, challenge, opportunity

We need to strengthen our:
  • Communication/Teamwork

We can do this by (be specific about the practices needed):

  • Currently working on call-outs with emphasis on weekend call-outs by staff

Step 2: Create the change team (choose members based on influence/willingness, relevance to problem)

Name Role




MDS Coordinator

Step 3: Define your aim(s)/goals

What will be achieved?

  • Communication among staff will be improved
  • Call-outs will decrease
  • Teamwork will be emphasized and noticeably improved throughout the organization
  • When and where the change will occur?
  • Staffing/call-outs is a topic of discussion at staff meetings (will continue)
  • Teamwork tools will be incorporated on agenda of staff meetings


  1. We will strengthen our communication skills and make it safe for all to advocate for patients. We will do this by using SBAR for communication between all who exchange patient information, and teaching all staff to use CUS. We will effectively use SBAR and CUS by December 1, 2009.
  2. We will improve our non-punitive response to error and perception of a just culture by being transparent with all staff about how the decision is made whether or not to hold an individual accountable. We will teach all managers to use the Unsafe Acts Algorithm part of this process.

Step 4: Design an intervention

Intervention: 8/27/09: New policy in place that will require a change in call-outs on the staff's scheduled weekend. If they call out without a true family emergency or MD documented illness, the staff member will be required to work the next weekend.

Tools/strategies: 8/27/09: Staff policy/orientation has already been done and policy is in effect

Step 5: Decide Measures for your intervention

  • Observations/monitored weekly
  • Counts (e.g. #Briefs, #Reports, #RCAs, #WalkRounds) # of staff calling out/weekend
  • Outcome measures: Pressure Ulcer rate
  • Repeat Safety Culture Survey 2010 Will be completed Spring/Summer of 2010
  • Resident/Staff satisfaction: MyInnerview

Step 6: Develop a plan

What When
Obtain support from Management by sharing results of Benchmark Graphs Ongoing
Provide Feedback to staff Ongoing
Departments engage in action planning reflecting specific weaknesses Ongoing
Communicate aims, goals of plan Ongoing
Conduct necessary training Ongoing
Ensure policies/procedures support action plans Ongoing

Step 7: How will you maintain changes?

Role modeling—Staff not calling out continually will be recognized

Monitoring—To be done weekly

Integrate into new employee orientation, competency testing—New policy is now a part of new employee orientation/existing staff received in-service education

*Once the staffing issues can be resolved, the thought is that communication and teamwork will be more easily accepted.

Step 8: Review of plan by key personnel—Date—_____________

This material was prepared by GMCF, the Medicare Quality Improvement Organization for Georgia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 9SOW-GA-PSF-10-19

Page last reviewed October 2010
Page originally created October 2010
Internet Citation: Nursing Home Survey on Patient Safety Culture Action Plan. Content last reviewed October 2010. Agency for Healthcare Research and Quality, Rockville, MD.