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HOSPITAL
SURVEY
ON
PATIENT
SAFETY
CULTURE
PATIENT
SAFETY
USER’S GUIDE
AHRQ Hospital Survey on
Patient Safety Culture:
User’s Guide
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
http://www.ahrq.gov
Contract No. HHSA290201300003C
Prepared by:
Westat, Rockville, MD
Joann Sorra, Ph.D.
Laura Gray, M.P.H.
Suzanne Streagle, M.A.
Theresa Famolaro, M.P.S.
Naomi Yount, Ph.D.
Jessica Behm, M.A.
AHRQ Publication No. 15(16)-0049-EF
Replaces 04-0041
January 2016
ii
This report may be used, in whole or in part, as the basis for development of clinical practice
guidelines and other quality enhancement tools, or a basis for reimbursement and coverage
policies. AHRQ or U.S. Department of Health and Human Services endorsement of such
derivative products may not be stated or implied.
AHRQ is the lead Federal agency charged with supporting research designed to improve the
quality of health care, reduce its cost, address patient safety and medical errors, and broaden
access to essential services. AHRQ sponsors and conducts research that provides evidence-
based information on health care outcomes; quality; and cost, use, and access. The
information helps health care decisionmakers—patients and clinicians, health system leaders,
and policymakers—make more informed decisions and improve the quality of health care
services.
This document is in the public domain and may be used and reprinted without permission except
those copyrighted materials noted for which further reproduction is prohibited without the
specific permission of the copyright holders.
Citation of the source is appreciated.
Suggested Citation:
Sorra J, Gray L, Streagle S, et al. AHRQ Hospital Survey on Patient Safety Culture: User’s
Guide. (Prepared by Westat, under Contract No. HHSA290201300003C). AHRQ Publication
No. 15-0049-EF (Replaces 04-0041). Rockville, MD: Agency for Healthcare Research and
Quality. January 2016. http://www.ahrq.gov/professionals/quality-patient-
safety/patientsafetyculture/hospital/index.html
iii
Contents of This Survey User’s Guide
The AHRQ Hospital Survey on Patient Safety Culture, this User’s Guide, and other toolkit
materials are available on the AHRQ Web site (http://www.ahrq.gov/professionals/quality-
patient-safety/patientsafetyculture/index.html). These materials are designed to provide hospitals
with the basic knowledge and tools needed to conduct a patient safety culture assessment, along
with ideas for using the data. This guide provides a general overview of the issues and major
decisions involved in conducting a survey and reporting the results.
Part One: Survey User’s Guide
Chapter 1. Introduction ....................................................................................................................1
Development of the Hospital Survey on Patient Safety Culture .................................................1
Patient Safety Culture Composites .............................................................................................3
Modifications to the Survey ........................................................................................................4
Chapter 2. Getting Started................................................................................................................5
Determine Available Resources and Project Scope ....................................................................5
Decide on Your Data Collection Method....................................................................................5
Decide Whether To Use Survey Identifiers ................................................................................6
Decide Whether To Use an Outside Vendor ...............................................................................7
Plan Your Project Schedule ........................................................................................................7
Form a Project Team ...................................................................................................................9
Establish Points of Contact Within the Hospital .........................................................................9
Chapter 3. Selecting Your Survey Population ...............................................................................11
Determine Whether To Conduct a Census or Sample ..............................................................11
Determine Whom To Survey ....................................................................................................11
Determine Your Sample Size ....................................................................................................12
Compile Your Sample List .......................................................................................................12
Review and Fine-Tune Your Sample ........................................................................................13
Chapter 4. Paper Surveys ...............................................................................................................15
Distributing Surveys .................................................................................................................15
Returning Surveys .....................................................................................................................15
Publicizing and Promoting the Survey ......................................................................................15
Following Survey Administration Steps ...................................................................................16
Developing and Assembling Survey Materials .........................................................................17
Chapter 5. Web-Only and Mixed-Mode Surveys ..........................................................................20
Publicize and Promote the Survey ............................................................................................20
Following Survey Administration Steps ...................................................................................20
Develop Survey-Related Materials ...........................................................................................22
Design and Pretest Web Surveys ..............................................................................................24
Chapter 6. Analyzing Data and Producing Reports .......................................................................27
Identify Incomplete and Ineligible Surveys ..............................................................................27
Calculate the Final Response Rate ............................................................................................27
Edit the Data and Prepare the Data File ....................................................................................27
Analyze the Data and Produce Reports of the Results ..............................................................29
Technical Assistance ......................................................................................................................32
References ......................................................................................................................................32
iv
Hospital Survey on Patient Safety Culture: Composites and Items ...............................................40
Appendix A. Sample Data Collection Protocol for the Hospital Point of Contact:
Paper Survey .............................................................................................................................43
Appendix B. Sample Data Collection Protocol for the Hospital Point of Contact:
Web Survey ..............................................................................................................................44
Appendix C. Sample Data Collection Protocol for the Hospital Point of Contact:
Mixed-Mode Survey .................................................................................................................45
List of Figures
Figure 1. Task Timeline for Project Planning for a Single Hospital………..…… .........................8
List of Tables
Table 1. Patient Safety Culture Composites and Definitions ..........................................................3
Table 2. Minimum Sample Sizes by Numbers of Physicians and Staff ........................................12
Table 3. Example of How To Compute Frequency Percentages ...................................................30
Table 4. Example of How To Calculate Item and Composite Percent Positive Scores.................31
1
Chapter 1. Introduction
As hospitals continually strive to improve patient safety and quality, hospital leadership
increasingly recognizes the importance of establishing a culture of safety. Achieving such a
culture requires leadership, physicians, and staff to understand their organizational values,
beliefs, and norms about what is important and what attitudes and behaviors are expected and
appropriate. A definition of safety culture applicable to all health care settings is provided below.
Safety Culture Definition
The safety culture of an organization is the product of individual and group values,
attitudes, perceptions, competencies, and patterns of behavior that determine the
commitment to, and the style and proficiency of, an organization’s health and safety
management. Organizations with a positive safety culture are characterized by
communications founded on mutual trust, by shared perceptions of the importance of
safety, and by confidence in the efficacy of preventive measures.
Study Group on Human Factors. Organising for safety: third report of the ACSNI (Advisory
Committee on the Safety of Nuclear Installations). Sudbury, England: HSE Books; 1993.
Development of the Hospital Survey on Patient Safety Culture
Purpose
The Agency for Healthcare Research and Quality (AHRQ) and Medical Errors Workgroup of the
Quality Interagency Coordination Task Force (QuIC) sponsored the development of the Hospital
Survey on Patient Safety Culture. The hospital survey is designed specifically for hospital staff
and asks for their opinions about the culture of patient safety at their hospitals.
The survey can be used to:
Raise staff awareness about patient safety,
Assess the current status of patient safety culture,
Identify strengths and areas for patient safety culture improvement,
Examine trends in patient safety culture change over time,
Evaluate the cultural impact of patient safety initiatives and interventions, and
Conduct comparisons within and across organizations.
Survey Development and Pilot Test
Under contract to AHRQ, a survey design team from Westat conducted the following activities
to identify key composites of hospital safety culture, relevant background questions about staff
and hospital characteristics, and appropriate terms and words to use in the survey:
Reviewed the literature, including existing surveys, pertaining to patient safety, hospital
medical errors and quality-related events, error reporting, safety climate and culture, and
organizational climate and culture.
2
Conducted background interviews with experts in the field of patient safety and with
hospital staff.
Based on these activities, the design team developed draft survey items to measure the identified
key composites and conducted cognitive interviews with hospital staff. Cognitive interview
participants included clinical staff, such as physicians, nurses, and other allied health
professionals, and nonclinical staff, including administrators and unit clerks. The design team
also received input on the draft survey from the Joint Commission, additional patient safety
researchers, hospital systems administration, and professional associations.
The draft survey was pilot tested with more than 1,400 hospital employees from 21 hospitals
across the United States. The design team examined the reliability and factor structure of the
patient safety culture composites. Based on these analyses, the final items and composites in the
Hospital Survey on Patient Safety Culture were determined to have sound psychometric
properties (Sorra and Nieva, 2003).
Hospital Definition
The purpose of the Hospital Survey on Patient Safety Culture is to measure the culture of patient
safety at a single hospital in a specific location. We therefore consider each unique facility to be
a separate site for the purposes of survey administration and providing hospital-specific
feedback. When you administer the survey at multiple hospitals, you should identify each
hospital as a separate site so that each site can receive its own results in addition to overall results
across sites.
We also recommend that there be at least 10 respondents from a hospital for a survey feedback
report to be provided to the site, to protect respondent anonymity. Hospitals that are part of a
health system can have their data aggregated with others for feedback purposes.
Identification of Survey Participants
The survey examines patient safety culture from a hospital staff perspective. All staff asked to
complete the survey should have enough knowledge about your hospital and its operations to
provide informed answers to the survey questions. Overall, when considering who should
complete the survey, ask yourself:
Does this person know about day-to-day activities in this hospital?
Does this person interact regularly with staff working in this hospital?
Types of Staff
The survey can be completed by all types of hospital staff—from housekeeping and security to
nurses and physicians. However, the survey is best suited for the following:
Hospital staff who have direct contact or interaction with patients (clinical staff, such as
nurses, or nonclinical staff, such as unit clerks);
3
Hospital staff who may not have direct contact or interaction with patients but whose
work directly affects patient care (e.g., staff in units such as pharmacy, laboratory/
pathology);
Hospital-employed physicians or contract physicians who spend most of their work hours
in the hospital (e.g., emergency department physicians, hospitalists, pathologists); and
Hospital supervisors, managers, and administrators.
Hospital-based physicians or physicians in outpatient settings with hospital privileges can be
asked to respond to the survey. They should respond about the hospital unit where they spend
most of their work time or provide most of their clinical services, or they can simply select
“Many different hospital units/No specific unit” when responding to the survey.
Patient Safety Culture Composites
The Hospital Survey on Patient Safety Culture emphasizes patient safety and error and event
reporting. There are 42 items grouped into 12 composite measures, or composites. In addition to
the composites, the survey 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 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, tenure in their work area/unit, etc.).
Table 1 provides the patient safety culture composites included in the survey and their
definitions.
Table 1. Patient Safety Culture Composites and Definitions
Patient Safety Culture Composite Definition: The extent to which…
Communication Openness Staff freely speak up if they see something that may
negatively affect a patient and feel free to question those
with more authority.
Feedback and Communication About
Error
Staff are informed about errors that happen, are given
feedback about changes implemented, and discuss ways to
prevent errors.
Frequency of Events Reported Mistakes of the following types are reported: (1) mistakes
caught and corrected before affecting the patient, (2)
mistakes with no potential to harm the patient, and (3)
mistakes that could harm the patient but do not.
Handoffs and Transitions Important patient care information is transferred across
hospital units and during shift changes.
Management Support for Patient Safety Hospital management provides a work climate that
promotes patient safety and shows that patient safety
is a
top
priority.
Nonpunitive Response to Error Staff feel that their mistakes and event reports are not held
against them and that mistakes are not kept in their
personnel file.
Organizational Learning—Continuous
Improvement
Mistakes have led to positive changes and changes are
evaluated for effectiveness.
Overall Perceptions of Patient Safety Procedures and systems are good at preventing errors and
there is a lack of patient safety problems.
4
Patient Safety Culture Composite Definition: The extent to which…
Staffing There are enough staff to handle the workload and work
hours are appropriate to provide the best care for patients.
Supervisor/Manager Expectations and Supervisors/managers consider staff suggestions for
Actions Promoting Patient Safety improving patient safety, praise staff for following patient
safety procedures, and do not overlook patient safety
problems.
Teamwork Across Units Hospital units cooperate and coordinate with one another to
provide the best care for patients.
Teamwork Within Units Staff support each other, treat each other with respect, and
work together as a team.
Modifications to the Survey
We recommend making changes to the survey only when absolutely necessary because any
changes may affect the reliability and validity of the survey and make comparisons with other
hospitals difficult.
Changing Background Items
The survey begins with a background question about the respondent’s primary work area or unit.
The survey ends with some additional background questions on staff position, tenure in the
organization, and work hours. Your hospital may wish to modify the responses to these
background questions so they are tailored to reflect the names of your staff position titles and
work units.
Modifying Work Areas or Staff Positions
If you modify the work areas or staff positions in your survey and plan to submit to the
AHRQ Hospital Survey on Patient Safety Culture Comparative Database, create a
crosswalk to recode your modified work areas or staff positions to the original survey’s
work areas or staff positions.
Adding Items
If your hospital adds items to the survey, add these items toward the end of the survey (just
before the Background Questions section).
Removing Items
You may decide you want to administer a shorter survey with fewer items. If so, identify specific
composites that your hospital does not want to assess, and delete all items in those composites
(see Part 2 on page 40 for a list of items within composites). We do not recommend removing
items from different composites across the entire surveys because your hospital’s composite
measure scores will not be comparable with other hospitals if any items are missing.
5
Chapter 2. Getting Started
Before you begin, it is important to understand the tasks involved in collecting survey data and
decide who will manage the project. This chapter is designed to guide you through the planning
and decisionmaking stages of your project.
Determine Available Resources and Project Scope
Two of the most important elements of an effective project are a clear budget to determine the
scope of your data collection effort and a realistic schedule. Think about your available
resources:
How much money and/or resources are available to conduct this project?
Who within the hospital is available to work on this project?
When do we need to have the survey results completed and available?
Do we have the technical capabilities to conduct this project in the hospital, or do we
need to consider using an outside company or vendor for some or all of the tasks?
Decide on Your Data Collection Method
The decision to use a paper survey, a Web survey (either via the Internet or through your
organization’s intranet), or mixed mode should be based on several important factors.
Comparative data for the hospital survey shows that more hospitals are administering the survey
via Web even though the average response rates are slightly higher with paper surveys (Sorra, et
al., 2014). To help you decide which data collection method is most appropriate for your
hospital, consider the following:
1. Response rates. Response rates are important because low rates may limit your ability to
generalize results to your entire hospital. When response rates are low, there is a danger
that the large number of staff who did not respond to the survey would have answered
very differently from those who did respond. The higher the response rate, the more
confident you can be that you have an adequate representation of staff views.
Comparative data for the hospital survey (Sorra, et al., 2014) show that response rates are
slightly higher with paper surveys (69 percent; range: 15-100 percent) compared with
Web only (54 percent; range 7-100 percent).
2. Your Hospital’s experience with Web surveys. You should also consider the following
factors when thinking about the possible use of Web surveys:
Access to computers or email. If staff have limited access to computers or do not
have hospital established email addresses, this may lead to low response rates or
difficulty administering successful Web surveys. Staff may also be concerned about
the privacy of their responses if they share computers and may decide not to take the
survey at work.
Hospital experience conducting Web surveys. If you have had previous success
surveying hospital staff online and achieved high response rates, you may prefer to
administer a Web survey.
6
3. Logistics. In small hospitals, the logistics of administering paper surveys may be
manageable. However, if you plan to administer the survey in a large hospital, Web
surveys offer several advantages:
There are no surveys or cover letters to print, survey packets to assemble, postage and
mailing envelopes to arrange, or completed paper surveys to manage.
The responses are automatically entered into a database, so the need for separate data
entry is eliminated.
The task of data cleaning is reduced because of programmed validation checks.
4. Costs and your hospital resources. If you plan to administer the survey in a large
hospital, a Web survey may be more cost effective than a paper survey.
5. Survey preparation and testing time. If you are using a Web survey and plan to
program it, allow sufficient time and resources to:
Ensure that the Web survey meets acceptable standards for functionality, usability,
and log-in passwords (if you use passwords) and allows respondents to save their
responses and return later to finish the survey,
Format the survey appropriately to reduce respondent error,
Put security safeguards in place to protect the data, and
Test it thoroughly to ensure that the resulting dataset has captured the data correctly.
Decide Whether To Use Survey Identifiers
You need to decide whether you will use individual survey identifiers and, if you are surveying
multiple hospitals, how you will identify responses from each hospital.
Individual Identifiers
Staff are usually concerned about the confidentiality of their responses, so we recommend that
you conduct an individually anonymous survey. This means you should not use identifiers to
track individuals. Also, do not ask respondents to provide their names. You want to ensure that
respondents feel comfortable reporting their true perceptions and confident that their answers
cannot be traced back to them.
Hospital Identifiers
If you are surveying multiple hospitals, you will need to use hospital-level identifiers to track
surveys from each hospital. Doing so will allow you to produce feedback reports for each
hospital. We offer a few ways of using identifiers for paper and Web surveys.
Paper Surveys
Vary survey color. Consider printing surveys on different-colored paper for each center.
Print a hospital identifier on the survey. You can print a hospital identifier on the surveys by
giving each hospital a unique form number (e.g., Form 1, Form 2, Form 3) to identify different
hospitals. Print the identifier on the survey (e.g., lower left corner of the back page). Be aware,
7
however, that some staff members will be so concerned about the confidentiality of their
responses that they might mark out the site identifier or form number.
Web Surveys
You can include a hospital identifier as part of the password used to access the survey. The
password would be linked to a particular site. Alternatively, you can use a customized hyperlink
for staff within a hospital that differs across sites.
Decide Whether To Use an Outside Vendor
You may want to use an outside company or vendor to handle some or all of your data collection,
analysis, and report preparation. Hiring a vendor may be a good idea for several reasons:
Working with an outside vendor may help ensure neutrality and the credibility of your
results.
Staff may feel their responses will be more confidential when their surveys are returned
to an outside vendor.
Vendors typically also have experienced staff to perform all the necessary activities and
the facilities and equipment to handle the tasks. A professional and experienced firm may
be able to provide your hospital with better quality results faster than if you were to do
the tasks yourself.
If you plan to hire a vendor, the following guidelines may help you to select the right one:
Look for a vendor with expertise in survey research.
Determine whether the vendor can handle all the project components. Some vendors will
be able to handle your data analysis and feedback report needs; others will not.
Provide potential vendors with a written, clear outline of work requirements. Make tasks,
expectations, deadlines, and deliverables clear and specific. Then, ask each vendor to
submit a short proposal describing the work they plan to complete, the qualifications of
their company and staff, and details regarding methods and costs.
Meet with the vendor to make sure you will be able to work well together and they
understand your expectations.
After choosing a vendor, institute monitoring and problem-resolution procedures.
Plan Your Project Schedule
The sample timeline in Figure 1 can be used as a guideline for administering a paper or Web
survey. Plan for at least 10 weeks from the beginning of the project to the end.
8
Figure 1. Task Timeline for Project Planning for a Single Hospital
Task Timeline for Project Planning
Planning
Sample
Selectio
n &
Preparat
ion
Data
Collection
Analysis
&
Reports
Week 1 2 3 4 5 6 7 8 9 10
Getting Started – Ch. 2
Determine Available Resources and Project Scope

Decide on Your Data Collection Method

Decide Whether To Use Survey Identifiers

Decide Whether To Use an Outside Vendor

Plan Your Project Schedule

Form a Project Team

Establish Points of Contact Within the Hospital

Selecting Your Survey Population – Ch. 3
Determine Whom To Survey

Determine Your Sample Size

Compile Your Sample List
Mode of Survey Administration
Paper Surveys – Ch. 4
Decide How Surveys Will Be Distributed and Returned

Publicize and Promote the Survey
Develop, Print, and Assemble Survey Materials
Distribute First Survey

Track Responses and Preliminary Response Rates
Distribute Second Survey

Close Out Data Collection

Web Surveys – Ch. 5
Design and Pretest Web Survey
Publicize and Promote the Survey
Send Prenotification Email
Send Survey Invitation Email

Track Responses and Preliminary Response Rates
Send Reminder Survey Invitation Email(s)
Close Out Data Collection

Analyzing Data and Producing Reports – Ch. 6
Identify Incomplete and Ineligible Surveys

Calculate the Final Response Rate

Prepare the Data File

Analyze the Data and Produce Reports of the Results
9
If you plan to survey multiple hospitals, you may need to adjust the timeline:
Establish a system-level point of contact (POC) as well as a POC in each hospital.
Allow more time to assemble survey materials and/or develop a Web survey (e.g., 4
weeks instead of 2 weeks for paper or 3 weeks for Web).
Add a week or more to the data collection period.
Add a week or more to the data analysis period.
Form a Project Team
Whether you conduct the survey in-house or through an outside vendor, you will need to
establish a project team responsible for planning and managing the project. Your team may
consist of one or more individuals from your own hospital staff, outsourced vendor staff, or a
combination. Their responsibilities will include the following:
Planning and budgeting—Determine the scope of the project given available resources,
plan project tasks, and monitor the budget.
Establishing contact persons—Assign a POC in the hospital to support survey
administration, maintain open communication throughout the project, and provide
assistance.
Preparing publicity materials—Create flyers, posters, and email and intranet messages
to announce and promote the survey in the hospital.
Preparing paper survey materials—Print surveys, prepare postage-paid return
envelopes and labels, and assemble these components for your survey distribution.
Developing a Web survey instrument (if conducting a Web survey)—Design the
instrument, program the survey, and pretest the instrument.
Distributing and receiving paper survey materials (if conducting a paper survey)—
Distribute surveys and reminder notices and handle receipt of completed surveys.
Tracking survey responses and calculating preliminary response rates—Monitor
survey returns and calculate preliminary response rates; if individual identification
numbers are used on the surveys to track nonrespondents (though we do not recommend
this), identify the nonrespondents who should receive followup materials.
Handling data entry, analysis, and report preparation—Review survey data for
respondent errors and data entry errors in electronic data files, conduct data analysis, and
prepare a report of the results.
Distributing and discussing feedback results with staff—Disseminate results broadly
to increase their usefulness.
Coordinating with and monitoring an outside vendor (optional)—Outline the
requirements of the project to solicit bids from outside vendors, select a vendor,
coordinate tasks to be completed in-house versus by the vendor, and monitor progress to
ensure that the necessary work is completed and deadlines are met.
Establish Points of Contact Within the Hospital
You will need to establish people in the hospital to serve as points of contact for the survey.
Decide how many points of contact are needed by taking into account the number of staff and
10
hospital areas or units taking the survey. We recommend using at least two types of points of
contact.
Main Hospital Point of Contact
At least one main hospital point of contact should be appointed from the project team. We
recommend including contact information for the main hospital point of contact in all survey
materials in case respondents have questions about the survey. The main hospital point of contact
has several duties, including:
Answering questions about survey items, instructions, or processes,
Responding to staff comments and concerns,
Helping to coordinate survey mailing and receipt of completed surveys,
Communicating with outside vendors as needed, and
Communicating with other points of contact as needed.
Additional Points of Contact
You may decide to recruit points of contact for each hospital work area/unit or staffing category
included in your sample. A unit-level point of contact is responsible for promoting and
administering the survey within his/her unit and for reminding unit staff to complete the survey.
Unit-level contacts typically are at the management or supervisory level, such as nurse managers,
department managers, or shift supervisors.
11
Chapter 3. Selecting Your Survey Population
The population from which you select your sample will be staff in your hospital or hospital
system. You either can administer surveys to everyone in your population of hospital physicians
and staff (i.e., a census), or you can administer surveys to a subset or sample of your population.
You may want to conduct a census because you are administering the survey as an educational
tool to raise staff awareness about value and efficiency. However, if you administer to a large
hospital, the additional time and resources required may make conducting a census more
difficult, particularly if you administer a paper survey.
When you select a sample, you select a group of people who closely represents the population so
that you can generalize your sample’s results to the broader population. To select your sample,
you need to determine which hospital physicians and staff you want to survey and the number
who need to be surveyed.
Determine Whether To Conduct a Census or Sample
If you administer the survey in a small hospital (i.e., fewer than 500 physicians and staff), you
should conduct a census and survey all physicians and staff. Even if you administer the survey in
a system with multiple hospitals, the size of the individual hospital will drive this decision.
Determine Whom To Survey
All physicians and staff in your hospital or hospital system represent your population. From this
population, you may want to survey physicians and staff from every area of the hospital, or you
may want to focus on specific units, staffing categories, or staffing levels. You can select a
sample from a population in several ways. Several types of samples are described below. Select
the type that best matches your needs, taking into account what is practical given your available
resources.
Staff in particular categories. You may be interested only in surveying staff in specific
staffing categories, such as nursing. With this approach, you may select all staff within a
staffing category or select a subset of the staff. This approach alone, however, may not be
sufficient to represent the views of all staff in the hospital.
Staff in particular areas/units. You may want to survey staff in particular hospital areas
or units, such as OB/GYN, Emergency, or Pharmacy. The list below presents three
examples of ways staff can be selected using this approach, listed in order from most to
least representative of the entire hospital population:
o A subset of staff from all areas/units (most representative).
o All staff from some areas/units.
o A subset of staff from some areas/units (least representative).
o A combined approach. If possible, we recommend surveying staff using a
combination of the two sample types just described. For example, you may be
interested in surveying all nurses (a staffing category) but only a subset of staff from
every hospital area (excluding nursing). Using a combination of sample types allows
you either to oversample or selectively sample certain types of staff in an attempt to
thoroughly represent the diversity of hospital staff.
12
Keep in mind that if you wish to report results for specific units or staff positions, we
recommend conducting a census of physicians and staff within these units or staff positions.
Determine Your Sample Size
The size of your sample will depend on whom you want to survey and your available resources.
While your resources may limit the number of staff you can survey, the more staff you survey,
the more likely you are to adequately represent your population.
Because not everyone will respond, you can expect to receive completed surveys from about 30
percent to 50 percent of your sample. See Table 2 for recommended minimum sample sizes
given the numbers of providers and staff in your hospital as well as the expected response
assuming a 50 percent response rate.
Table 2. Minimum Sample Sizes by Numbers of Physicians and Staff
Population of Physicians and Staff Minimum Sample Size*
Expected Response
(Assuming 50%
Response Rate)
500 or fewer Census (all providers and staff) At least 50%
501-999 500 250
1,000 -2,999 600 300
3,000 or more 800 400
*The target sample size is based on three assumptions: simple random or systematic random sampling, a response
rate of 50 percent, and a confidence interval of +/− 5 percent. See http://www.gifted.uconn.edu/siegle/
research/Samples/samsize.html.
Your budget may determine the number of staff you can sample, particularly if you administer a
paper survey. To reach an adequate number of responses, you will need to send initial surveys as
well as followup surveys to those who do not respond to the first survey. Your budget also
should take into consideration additional costs for materials such as envelopes and postage, if
you are mailing surveys.
Compile Your Sample List
After you determine whom you want to survey and your sample size, compile a list of the staff
from which to select your sample. When compiling your sample list, include several items of
information for each staff member:
First and last name,
Internal hospital mailing address, or home or office address if surveys will be mailed,
Email address (if conducting a Web-based survey or using email to send prenotification
letters, Web survey hyperlinks, or reminders),
Hospital area/unit, and
Staffing category or job title.
If you select ALL staff in a particular staffing category, hospital area, or unit, no sampling is
needed; simply compile a list of all these staff. If you select a subset or sample of staff from a
13
particular staffing category, hospital area, or unit, you will need to use a method such as simple
random sampling or systematic sampling.
Simple Random vs. Systematic Sampling
Simple random sampling involves selecting staff randomly so that each staff member
has an equal chance of being selected. Systematic sampling essentially involves
selecting every N
th
person from a population list. For example, if you have a list of 100
names in a particular group and need to select 25 to include in your sample, you
would begin at a random point on the list and then select every 4th staff member to
compile your sample list. Thus, if you began with the first person on the list, you
would select the 4th, 8th, 12th, 16th, etc., staff member, up to the 100th staff member,
compiling a total of 25 names in your sample list.
Review and Fine-Tune Your Sample
Once you have compiled your sample list, review the list to make sure it is appropriate to survey
each staff member on the list. To the extent possible, ensure that this information is complete, up
to date, and accurate. Points to check include:
Staff on administrative or extended sick leave,
Staff who appear in more than one staffing category or hospital area/unit,
Staff who have moved to another hospital area/unit,
Staff who no longer work at the hospital, and
Other changes that may affect the accuracy of your list of names or mailing addresses.
If you believe certain staff should not receive the survey or that your records are not complete,
selectively remove people from the list. If you remove someone from the list, add another staff
member in his or her place.
14
Selecting a Sample—An Example
Suppose you work in a 300-bed hospital with 1,600 staff members. Nursing is
the single largest staffing category, with 1,200 staff. Smaller hospital areas or
units have a combined total of 100 nonnursing staff, and larger hospital areas or
units have a combined total of 300 nonnursing staff.
Determine Whom To Survey. You decide to survey a sample of nurses,
all nonnursing staff from smaller hospital areas or units, and all
nonnursing staff from larger hospital areas or units. You therefore
choose a combination approach to select your sample.
Determine Your Sample Size. You are only sampling nurses and have
a population of 1,200 nurses so according to Table 2, your minimum
sample size should be 600 nurses.
Compile Your Sample List. Your final sample list of 1,000 staff
members consists of:
1. Nursing—From the total of 1,200 nurses, a sample of 600 nurses is
selected. The sample was selected as follows:
A list of the 1,200 nurses was produced.
Using systematic sampling from a random start point on the list,
every other nurse on the list was selected to be included in the
sample until 600 names were selected (1,200 total nurses divided
by 600 nurses needed = every 2
nd
nurse).
2. Smaller hospital areas or units—All 100 nonnursing staff.
3. Larger hospital areas or units—All 300 nonnursing staff.
Review and Fine-Tune Your Sample. When verifying the contact
information for the initial sample of 1,000 staff, you found that 25 staff
no longer worked for the hospital and needed to be dropped from the list.
You may or may not want to replace these names. To replace the names,
randomly select additional staff from the same staffing categories or
hospital areas as the staff who were dropped.
15
Chapter 4. Paper Surveys
In this chapter, we present information to help you decide how your paper surveys will be
distributed and returned, suggest ways to promote and publicize your survey, describe survey
administration steps, and provide a detailed description of how to develop and assemble the
survey materials.
Distributing Surveys
We recommend that designated points of contact distribute the surveys to hospital staff. To
promote participation, you can distribute the surveys at staff meetings and serve refreshments,
following these guidelines for distributing surveys:
Provide explicit instructions for completing the survey.
Inform staff that completing the survey is voluntary.
Assure them that their responses will be kept confidential. Emphasize that reports of
findings will include only summary data and will not identify individuals.
Caution them (especially if they complete the survey during a meeting) not to discuss the
survey with other staff while answering the survey.
Permit staff to complete the survey during work time to emphasize that hospital
administration supports the data collection effort.
Returning Surveys
There are several options for respondents to return completed paper surveys:
Drop-boxes: Surveys can be returned to locked drop-boxes placed throughout your
hospital.
Interoffice mail: Surveys can be returned via interoffice mail to a designated POC
within your hospital office or to a corporate headquarters address.
Mail: If you use a vendor or do not have an interoffice mail system, staff can also mail
their completed surveys to the outside vendor or designated POC. If surveys are returned
through the mail, you will need to account for return postage in your budget.
Whatever process you decide, it should help reassure staff that no one at their hospital will see
the completed surveys.
Publicizing and Promoting the Survey
We strongly recommend publicizing the survey before and during data collection. Be sure to
advertise that hospital leadership supports the survey. Publicity activities may include:
Posting flyers or posters at the hospital, sending staff emails, and posting information
about the survey on the hospital intranet,
Promoting the survey during staff meetings, and
Having a senior leader or executive send a supportive email or letter of support for the
data collection effort.
16
Publicity materials can help legitimize the survey effort and increase your response rate by
including some or all of the following types of information:
Endorsements of the survey from your leadership
Clear statements about the purpose of the survey, which is to assess staff attitudes and
opinions about the culture of patient safety in your hospital
Description of how the collected data will be used to identify ways to improve patient
safety culture
Assurances that only summary (aggregated) data will be reported, thus keeping individual
responses confidential
Assurance of individual anonymity (if no individual identifiers are used) or
confidentiality of response (if individual identifiers are used)
Introductions to the survey vendor, if you have chosen to use a vendor
Contact information for the designated points of contact
Following Survey Administration Steps
We recommend the following basic data collection steps to achieve high response rates:
1. Optional prenotification letter for paper surveys. If you have publicized your survey
well and your survey cover letter explains the purposes of the survey, distributing a
prenotification letter announcing the upcoming survey is optional. If you obtained a letter
of support from your leadership, you can use this as your prenotification letter.
2. First paper survey. About 1 week after publicizing the survey, distribute a survey packet
to each staff member that includes the survey, a supporting cover letter, and a return
envelope. If you want staff to return their surveys by mail, include a preaddressed
postage-paid envelope.
3. Second survey. To promote a higher response, 2 weeks after the first survey is
distributed, distribute a second survey to everyone at your hospital (it has to go to
everyone if you are conducting an individually anonymous survey because you do not
know who responded). Include a cover letter thanking those who have already responded
and reminding others to please complete the second survey. If you used individual
identifiers on your surveys (although not recommended), you can distribute second
surveys only to nonrespondents.
4. Calculate preliminary response rates. Calculate a preliminary response rate at least
once a week to track your response progress. Divide the number of returned surveys
(numerator) by the number of eligible staff who received the survey (denominator).
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑠𝑢𝑟𝑣𝑒𝑦𝑠 𝑟𝑒𝑡𝑢𝑟𝑛𝑒𝑑
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑒𝑙𝑖𝑔𝑖𝑏𝑙𝑒 𝑠𝑡𝑎𝑓𝑓 𝑤ℎ𝑜 𝑟𝑒𝑐𝑒𝑖𝑣𝑒𝑑 𝑎 𝑠𝑢𝑟𝑣𝑒𝑦
If staff members’ employment ends during data collection, they are still considered
eligible and should be included in the denominator even if they did not complete and
return the survey. See Chapter 6 for a discussion of how to calculate the final official
response rate for your hospital.
17
5. Close out data collection. Keep in mind that your goal is to achieve a high response rate.
If your response rate is still too low after distributing the second survey, add another
week to the data collection period or consider sending a followup reminder notice.
Consider Using Incentives To Maximize Response Rates
Offering incentives can be a good way to increase responses to a survey because
respondents often ask, “What’s in it for me?” You may want to offer individual
incentives, such as a raffle for cash prizes or gift certificates, or you can offer group
incentives, such as catered lunches for hospital work areas/units with at least a 75
percent response rate. Be creative and think about what would motivate your
physicians and staff to complete the survey.
Developing and Assembling Survey Materials
Estimate the number of surveys you need to print, and assemble the following materials for your
paper survey data collection.
We suggest the following printing guidelines:
If you are conducting an anonymous survey and plan to send second surveys to everyone,
print at least twice the number of surveys as staff in your sample. Include a few extra
surveys in case some staff misplace theirs.
If you are tracking responses and will send second surveys only to nonrespondents, you
may print fewer surveys overall. For example, if you are administering the survey to 800
staff and your hospital typically experiences a 40 percent response to the first survey
packet, print 800 first surveys and 480 second surveys (800 staff x 60% nonrespondents =
480), for a total of 1,280 printed surveys. Add a few extra surveys in case some staff
misplace theirs.
Points-of-Contact Letters and Instructions
Send a letter to each unit-level contact person describing the purposes of the survey and
explaining his or her role in the survey effort. The letter should be printed on official hospital
letterhead, signed by the hospital chief executive officer. Provide the points of contact with the
data collection protocol that describes their tasks, along with a proposed timeline. (See a sample
data collection protocol in Appendix A.)
Cover Letter in First Survey Packet
The cover letter should be on official hospital letterhead and signed by a senior hospital leader or
executive. The cover letter should address the following points:
Why the hospital is conducting the survey, how survey responses will be used, and why
the staff member’s response is important
How much time is needed to complete the survey
Assurances that the survey is voluntary and can be completed during work time
18
Assurances of individual anonymity (if no individual identifiers are used) or
confidentiality of response (if individual identifiers are used)
How to return completed surveys
Incentives for survey participation (optional)
Contact information for the points of contact
Sample Cover Letter Text for Paper Survey
The enclosed survey is part of our hospital’s efforts to better address patient safety.
All hospital staff are being asked to complete this survey. Your participation is
voluntary, but we encourage you to complete the survey to help us improve the way
we do things at this hospital. It will take about 10 to 15 minutes to complete, and
your individual responses will be kept anonymous [say confidential if you are using
respondent identifiers]. Only group statistics, not individual responses, will be
prepared and reported.
Please complete your survey WITHIN THE NEXT 7 DAYS. When you have
completed your survey, please [provide return instructions for paper surveys].
[Optional incentive text: In appreciation for participation, staff who complete and
return their surveys will receive (describe incentive).]
Please contact [POC name and job position] if you have any questions [provide
phone number and email address]. Thank you in advance for your participation in
this important effort.
Cover Letter in Second Paper Survey Packet
The contents of the second survey cover letter should be similar to the first cover letter but
should have a different beginning. If you conduct an anonymous survey, you will have to
distribute second surveys to everyone, so you might begin with: “About X days ago a copy of the
Hospital Survey on Patient Safety Culture was distributed to you and other staff at your hospital.
If you have already returned a completed survey, thank you very much and please disregard this
second survey packet.” If you use individual identifiers, you can send the second survey to
nonrespondents only.
Followup Reminder Notices
If needed to improve response, distribute reminder notices after the second survey
administration. The notices, which can be on a half-page of cardstock, should ask staff to please
complete and return their surveys and should include a thank you to those who have done so
already. If you use individual identifiers to track responses, you can distribute the reminders to
nonrespondents only.
19
Labels and Envelopes for Paper Survey Packets
Outer envelope labels with staff names are a good idea even if the survey itself is completed
anonymously to ensure that every staff member receives a survey. Return labels should be used
on return envelopes. Labels may also be used to place hospital identifiers onto surveys.
Use a slightly larger outer envelope to keep from bending or folding the survey or return
envelope contained in the survey packet. Use your estimate of the number of surveys to print to
estimate the numbers of outer and return envelopes you will need.
Postage for Returning Paper Surveys
If staff will return their surveys by mail, weigh the survey and the return envelope to ensure you
have adequate postage on the envelopes. When calculating the total cost of postage, be sure to
base the amount on your estimated number of any initial and followup surveys that need to be
mailed.
20
Chapter 5. Web-Only and Mixed-Mode Surveys
In this chapter, we suggest ways to publicize your survey, describe survey administration steps
for Web-only and mixed-mode surveys, describe materials that need to be developed, and
highlight important best practices in Web survey design and pretesting.
Publicize and Promote the Survey
As with paper surveys, we strongly recommend publicizing the survey before and during data
collection. Be sure to advertise that hospital leaders support the survey. Publicity activities may
include:
Posting flyers or posters in the hospital, sending staff emails, and posting information
about the survey on a hospital intranet,
Promoting the survey during staff meetings, and
Having a senior leader or executive send a supportive email during data collection,
thanking staff if they have completed the survey and encouraging others to do so.
Publicity materials can help legitimize the survey effort and increase your response rate by
including some or all of the following types of information:
Endorsements of the survey from your leadership
Clear statements about the purpose of the survey, which is to assess staff attitudes and
opinions about the culture of patient safety in your hospital
Description of how the collected data will be used to identify ways to improve patient
safety culture
Assurances that only summary (aggregated) data will be reported, thus keeping individual
responses confidential
Assurance of individual anonymity (if no individual identifiers are used) or
confidentiality of response (if individual identifiers are used)
Introductions to the survey vendor, if you have chosen to use a vendor
Contact information for the designated POCs
Following Survey Administration Steps
We recommend the following basic data collection steps to achieve high response rates:
1. Prenotification email. Email staff a prenotification letter telling them about the
upcoming survey and alerting them that they will soon receive an invitation to complete
the Web survey. You will need an up-to-date list of staff email addresses. If you obtained
a letter of support from your leadership, you can use this as your prenotification email.
2. Survey invitation email. Send the survey invitation email a few days after sending the
prenotification email. Include the hyperlink to the Web survey (or instructions for
accessing the survey on the hospital intranet), along with the individual’s password, if
applicable. Provide instructions about whom to contact for help accessing and navigating
the survey.
21
3. Followup communications. Send an email reminder one week after sending the survey
invitation. In the message, thank those who have already completed the survey and
encourage others to do so. Distribute a second reminder a week later. Consider sending a
third email reminder to boost response as needed. Be sure to make the subject lines of
followup email reminder messages slightly different to capture recipients’ attention.
Reminders should also include the original message and instructions for accessing the
survey.
If you use individual identifiers, you can send email reminders only to nonrespondents.
Otherwise, reminders must be sent to everyone. Be sure to thank those who have already
completed their surveys and ask them to disregard the reminder.
4. Calculate preliminary response rates. Calculate a preliminary response rate at least
once a week to track your response progress. Divide the number of returned surveys
(numerator) by the number of eligible staff who received the survey (denominator).
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑠𝑢𝑟𝑣𝑒𝑦𝑠 𝑟𝑒𝑡𝑢𝑟𝑛𝑒𝑑
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑒𝑙𝑖𝑔𝑖𝑏𝑙𝑒 𝑠𝑡𝑎𝑓𝑓 𝑤ℎ𝑜 𝑟𝑒𝑐𝑒𝑖𝑣𝑒𝑑 𝑎 𝑠𝑢𝑟𝑣𝑒𝑦
If any staff members’ employment ends during data collection, they are still considered
eligible and should be included in the denominator even if they did not complete and
return the survey. See Chapter 6 for a discussion of how to calculate the final official
response rate for your hospital.
5. Close out data collection. Keep in mind that your goal is to achieve a high response rate.
If your response rate is still too low after distributing the second survey, add another
week to the data collection period and consider sending another reminder email.
Survey Administration Steps for Mixed-Mode Surveys
Administer the Web survey first, followed by a paper survey.
Week 1: Carry out Web survey administration steps for the first week of data
collection.
Week 2: Email or distribute a followup reminder.
Week 3: Distribute survey packets to all staff (or to nonrespondents only if
using identifiers to track response). In the cover letter, tell staff to disregard
the paper survey if they completed and submitted the Web survey.
Follow paper survey administration steps but continue the Web survey option.
For followup reminders (if needed), you can use a mix of email and printed
(or in-person) reminders.
22
Consider Using Incentives To Maximize Response Rates
Offering incentives can be a good way to increase responses to a survey because
respondents often ask, “What’s in it for me?” You may want to offer individual
incentives, such as a raffle for cash prizes or gift certificates, or you can offer group
incentives, such as catered lunches for hospital work areas/units with at least a 75
percent response rate. Be creative and think about what would motivate your providers
and staff to complete the survey.
Develop Survey-Related Materials
The following materials will need to be developed in preparation for Web survey data collection.
Points-of-Contact Letters and Instructions
Send a letter to each POC describing the purpose of the survey and explaining his or her role in
the survey effort. The letter should be on company letterhead, signed by a senior executive. We
also recommend that you provide POCs with a data collection protocol that describes their tasks,
along with a proposed timeline. (See sample data collection protocols in Appendixes B and C.)
Prenotification Email
We recommend the following for the prenotification email to help boost survey response:
Have it signed by a senior hospital leader or executive.
Use a name or email address in the “From” line that will be easily recognizable to staff to
prevent them from mistaking your email for spam and deleting it.
Include the following points in your message:
o Statement that in a few days the person will receive an invitation from [XXX] to
participate in a brief survey on patient safety in the hospital,
o Statement about the purpose and intended use of the survey and the importance of
responding,
o Assurance of individual anonymity (if no individual identifiers are used) or
confidentiality of response (if individual identifiers are used), and
o Introduction to survey vendor (if applicable).
Survey Invitation
The survey invitation email should also be signed by a senior hospital leader or executive. We
recommend providing hyperlinks to the Web survey in your invitation email and any followup
email reminders. Respondents will be able to click directly on the hyperlink. You may also
provide passwords for beginning the survey. If the survey is located on the hospital intranet,
provide instructions for accessing the survey.
23
The survey invitation message should include the following information:
Brief restatement of why the hospital is conducting the survey, how it will use the data,
and why the staff member’s response is important,
How much time is needed to complete the survey,
Assurances that the survey is voluntary and can be completed during work time,
Assurance of individual anonymity (if no individual identifiers are used) or
confidentiality of response (if individual identifiers are used),
Incentives for survey participation (optional), and
Contact information for the hospital POC (and system-level POC, if applicable).
If someone other than the POC will handle questions about possible technical problems with the
survey, provide contact information for that person.
Sample Survey Invitation Email
You are invited to participate in an important survey that is part of our hospital’s
patient safety program. All staff are being asked to complete this survey. Your
participation is voluntary, but we encourage you to complete the survey to help us
improve the way we do things at this hospital. It will take about 10 to 15 minutes
to complete and you may take it during work time. Your individual responses will
be kept anonymous [say confidential if you are using respondent identifiers]. Only
group statistics, not individual responses, will be prepared and reported.
To access the secure survey Web site, click on the following link: http://www...
[Optional, if using passwords: Then enter the following password to begin the
survey: xxxxxxxxxx]
[Optional incentive text: In appreciation for participation, staff will receive
(describe incentive).]
Please contact [POC name and job position] if you have any questions about the
survey [provide phone number and email address]. If you have a technical
problem with the survey, please respond to this email with a description of your
problem or contact [Name, phone number].
Thank you in advance for participating in this important patient safety effort.
Followup Reminder Notices
Send email reminder notices a few days after data collection begins and again a week after that.
The contents of the reminder notices should be similar to the first invitation email but should
have a different beginning. If you conduct an anonymous survey, you will have to send a
reminder to everyone, so you might begin with: “About X days ago an invitation to participate in
24
the Hospital Survey on Patient Safety was emailed to you and other staff at your hospital. If you
have already completed the survey, thank you very much and please disregard this reminder.” If
you use individual identifiers, you can send the reminders to nonrespondents only.
Design and Pretest Web Surveys
If you decide to conduct a Web survey, there are a number of Web survey design aspects to
consider. Whether you use commercial off-the-shelf software or have a vendor conduct a Web
survey, you should assess the various Web survey options available to you. Below we present a
number of important features for designing a Web survey.
Web Survey Design Features
Although research on the best ways to design Web-administered surveys continues to evolve,
current knowledge suggests that a good Web-based survey follows the principles below:
1. Do not force respondents to answer every question. There are several good reasons for
allowing staff to not answer a particular question:
Forcing respondents to answer each question may annoy respondents and lessen their
motivation to complete the survey.
Some respondents may have legitimate reasons for not answering an item. Forcing a
response may cause them to make a wild guess, rather than provide an informed
answer.
You will want the Web version to be similar to the paper version, which does not
require an answer to every question.
2. Display notifications for questions with missing answers before the respondent
leaves the Web page. To help prevent missing data, it is a good idea to display
notifications for questions with missing answers before the respondent proceeds to the
next Web page. Do not force the respondent to answer the question, but let the
respondent see which questions are missing answers.
3. Decide on the number of questions on each Web page.
If possible, use one Web page for each section of the survey. Most Web survey
applications have space for 6 or more questions on an individual page without
scrolling, which will accommodate most of the sections. For larger sections of the
survey (i.e., Section A and Section F), we recommend you display the questions in
chunks of 5 or 6 questions per individual Web page. It is better to avoid vertical
scrolling if possible since respondents can miss questions not visible on the Web page
and just proceed to the next section.
We do not recommend that you format the survey with one item per page. This
increases the time it takes to complete the survey.
Also, we do not recommend that you program the survey so that respondents must
scroll horizontally to see parts of the survey. This can contribute to response error if
respondents overlook parts of the survey, and it may annoy respondents.
25
4. Make sure the response categories (e.g., Strongly disagree, Disagree) appear on
every Web page. Response errors may occur if the respondent cannot see the response
categories when the question appears across more than one Web page. Be sure that the
response categories are repeated as frequently as necessary so that respondents always
see them when answering every question. Use a large screen resolution of 800 pixels by
600 pixels when testing the Web survey because this issue is more problematic the larger
the screen resolution.
5. Design for mobile devices. It is important to test your Web survey on different types of
mobile devices (e.g., tablet computers, smart phones) to ensure that it is viewable and can
be taken on those devices.
6. Do not indicate progress by Web page. Current survey research also suggests that for
short surveys, progress indicators (e.g., a progress bar) could be counterproductive since
they often do not display progress accurately. Rather, it is recommended to tell the
respondent that the survey takes about 10 to 15 minutes to complete. If you nonetheless
want some indication of where the respondent is in the survey, you can have a section
indicator that shows which section of the survey the respondent is currently completing.
7. Save the survey. It is important that the respondent’s answers are saved automatically as
the respondent moves from Web page to Web page. Sometimes the respondent will break
off and complete the survey at a later time. You do not want to lose the respondent’s
answers due to a temporary breakoff.
8. (Optional) Allow respondents to print a hard-copy version of the survey and
complete it on paper. Some respondents may prefer to complete a paper version of the
survey, and providing this option may boost your response rate. It is possible to design
your Web survey so it can be printed in paper form, but test this functionality thoroughly
to ensure that the survey prints properly on different printers. Attention must be given to
line lengths and page lengths in the design of the Web survey pages to be sure they print
properly.
Alternatively, you can include a link to a portable document file (PDF) version of the
survey on the Web site. With either alternative, respondents will need instructions to
know where to return the completed paper surveys. Designated personnel then must enter
the responses into your dataset (paper survey data can be entered via the Web site). Also,
if you use individual identifiers, there should be a way to include the identifier on the
printed version of the survey or otherwise identify the paper response.
Thoroughly Test the Survey
It is essential to thoroughly test the survey. When testing:
Use the same type of computer that will be available to staff taking the survey at your
hospital. If you have more than one type of computer, be sure to test with a range of
computer types and include the lower end type with slower Internet connections. You
may also want to test the Web survey using mobile devices with small screens if you
think some staff will complete the survey on a cell phone or tablet.
Test the survey with various Internet browsers (e.g., with different iterations of Internet
Explorer, Safari, Firefox, Chrome, Mozilla, Opera), different display settings (screen
resolutions set at 800 x 600 pixels versus 1200 x 800 pixels), and so forth.
26
After you have completed the first two testing steps, submit test survey responses to
ensure that the Web survey is working properly and is easy to use.
Check the Web survey data output. For example, check to make sure the responses (e.g.,
Strongly disagree through Strongly agree) have the correct 1 to 5 values. If the Web
responses are miscoded, there is no way to correct the dataset after the survey has been
administered.
Testing will help to ensure that the survey appears and performs as it should despite the different
settings and personal preferences that staff may use. For more information on Web survey design
principles and survey testing, see Couper (2008); Dillman, et al. (2009); and Tourangeau, et al.
(2013).
27
Chapter 6. Analyzing Data and Producing Reports
You will need to prepare the collected survey data for analysis. If you decide to do your own
data entry, analysis, and report preparation, use this chapter to guide you through the various
decisions and steps. If you decide to hire a vendor for any of these tasks, use this chapter as a
guide to establish data preparation procedures.
If you plan to conduct a Web survey, you can minimize data cleaning by programming the Web
survey to perform some of these steps automatically. Also, if you plan to administer the survey at
more than one hospital, you will need to report the results separately for each site.
Identify Incomplete and Ineligible Surveys
Examine each returned survey for possible problems before the survey responses are entered into
the dataset. We recommend that you exclude returned surveys that:
Are completely blank or contain responses only for the background demographic
questions, or
Contain the exact same answer to all the questions in the survey (since a few survey items
are negatively worded, the same exact response to all items indicates the respondent
probably did not pay careful attention and the responses are probably not valid).
Calculate the Final Response Rate
After you have identified which returned surveys will be included in the analysis data file, you
can use the following formula to calculate the official response rate:
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑠𝑢𝑟𝑣𝑒𝑦𝑠 𝑟𝑒𝑡𝑢𝑟𝑛𝑒𝑑 − 𝑖𝑛𝑐𝑜𝑚𝑝𝑙𝑒𝑡𝑒𝑠
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑒𝑙𝑖𝑔𝑖𝑏𝑙𝑒 𝑠𝑡𝑎𝑓𝑓 𝑤ℎ𝑜 𝑟𝑒𝑐𝑒𝑖𝑣𝑒𝑑 𝑎 𝑠𝑢𝑟𝑣𝑒𝑦
Note that the numerator may be smaller than in your last preliminary response rate calculation
because, during your examination of all returned surveys, you may find that some of the returned
surveys are incomplete or ineligible.
Edit the Data and Prepare the Data File
In this section we describe several data file preparation tasks.
Edit Illegible, Mismarked, and Double-Marked Responses (Paper Only)
Problematic responses may occur with paper surveys if some respondents write in an answer
such as 3.5 when they have been instructed to mark only one numeric response. Or they may
mark two answers for one item. Develop and document editing rules that address these problems
and apply them consistently. Examples of such rules are to use the highest or most positive
response when two responses are provided (e.g., a response with both 2 and 3 would convert to a
3) or to mark all of these types of inappropriate responses as missing.
28
Create and Clean Data File
Paper survey data files. After your paper surveys have been edited as needed, you can enter the
data directly into an electronic file by using statistical software such as SAS
®
, SPSS
®
, or
Microsoft Excel
®
, or you can create a text file that can be easily imported into a data analysis
software program. AHRQ has developed a Hospital Data Entry and Analysis Tool that works
with Microsoft Excel
®
and makes it easy to input your individual-level data from the survey. The
tool then automatically creates tables and graphs to display your survey results. To request the
tool, email DatabasesOnSafetyCulture@westat.com.
If you are not using the Hospital Data Entry and Analysis Tool, each row in your data file should
represent one staff member’s responses and each column should represent a different survey
question. The next step is to check the data file for possible data entry errors. To do so, produce
frequencies of responses for each item and look for out-of-range values or values that are not
valid responses.
Most items in the survey require a response between 1 and 5. Check through the data file to
ensure that all responses are within the valid range (e.g., that a response of 7 has not been
entered). If you find out-of-range values, return to the original survey and determine the response
that should have been entered.
Web surveys. Your pretesting should have ensured that responses would be coded and captured
correctly in the data file, so the file should not contain invalid values. But you should verify this
by again checking that all responses are within the valid range.
Include Individual Identifiers in Your Data File
If you used individual identifiers on your surveys, enter the identification number in the
electronic data file and then destroy any information linking the identifiers to individual names.
You want to eliminate the possibility of linking responses on the electronic file to individuals.
If you used paper surveys without individual identifiers, include some type of respondent
identifier in the data file. Create an identification number for each completed paper survey and
write it on the completed paper survey in addition to entering it into the electronic data file. This
identifier can be as simple as numbering the returned surveys consecutively, beginning with the
number 1. This number will enable you to check the electronic data file against a respondent’s
original answers if any values look like they were entered incorrectly.
If you used Web surveys without respondent identifiers, you can electronically generate and
assign an identifier to each respondent in the data file.
Deidentify, Analyze, and Code Open-Ended Comments
Respondents are given the opportunity to provide written comments at the end of the survey.
Comments can be used to obtain direct quotes for feedback purposes, but they should be
carefully reviewed and deidentified first to ensure that they do not contain any information that
could be used to identify who wrote the comment or individuals referred to in the comment.
29
You may also want to analyze the comments and identify common themes (e.g., communication,
staffing, teamwork). You can then assign code numbers to match comments to themes and tally
the number of comments per theme. Open-ended comments on paper surveys may be coded
either before or after the data have been entered electronically.
Analyze the Data and Produce Reports of the Results
Minimum Number of Respondents to Produce Reports
To protect the confidentiality of individual respondents, do not provide any type of
survey feedback report for a hospital if fewer than 10 respondents have answered
the survey. Also, if fewer than three respondents answered a particular survey item, do
not report percentages of positive, neutral, or negative response for that item—simply
indicate there were not enough data to report results for the item.
Ideally, feedback should be provided broadly—to management, administrators, boards of
directors, committees, and staff—either directly during meetings or through communication tools
such as email, intranet sites, or newsletters. The more broadly the results are disseminated, the
more useful the information is likely to become and the more likely respondents will feel that
taking the survey was worthwhile.
Feedback reports can be customized for each audience, from one- or two-page executive
summaries to more complete reports that use statistics to draw conclusions or make comparisons.
In any feedback reports, include the following types of information:
How the survey was conducted (paper, Web, survey administration period) and your
response rate.
Background characteristics of all respondents—their work area/unit, staff position, tenure
with the hospital, tenure within unit, weekly hours, etc.—to help others understand who
responded to the survey.
Composite and item-level results. As noted in the callout box above, do not report results
for an item if the total number of respondents is fewer than three.
Breakouts of results by staff position, work area/unit, or other background characteristics.
Do not report results for any background characteristic category (e.g., nurses) if there are
fewer than five respondents in that category and if there are fewer than three respondents
to an item in that category.
o It is possible to still provide breakout results when you have fewer respondents by
collapsing categories together. For example, if in a medical office, only two
respondents are Physicians and four are Physician Assistants, you could collapse
these categories for analysis and reporting purposes.
Calculate Frequencies of Response
One of the simplest ways to present results is to calculate the frequency of response for each
survey item. To make the results easier to view in the report, you can combine the two lowest
response categories (e.g., Strongly disagree/Disagree and Never/Rarely) and the two highest
30
response categories (e.g., Strongly agree/Agree and Most of the time/Always). The midpoints of
the scales are reported as a separate category (Neither or Sometimes).
Each survey item will probably have some missing data from respondents who simply did not
answer the question. Missing responses are excluded when displaying percentages of response to
the survey items. An example of how to handle the missing response when calculating the survey
results is shown in Table 3.
Table 3. Example of How To Compute Frequency Percentages
Item A1. People support one another in this unit.
Response
Frequency (Number of
Responses)
Response
Percentage
Combined
Percentages
1 = Strongly disagree 1 10% 30% Negative
2 = Disagree 2 20%
3 = Neither 1 10% 10% Neutral
4 = Agree 4 40% 60% Positive
5 = Strongly agree 2 20%
Total 10 100% 100%
Missing (did not answer) 3 - -
Total Number of Responses 13 - -
Calculate Item and Composite Percent Positive Scores
It can be useful to calculate an overall score for items within a composite. To calculate your
hospital’s score on a particular safety culture composite, average the percent positive responses
on all items included in the composite.
To calculate percent positive scores, you will need to reverse code negatively worded items.
Disagreeing or responding Never to a negatively worded item indicates a positive response.
Negatively worded items are identified in the document Hospital Survey on Patient Safety
Culture: Composites and Items.
Use the following guidelines for reverse coding negatively worded items:
If respondents answer Strongly disagree or Never to a negatively worded item, answers
should be recoded from 1 to 5.
If respondents answer Disagree or Rarely to a negatively worded item, answers should be
recoded from 2 to 4.
The neutral response categories Neither agree nor disagree and Sometimes are not
affected by negatively worded items and will always be coded as 3.
If respondents answer Most of the time or Agree to a negatively worded item, answers
should be recoded from 4 to 2.
If respondents answer Always or Strongly agree to a negatively worded item, answers
should be recoded from 5 to 1.
Here is an example of computing a percent positive composite score for the composite Overall
Perceptions of Safety:
31
There are four items in this composite—two are positively worded (A15) and (A18), and
two are negatively worded (A10) and (A17). Keep in mind that DISAGREEING with a
negatively worded item indicates a POSITIVE response.
Calculate the percent positive response at the item level (see example in Table 4). In this
example, averaging the item-level percent positive scores [(71% + 64% + 70% + 75%) /
4 = 70%] results in a composite score of 70 percent positive on Overall Perceptions of
Safety.
Table 4. Example of How To Calculate Item and Composite Percent Positive Scores
Four Items Measuring
Overall Perceptions of
Safety
For Positively
Worded Items,
# of “Strongly
agree” or
“Agree”
Responses
For Negatively
Worded Items,
# of “Strongly
disagree” or
“Disagree”
Responses
Total # of
Responses
to Item
(Excluding
Missing
Responses)
Percent
Positive
Response to
Item
Item A15-positively worded:
“Patient safety is never
sacrificed to get more work
done.”
185
NA
260 185/260 = 71%
Item A18-positively worded:
“Our procedures and systems
are good at preventing errors
from happening.”
160 N/A 250 160/250 = 64%
Item A10-negatively worded:
“It is just by chance that more
serious mistakes don’t happen
around here.”
N/A 168 240 168/240 = 70%
Item A17-negatively worded:
“We have patient safety
problems in this unit.”
N/A 188 250 188/250 = 75%
N/A = Not applicable
Average percent positive response across the 4 items = 70%
Compare Results Within Your Hospital and to Other Hospitals
Another way to understand your results is to compare results within your hospital. The Hospital
Data Entry and Analysis Tool mentioned earlier in this chapter will produce comparisons by
work area/unit, staff position, interaction with patients, and tenure at the hospital unit level.
Many hospitals using the survey have expressed interest in comparing their results to other
hospitals. In response, AHRQ has established the Hospital Survey on Patient Safety Culture
Comparative Database. This database is a central repository for survey data from hospitals that
have administered the AHRQ patient safety culture survey instrument. If you choose to submit
your data, you will be able to compare your hospital results with the overall hospital comparative
data.
32
Submitting to the Comparative Database
If your hospital is interested in submitting its data to the Hospital Comparative
Database, send an email to DatabasesOnSafetyCulture@westat.com or go to
http://www.ahrq.gov/professionals/quality-patient-
safety/patientsafetyculture/hospital/resources/y2dbsubmission.html.
Technical Assistance
For free technical assistance on the Hospital Survey on Patient Safety Culture, email
SafetyCultureSurveys@westat.com.
References
Couper MP. Designing effective Web surveys. New York: Cambridge University Press; 2008.
Dillman DA, Smyth JD, Christian LM. Internet, mail, and mixed-mode surveys: the tailored design method. 3rd ed.
New York: Wiley; 2009.
Lozar Manfreda K, Bosnjak M, Berzelak J, et al. Web surveys versus other survey modes: a meta-analysis
comparing response rates. Int J Mark Res 2008;50(1):79-104.
Shih T, Fan X. Comparing response rates from Web and mail surveys: a meta-analysis. Field Methods
2008;20(3):249-71. http://fmx.sagepub.com/cgi/content/abstract/20/3/249. Accessed January 22, 2015.
Sorra J, Famolaro T, Yount N, et al. Hospital Survey on Patient Safety Culture 2014 user comparative database
report. (Prepared by Westat, Rockville, MD, under contract No HHSA 290201300003C.) Rockville, MD: Agency
for Healthcare Research and Quality; March 2014. AHRQ Publication No. 14-0019-EF.
http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/hospital/2014/index.html.
Sorra J, Famolaro T, Dyer N, et al. Medical Office Survey on Patient Safety Culture 2012 user comparative database
report. (Prepared by Westat, Rockville, MD, under contract No. HHSA 290200710024C.) Rockville, MD: Agency
for Healthcare Research and Quality; May 2012. AHRQ Publication No. 12-0052.
http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/medical-office/2012/index.html.
Sorra, JS and Nieva, VF. Psychometric analysis of the Hospital Survey on Patient Safety. (Prepared by Westat,
under contract to BearingPoint, and delivered to the Agency for Healthcare Research and Quality [AHRQ], under
Contract No. 29-96-0004.) Rockville, MD: Agency for Healthcare Research and Quality; 2003.
Tourangeau R, Conrad FG, Couper M. The science of Web surveys. New York: Oxford University Press; 2013.
33
PART TWO: SURVEY MATERIALS
1. Hospital Survey on Patient Safety Culture
2. Hospital Survey on Patient Safety Culture:
Composites and Items
34
35
Hospital Survey on Patient Safety
Instructions
This survey asks for your opinions about patient safety issues, medical error, and event reporting in your
hospital and will take about 10 to 15 minutes to complete.
If you do not wish to answer a question, or if a question does not apply to you, you may leave your answer blank.
An “event” is defined as any type of error, mistake, incident, accident, or
deviation, regardless of whether or not it results in patient harm.
“Patient safety” is defined as the avoidance and prevention of patient injuries
or adverse events resulting from the processes of health care delivery.
SECTION A: Your Work Area/Unit
In this survey, think of your “unit” as the work area, department, or clinical area of the hospital where you spend
most of your work time or provide most of your clinical services.
What is your primary work area or unit in this hospital? Select ONE answer.
a. Many different hospital units/No specific unit
b. Medicine (non-surgical)
h. Psychiatry/mental health
n. Other, please specify:
c. Surgery
i. Rehabilitation
d. Obstetrics
j. Pharmacy
e. Pediatrics
k. Laboratory
f. Emergency department
l. Radiology
g. Intensive care unit (any type)
m. Anesthesiology
Please indicate your agreement or disagreement with the following statements about your work area/unit.
Think about your hospital work area/unit…
Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
1. People support one another in this unit ......................................................
1 2 3 4 5
2. We have enough staff to handle the workload ............................................
1 2 3 4 5
3. When a lot of work needs to be done quickly, we work together as a
team to get the work done ..........................................................................
1 2 3 4 5
4. In this unit, people treat each other with respect ........................................
1 2 3 4 5
5. Staff in this unit work longer hours than is best for patient care .................
1 2 3 4 5
36
SECTION A: Your Work Area/Unit (continued)
Think about your hospital work area/unit…
Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
6. We are actively doing things to improve patient safety ..............................
1 2 3 4 5
7. We use more agency/temporary staff than is best for patient care ............
1 2 3 4 5
8. Staff feel like their mistakes are held against them ....................................
1 2 3 4 5
9. Mistakes have led to positive changes here ................................................
1 2 3 4 5
10. It is just by chance that more serious mistakes don’t happen around
here ..............................................................................................................
1 2 3 4 5
11. When one area in this unit gets really busy, others help out .......................
1 2 3 4 5
12. When an event is reported, it feels like the person is being written up,
not the problem ............................................................................................
1 2 3 4 5
13. After we make changes to improve patient safety, we evaluate their
effectiveness ...............................................................................................
1 2 3 4 5
14. We work in "crisis mode" trying to do too much, too quickly ......................
1 2 3 4 5
15. Patient safety is never sacrificed to get more work done ...........................
1 2 3 4 5
16. Staff worry that mistakes they make are kept in their personnel file ..........
1 2 3 4 5
17. We have patient safety problems in this unit ..............................................
1 2 3 4 5
18. Our procedures and systems are good at preventing errors from
happening ...................................................................................................
1 2 3 4 5
SECTION B: Your Supervisor/Manager
Please indicate your agreement or disagreement with the following statements about your immediate
supervisor/manager or person to whom you directly report.
Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
1. My supervisor/manager says a good word when he/she sees a job
done according to established patient safety procedures ..........................
1 2 3 4 5
2. My supervisor/manager seriously considers staff suggestions for
improving patient safety ..............................................................................
1 2 3 4 5
3. Whenever pressure builds up, my supervisor/manager wants us to
work faster, even if it means taking shortcuts .............................................
1 2 3 4 5
4. My supervisor/manager overlooks patient safety problems that happen
over and over ..............................................................................................
1 2 3 4 5
37
SECTION C: Communications
How often do the following things happen in your work area/unit?
Think about your hospital work area/unit…
Never
Rarely
Some-
times
Most of
the time
Always
1. We are given feedback about changes put into place based on event
reports .........................................................................................................
1 2 3 4 5
2. Staff will freely speak up if they see something that may negatively
affect patient care .......................................................................................
1 2 3 4 5
3. We are informed about errors that happen in this unit ...............................
1 2 3 4 5
4. Staff feel free to question the decisions or actions of those with more
authority ......................................................................................................
1 2 3 4 5
5. In this unit, we discuss ways to prevent errors from happening again ........
1 2 3 4 5
6. Staff are afraid to ask questions when something does not seem right .....
1 2 3 4 5
SECTION D: Frequency of Events Reported
In your hospital work area/unit, when the following mistakes happen, how often are they reported?
Never
Rarely
Some-
times
Most of
the time
Always
1. When a mistake is made, but is caught and corrected before affecting
the patient, how often is this reported? .......................................................
1 2 3 4 5
2. When a mistake is made, but has no potential to harm the patient, how
often is this reported? ..................................................................................
1 2 3 4 5
3. When a mistake is made that could harm the patient, but does not,
how often is this reported? ...........................................................................
1 2 3 4 5
SECT
ION E: Patient Safety Grade
Please give your work area/unit in this hospital an overall grade on patient safety.
A
Excellent
B
Very Good
C
Acceptable
D
Poor
E
Failing
SECTION F: Your Hospital
Please indicate your agreement or disagreement with the following statements about your hospital.
Think about your hospital…
Strongly
Disagree
Disagree
Neither
Agree
Strongly
Agree
1. Hospital management provides a work climate that promotes patient
safety ...........................................................................................................
1 2 3 4 5
2. Hospital units do not coordinate well with each other .................................
1 2 3 4 5
3. Things “fall between the cracks” when transferring patients from one
unit to another ..............................................................................................
1 2 3 4 5
4. There is good cooperation among hospital units that need to work
together ................................
.......................................................................
1 2 3 4 5
38
SECTION F: Your Hospital (continued)
Think about your hospital…
Disagree
Disagree
Neither
Agree
Agree
5. Important patient care information is often lost during shift changes .........
1 2 3 4 5
6. It is often unpleasant to work with staff from other hospital units ...............
1 2 3 4 5
7. Problems often occur in the exchange of information across hospital
units ................................
.............................................................................
1 2 3 4 5
8. The actions of hospital management show that patient safety is a top
priority .........................................................................................................
1 2 3 4 5
9. Hospital management seems interested in patient safety only after an
adverse event happens ................................................................
...............
1 2 3 4 5
10. Hospital units work well together to provide the best care for patients ......
1 2 3 4 5
11. Shift changes are problematic for patients in this hospital ..........................
1 2 3 4 5
Strongly Strongly
S
ECTION G: Number of Events Reported
In the past 12 months, how many event reports have you filled out and submitted?
a. No event reports d. 6 to 10 event reports
b. 1 to 2 event reports e. 11 to 20 event reports
c. 3 to 5 event reports f. 21 event reports or more
SECTION H: Background Information
This information will help in the analysis of the survey results.
1. How long have you worked in this hospital?
a. Less than 1 year d. 11 to 15 years
b. 1 to 5 years e. 16 to 20 years
c. 6 to 10 years f. 21 years or more
2. How long have you worked in your current hospital work area/unit?
a. Less than 1 year d. 11 to 15 years
b. 1 to 5 years e. 16 to 20 years
c. 6 to 10 years f. 21 years or more
3. Typically, how many hours per week do you work in this hospital?
a. Less than 20 hours per week d. 60 to 79 hours per week
b. 20 to 39 hours per week e. 80 to 99 hours per week
c. 40 to 59 hours per week f. 100 hours per week or more
39
SECTION H: Background Information (continued)
4. What is your staff position in this hospital? Select ONE answer that best describes your staff position.
a. Registered Nurse j. Respiratory Therapist
b. Physician Assistant/Nurse Practitioner k. Physical, Occupational, or Speech Therapist
c. LVN/LPN l. Technician (e.g., EKG, Lab, Radiology)
d. Patient Care Asst/Hospital Aide/Care Partner m. Administration/Management
e. Attending/Staff Physician n. Other, please specify:
f. Resident Physician/Physician in Training
g. Pharmacist
h. Dietician
i. Unit Assistant/Clerk/Secretary
5. In your staff position, do you typically have direct interaction or contact with patients?
a. YES, I typically have direct interaction or contact with patients.
b. NO, I typically do NOT have direct interaction or contact with patients.
6. How long have you worked in your current specialty or profession?
a. Less than 1 year d. 11 to 15 years
b. 1 to 5 years e. 16 to 20 years
c. 6 to 10 years f. 21 years or more
SECTION I: Your Comments
Please feel free to write any comments about patient safety, error, or event reporting in your hospital.
THANK YOU FOR COMPLETING THIS SURVEY.
40
Hospital Survey on Patient Safety Culture: Composites and
Items
In this document, the items in the Hospital Survey on Patient Safety Culture are grouped according to the
safety culture composites they are intended to measure. The item’s survey location is shown to the left of
each item. Negatively worded items are indicated.
1. Teamwork Within Units
(Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
A1. People support one another in this unit.
A3. When a lot of work needs to be done quickly, we work together as a team to get the work
done.
A4. In this unit, people treat each other with respect.
A11. When one area in this unit gets really busy, others help out.
2. Supervisor/Manager Expectations & Actions Promoting Patient Safety
1
(Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
B1. My supervisor/manager says a good word when he/she sees a job done according to
established patient safety procedures.
B2. My supervisor/manager seriously considers staff suggestions for improving patient safety.
B3. Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it
means taking shortcuts. (negatively worded)
B4. My supervisor/manager overlooks patient safety problems that happen over and over.
(negatively worded)
3. Organizational Learning—Continuous Improvement
(Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
A6. We are actively doing things to improve patient safety.
A9. Mistakes have led to positive changes here.
A13. After we make changes to improve patient safety, we evaluate their effectiveness.
4. Management Support for Patient Safety
(Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
F1. Hospital management provides a work climate that promotes patient safety.
F8. The actions of hospital management show that patient safety is a top priority.
F9. Hospital management seems interested in patient safety only after an adverse event
happens. (negatively worded)
NOTE: Negatively worded questions should be reverse coded when calculating percent “positive”
response, means, and composites.
1
Adapted from Zohar D. A group-level model of safety climate: testing the effect of group climate on
microaccidents in manufacturing jobs. J Appl Psychol 2000;85(4):587-96.
http://psycnet.apa.org/journals/apl/85/4/587.html. Accessed January 15, 2015.
41
5. Overall Perceptions of Patient Safety
(Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
A15. Patient safety is never sacrificed to get more work done.
A18. Our procedures and systems are good at preventing errors from happening.
A10. It is just by chance that more serious mistakes don't happen around here. (negatively
worded)
A17. We have patient safety problems in this unit. (negatively worded)
6. Feedback & Communication About Error
(Never, Rarely, Sometimes, Most of the time, Always)
C1. We are given feedback about changes put into place based on event reports.
C3. We are informed about errors that happen in this unit.
C5. In this unit, we discuss ways to prevent errors from happening again.
7. Communication Openness
(Never, Rarely, Sometimes, Most of the time, Always)
C2. Staff will freely speak up if they see something that may negatively affect patient care.
C4. Staff feel free to question the decisions or actions of those with more authority.
C6. Staff are afraid to ask questions when something does not seem right. (negatively worded)
8. Frequency of Events Reported
(Never, Rarely, Sometimes, Most of the time, Always)
D1. When a mistake is made, but is caught and corrected before affecting the patient, how often
is this reported?
D2. When a mistake is made, but has no potential to harm the patient, how often is this reported?
D3. When a mistake is made that could harm the patient, but does not, how often is this
reported?
9. Teamwork Across Units
(Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
F4. There is good cooperation among hospital units that need to work together.
F10. Hospital units work well together to provide the best care for patients.
F2. Hospital units do not coordinate well with each other. (negatively worded)
F6. It is often unpleasant to work with staff from other hospital units. (negatively worded)
10. Staffing
(Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
A2. We have enough staff to handle the workload.
A5. Staff in this unit work longer hours than is best for patient care. (negatively worded)
A7. We use more agency/temporary staff than is best for patient care. (negatively worded)
A14. We work in "crisis mode" trying to do too much, too quickly. (negatively worded)
NOTE: Negatively worded questions should be reverse coded when calculating percent “positive”
response, means, and composites.
42
11. Handoffs & Transitions
(Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
F3. Things "fall between the cracks" when transferring patients from one unit to another.
(negatively worded)
F5. Important patient care information is often lost during shift changes. (negatively worded)
F7. Problems often occur in the exchange of information across hospital units. (negatively
worded)
F11. Shift changes are problematic for patients in this hospital. (negatively worded)
12. Nonpunitive Response to Errors
(Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
A8. Staff feel like their mistakes are held against them. (negatively worded)
A12. When an event is reported, it feels like the person is being written up, not the problem.
(negatively worded)
A16. Staff worry that mistakes they make are kept in their personnel file. (negatively worded)
Patient Safety Grade
(Excellent, Very Good, Acceptable, Poor, Failing)
E1. Please give your work area/unit in this hospital an overall grade on patient safety.
Number of Events Reported
(No event reports, 1 to 2 event reports, 3 to 5 event report, 6 to 10 event reports, 11 to 20 event reports,
21 event reports or more)
G1. In the past 12 months, how many event reports have you filled out and submitted?
NOTE: Negatively worded questions should be reverse coded when calculating percent “positive”
response, means, and composites.
43
Appendix A. Sample Data Collection Protocol for the Hospital
Point of Contact: Paper Survey
Your Data Collection Tasks and Schedule for the Hospital Survey on
Patient Safety Culture
Listed below are the schedule and tasks for administering the paper survey. Fill in the dates for
your survey. Post this protocol in your office to remind you of the schedule.
Target Date Activity
Three weeks before survey
distribution
Date: ___________
Print and post publicity materials. Post survey flyers
throughout the hospital (e.g., on bulletin boards, in work
areas). Promote survey throughout the data collection period.
Beginning of Week 1
(Start of Survey Data
Collection)
Date: ___________
Distribute survey packets to all staff members on the
survey distribution list. Consider distributing the packets at
staff meetings and encourage survey participation. Caution
staff, however, not to discuss their answers if they complete
their surveys during the meeting.
Beginning of Week 3
Date: ___________
Distribute a second survey packet. If you are not using
individual identifiers to track respondents, distribute second
survey packets to all staff. If you are using identifiers to track
respondents, distribute second survey packets only to
nonrespondents.
Near End of Week 4
Closeout Date:
___________
Calculate preliminary response rate. If the rate is high
enough, close out data collection at the end of Week 4.
To increase your response rate, extend data collection by a
few days or a week. If your response rate is lower than 50
percent, consider distributing reminder cards to all staff (or
only to nonrespondents if you are using identifiers). It may be
sufficient to remind staff in person to complete the survey.
New Closeout Date:
_____________
Close Out Extended Data Collection
44
Appendix B. Sample Data Collection Protocol for the Hospital
Point of Contact: Web Survey
Your Data Collection Tasks and Schedule for the Hospital Survey on
Patient Safety Culture
Listed below are the schedule and tasks for administering the Web survey. Fill in the dates for
your survey. Post this protocol in your office to remind you of the schedule.
Target Date Activity
Three weeks before
survey distribution
Date: ___________
Print and post publicity materials. Post survey flyers
throughout the hospital (e.g., on bulletin boards, in work
areas). Promote survey throughout the data collection period.
One week before starting
data collection
Date: ___________
Email the prenotification message about the survey. Send
the invitation to all staff with email access in the hospital. You
can share the message with staff without email access.
Beginning of Week 1
(Start of Survey Data
Collection)
Date: ___________
Email the survey invitation (or announce the start of data
collection). If the survey is hosted on the World Wide Web,
include a hyperlink (URL) and password in the email invitation.
If the survey is hosted on the hospital intranet, provide
instructions for locating and taking the survey.
Beginning of Week 2
Date: ___________
Distribute 1st reminder notice. Email your prepared
reminder notices and/or distribute reminder cards to all staff. If
you are using identifiers to track respondents, email/distribute
reminders only to nonrespondents. It may be sufficient to
remind staff in person to complete the survey.
Beginning of Week 3
Date: ___________
Distribute 2nd reminder notice. Email your 2nd reminder
notice to all staff (or only to nonrespondents if you are using
identifiers). It may be sufficient to remind staff in person to take
the survey.
Near End of Week 4
Closeout Date:
___________
Calculate preliminary response rate. If the rate is high
enough, close out data collection at the end of Week 4.
To increase your response rate, extend data collection by a
few days or a week. If your response rate is lower than 50
percent, email or distribute 3rd reminders to all staff (or only to
nonrespondents if you are using identifiers). It may be
sufficient to remind staff in person to complete the survey.
New Closeout Date:
_____________
Close Out Extended Data Collection
45
Appendix C. Sample Data Collection Protocol for the Hospital
Point of Contact: Mixed-Mode Survey
Your Data Collection Tasks and Schedule for the Hospital Survey on
Patient Safety Culture
Listed below are the schedule and tasks for administering the survey when you are using both
Web and paper surveys at the same hospital. Fill in the dates for your survey. Post this protocol
in your office to remind you of the schedule.
Target Date Activity
Three weeks before
survey distribution
Date: ___________
Print and post publicity materials. Post survey flyers
throughout the hospital (e.g., on bulletin boards, in work
areas). Promote survey throughout the data collection period.
One week before starting
data collection
Date: ___________
Email the prenotification message about the Web survey.
Send the invitation to all staff with email access in the hospital.
You can share the message with staff without email access.
Beginning of Week 1
(Start of Survey Data
Collection)
Date: ___________
Email the survey invitation (or announce the start of data
collection). If the survey is hosted on the World Wide Web,
include a hyperlink (URL) and password in the email invitation.
If the survey is hosted on the hospital intranet, provide
instructions for locating and taking the survey.
Beginning of Week 2
Date: ___________
Distribute 1st reminder notice. Email your prepared
reminder notices and/or distribute reminder cards to all staff. If
you are using identifiers to track respondents, email/distribute
reminders only to nonrespondents. It may be sufficient to
remind staff in person to take the survey.
Beginning of Week 3
Date: ___________
Distribute paper survey packets. Distribute paper survey
packets to all staff (or only to nonrespondents if you are using
identifiers).
Near End of Week 4
Closeout Date:
________________
Calculate preliminary response rate. If the rate is high
enough, close out data collection at the end of Week 4.
To increase your response rate, extend your data collection by
a few days or a week and distribute 2nd reminders to all staff
(or only to nonrespondents if you are using identifiers). It may
be sufficient to do in-person reminders.
New Closeout Date:
________________
Close Out Extended Data Collection
AHRQ Publication No. 15(16)-0049-EF
January 2016
www.ahrq.gov
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Hospital Survey On Patient Safety Culture: User's Guide (AHRQ)

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