Understanding and Using Your HSOPS Results Dolores Hagan, RN BSN K-HEN Education/Data Manager...

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Understanding and Using Your HSOPS Results

Dolores Hagan, RN BSNK-HEN Education/Data ManagerKentucky Hospital Association

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Goals• Provide a safer environment for patients• Encourage error reporting for the purpose

of learning from and preventing errors• Encourage error and system analysis – not

person analysis• Empower staff to speak up appropriately

when a patient safety risk is observed

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Survey Purpose• Examines patient safety culture from a staff

perspective• May be completed by all types of staff from

housekeeping to nurses and physicians• Best suited for

– Staff who have direct contact or interaction with patients (clinical and non-clinical)

– Staff whose work directly affects patient care (pharmacy, lab, environmental services, etc

– Physicians or physician extenders who spend most of their work

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• Best suited for – Staff who have direct contact or interaction with

patients (clinical and non-clinical)– Staff whose work directly affects patient care

(pharmacy, lab, environmental services, etc– Physicians or physician extenders who spend

most of their work hours in the hospital (ED physicians, hospitalists, etc)

– Hospital supervisors and managers

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What it Measures• Seven unit-level aspects of safety culture

– Supervisor/Management expectations and actions promoting safety (4 items)

– Organizational learning—continuous improvement (3 items)

– Teamwork within units (4 items)– Communication openness (3 items)– Feedback and communication about errors (3 items)– Nonpunitive response to error (3 items)– Staffing (4 items)

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• Three hospital-level aspects of safety culture– Hospital management support for patient

safety (3 items)– Teamwork across units (4 items)– Hospital handoffs and transitions (4 items)

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• Four Outcome variables– Overall perceptions of safety (4 items)– Frequency of event reporting (3 items)– Patient safety grade (of the hospital unit) (1

item)– Number of events reported (1 item)

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Response Rate• Agency for Healthcare Research and Quality

(ARHQ) recommends a minimum of 50 percent to ensure a reasonable level of reliability

• Encourage that you set your minimum goal to 60% (# eligible respondents X 0.6)

• Monitor response rate throughout the survey period

• Encourage staff to complete

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Survey Specifics• Survey period is typically 14 days

– May be extended for 7 days if your response rate is too low

• Resurvey is recommended in approximately 12 months

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Survey Coordinator Checklist• Determine the best dates for your hospital• Select departments and/or staff types that will

be eligible to complete the survey– Calculate the total number eligible and provide to

KHA• Encourage senior leadership support(especially

CEO) and promotion of the survey• Distribute the survey link to staff• Monitor response rate at 7 and 10 days

For further information about this feedback report, contact:

Dolores Hagan, RN, BSNK-HEN Education and Data ManagerKentucky Hospital Association(502) [email protected]

Hospital Survey on Patient Safety Culture

Feedback ResultsGood Care HospitalAnywhere, Kentucky September 2012

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Survey BackgroundThe Hospital Survey on Patient Safety Culture was

sponsored by the Quality Interagency Coordination Task Force (QuIC), a group established in accordance with a 1998 Presidential directive to ensure that all Federal agencies involved in purchasing, providing, studying, or regulating health care services are working together and toward a common goal of improving quality care. The survey was funded by the Agency for Healthcare Research and Quality (AHRQ).

The development of this safety culture assessment tool included a review of the scientific literature pertaining to safety, error and accidents, as well as error reporting. In addition, hospital employees and managers were interviewed to identify key patient safety and error reporting issues. Other published and unpublished safety culture assessment tools also were examined.

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Survey Measures

Four overall patient safety outcomes:1. Overall perceptions of safety2. Frequency of events reported3. Number of events reported4. Overall patient safety grade

The research survey also is intended to measure:

The Hospital Survey on Patient Safety Culture is designed to measure:

Ten dimensions of culture pertaining to patient safety:1. Supervisor/manager expectations & 6. Nonpunitive response to error

actions promoting patient safety 7. Staffing 2. Organizational learning – continuous 8. Hospital management support improvement for patient safety3. Teamwork within units 9. Teamwork across hospital units 4. Communication openness 10. Hospital handoffs & transitions 5. Feedback & communications

about error

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Survey Methodology

•In September, 2012 the Hospital Survey on Patient Safety Culture was distributed to Good Care Hospital employees. Overall, 83 responses to the survey were received, a 70% response rate.

• In this report, the percentages of employee responses to specific survey items are grouped according to the safety culture dimensions being assessed. Some percentages shown in the graphs may not add to exactly 100%, due to rounding. Since the total number of respondents was 70%, in each graph 1 % is approximately equivalent to one person’s answers.

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Demographic Data about Respondents1. Primary hospital work area, department or clinical area where respondents

spend most of their work time:

9% Many different hospital units/No specific unit 0% Psychiatry/mental health

10% Medicine (non-surgical) 5% Rehabilitation

6% Surgery 4% Pharmacy

7% Obstetrics 7% Laboratory

0% Pediatrics 10% Radiology

3% Emergency department 1% Anesthesiology

3% Intensive care unit (any type) 37% Other

0% Blank/Missing

2. Staff position in the hospital:20% Registered nurse 0% Dietitian

0% Physician Assistant/Nurse Practitioner 7% Unit Assistant/Clerk/Secretary

4% LVN/LPN 5% Respiratory Therapist

3% Patient care assistant/Hospital aide/care partner 3% Physical, occupational, or speech therapist

0% Attending/Staff physician 14% Technician (e.g. EKG, Lab, Radiology)

0% Resident physician/Physician in training 8% Administration/Management

1% Pharmacist 35% Other

0% Blank/Missing15

Demographic Data (continued)

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3. Time worked

--in the hospital (hours /week)

3% Less than 20 hours 43% 20 to 39 hours 55% 40 hours or more

--in the hospital (years)

9% Less than 1 year 39% 1 to 5 years 18% 6 to 10 years

16% 11 to 15 years 7% 16 to 20 years 12% 21 or more years

--in their current hospital work area(years)



--in their current specialty (years)



4. Percentage of respondents with direct interaction or contact with patients: 73%

Main Findings: StrengthsWe identify as strengths, those positively worded items which about 75% of respondents endorse by answering “Agree/Strongly agree,” or “Most of the time/ Always” (or when about 75% of respondents disagreed with negatively worded items).

A number of strengths emerged from the results*:

Composite-Level• Teamwork Within Units – 85%

• Supervisor/Manager Expectations & Actions Promoting Patient Safety – 81%

• Organizational Learning – Continuous Improvement – 80%

• Management Support for Patient Safety – 83%

• Feedback and Communication about Error – 76%

• Overall Perceptions of Safety – 78%

• Teamwork Across Hospital Units – 75%17

*All taken from general results—not department/title specific

Main Findings: Strengths (Cont’d)

Item-Level• Frequency of Events Reported

– When a mistake is made that could harm the patient, but does not it is often reported – 85%

• Staffing– We use more agency/temporary staff than is best for patient care – 76%

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*All taken from general results—not department/title specific

Main Findings: Areas for ImprovementAreas with the potential for improvement were identified as items which about 50% of respondents answered negatively using “Disagree/Strongly disagree” or “Never/Rarely” (or when 50% of respondents disagreed with positively worded items).

A number of areas for improvement emerged from the results:

Item-Level• Non-punitive Response to Error

– Staff worry that mistakes they make are kept in their personnel fileR - 46%

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Overall Perceptions of Safety

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25

14

80

12

71

63

14

13 7

14

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R Indicates reversed-worded items.NOTE: The item letter and number in parentheses indicate the item’s survey location.

Survey Items % Strongly Disagree/ % Neither % Strongly Agree/ Disagree Agree

1. Patient safety is never sacrificed to get more work done. (A15)

2. Our procedures and systems are good at preventing errors from happening. (A18)

R3. It is just by chance that more serious mistakes don’t happen around here. (A10)

R4. We have patient safety problems in this unit. (A17)

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21

19

12

65

835

14

14

67

Frequency of Events Reported

1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported? (D1)

2. When a mistake is made, but has no potential to harm the patient, how often is this reported? (D2)

3. When a mistake is made that could harm the patient, but does not, how often is this reported? (D3)

% Never/ % Sometimes % Most of the Rarely time/Always

Survey Items

NOTE: The item letter and number in parentheses indicate the item’s survey location.

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Number of Events Reported Respondents were asked to indicate the number of events they had reported in the past 12 months.

1. In the past 12 months, how many event reports have you filled out and submitted? (Survey item G1)

Zero or no response

1 to 2 3 to 5 6 to 10 11 to 20 21 or more0

20

40

60

80

100

79

196 3 0 1

Number of Events Reported

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Overall Patient Safety GradeRespondents were asked to give their work unit an overall grade on patient safety.

2. Please give your work area/unit in this hospital an overall grade on patient safety. (Survey item E1)

Series10

20

40

60

80

100

39

52

9

0 0

Chart Title

% of Respondents

A Excellent

B Very Good

C Acceptable

D Poor

E Failing

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Supervisor/Manager Expectations & Actions Promoting Patient Safety

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4

12

13

80

2

2

9

4

86

86

93



1. My supervisor/manager says a good word when he/she sees a job done according to established patient safety procedures. (B1)

2. My supervisor/manager seriously considers staff suggestions for improving patient safety. (B2)

R3. Whenever pressure builds up, my

supervisor/manager wants us to work faster, even if it means taking shortcuts. (B3)

R4. My supervisor/manager overlooks patient safety problems that happen over and over.(B4)

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Organizational Learning—Continuous Improvement

11

28

17

88

786

9

2

63



1. We are actively doing things to improvepatient safety. (A6)

2. Mistakes have led to positive changeshere. (A9)

3. After we make changes to improvepatient safety, we evaluate theireffectiveness. (A13)

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Teamwork Within Units

2

0

3

14

93

93

18

3

4

5

68

96



1. People support one another in this unit. (A1)

2. When a lot of work needs to be donequickly, we work together as a team to get the work done. (A3)

3. In this unit, people treat each other withrespect. (A4)

4. When one area in this unit gets really busy, others help out. (A11)

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Communication Openness

1. Staff will freely speak up if they see something that may negatively affect patient care. (C2)

2. Staff feel free to question the decisions or actions of those with more authority. (C4)

R3. Staff are afraid to ask questions when something does not seem right. (C6)

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22

19

81

279

10

2

67


Survey Items % Never/ % Sometimes % Most of the Rarely time/Always

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Feedback and Communication About Error

1. We are given feedback about changes putinto place based on event reports. (C1)

2. We are informed about errors that happen in this unit. (C3)

3. In this unit, we discuss ways to prevent errors from happening again. (C5)

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18

9

58

89

9

5

2

76


Survey Items % Never/ % Sometimes % Most of the Rarely time/Always

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Nonpunitive Response to Error

R1. Staff feel like their mistakes are held

against them. (A8)R2. When an event is reported, it feels like

the person is being written up, not the

problem. (A12)R3. Staff worry that mistakes they make are

kept in their personnel file. (A16)

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29

32

16

1949

51

62

20



2929

Staffing

7

28

43

21

81

4

70

53

41

12

9

31



1. We have enough staff to handle the workload. (A2)

R2. Staff in this unit work longer hours than is best for patient care. (A5)

R3. We use more agency/temporary staff than is best for patient care. (A7)

R4. We work in “crisis mode” trying to do too much, too quickly. (A14)

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Hospital Management Support for Patient Safety

5

4

19

82

6

12

5

75

91



1. Hospital management provides a work climate that promotes patient safety. (F1)

2. The actions of hospital management show that patient safety is a top priority. (F8)

R3. Hospital management seems interested in patient safety only after an adverse event happens. (F9)

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Teamwork Across Hospital Units

15

11

14

24

78

18

69

68

13

7

7

76



1. There is good cooperation among hospital units that need to work together. (F4)

2. Hospital units work well together to provide the best care for patients. (F10)

R3. Hospital units do not coordinate well with each other. (F2)

R4. It is often unpleasant to work with staff from other hospital units. (F6)

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Hospital Handoffs & Transitions


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27

25

42

12

22

12

56

53

53

46

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R1. Things “fall between the cracks” when transferring patients from one unit to

another. (F3)

R2. Important patient care information is often lost during shift changes. (F5)

R3. Problems often occur in the exchange

of information across hospital units. (F7)

R4. Shift changes are problematic for patients in this hospital. (F11)

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(verbatim with spelling and grammar edits)

9% of respondents wrote comments (N = 6)

“Section I: Your Comments—Please feel free to write any comments about patient safety, error, or event reporting in your hospital.”1. HOPE THIS IS A GOOD SURVERY, UNALBLE TO ANSWER SOME QUESTIONS BECAUSE IT IS NEVER BLACK

OR WHITE2. PATIENT & STAFF SAFETY IS, HAS BEEN AND ALWAYS WILL BE VERY IMPORTANT TO ME!3. Any comment or suggestion regarding patient safety is taken very seriously by our EOC Committee and

actions are taken to address concerns presented. Administration fully supports the EOC and all hospital committee's. We are very fortunate.

4. If it is not already being done regularly (at least weekly), I would like to suggest that a system be implemented to check ALL wheelchair, and hospital bed brakes to make sure they are working correctly.

5. I used to love coming to work. Now I hate it. Sometimes coworkers are laughing, singing and talking so loud I can't concentrate. Then you end up doing their work because they have been busy doing other things not related to work.

Staff Comments

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Understanding and Using Your HSOPS Results Dolores Hagan, RN BSN K-HEN Education/Data Manager...

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