An Overview of the AHRQ Hospital Survey on Patient Safety Culture TM (SOPS TM ) and Value and Efficiency Supplemental Item Set

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An Overview of the AHRQ Hospital Survey on Patient Safety Culture TM (SOPS TM ) and Value and Efficiency Supplemental Item Set Using the SOPS Toolkit for Patient Safety Improvement Theresa Famolaro, MPS, MS, MBA SOPS Database Manager and Westat Senior Study Director March 6, 2018

Objectives Provide overview of the following: SOPS Hospital Survey SOPS Databases Results from the 2016 Hospital Database Hospital Value and Efficiency Results SOPS Updates and Products

What is patient safety culture?

Why should you do a culture survey? Raise staff awareness about patient safety Assess patient safety culture in hospital units/work areas Identify strengths and areas for improvement Examine change over time Evaluate the impact of patient safety initiatives Conduct internal and external comparisons

Background Hospital Survey Developed by Westat, funded by AHRQ Final survey released November 2004

Hospital SOPS Survey Development Process 6

HSOPS Patient Safety Culture Dimensions 42 items assess 12 composites of patient safety culture 1. Communication openness 2. Feedback & communication about error 3. Frequency of event reporting 4. Handoffs & transitions 5. Management support for patient safety 6. Nonpunitive response to error 7. Organizational learning--continuous improvement 8. Overall perceptions of patient safety 9. Staffing 10. Supv/mgr expectations & actions promoting patient safety 11. Teamwork across units 12. Teamwork within units Patient safety grade (Excellent to Poor) Number of events reported in past 12 months

SOPS Databases

SOPS Databases Repositories for data from SOPS surveys

Benefits of All SOPS Databases Individual facility feedback reports comparing results to the database Database Report of aggregate facility-level statistics Additional results by facility characteristics and respondent characteristics Facilities de-identified in the database

SOPS Hospital Database 2016 Report 680 U.S. hospitals, 447,584 respondents Average # respondents per hospital = 658 staff 326 trending hospitals Survey modes Paper 7% Web 78%, In 2007 was 25% Both 16% Average hospital response rate = 55% Paper 71% Web 54% Both 55%

Hospital Work Areas Hospital Work Areas % Medicine 12% Surgery 10% Many areas/no specific areas 8% ICU 7% Emergency 6% Radiology 5% Lab 5%

Staff Positions & Patient Contact Hospital Work Areas % Nursing 36% Technicians 11% Management, administration 7% Pt. care asst/aide/care partner 6% Physicians, PAs, NPs 6% 77% had direct interaction with patients

Hospital Strengths

Hospital Areas for Improvement

Patient Safety Grade

Number of Events Reported

How Do I Compare My Results? Compare Percent Positive Results Compare Results by Hospital and Respondent Characteristics

Hospital Value and Efficiency Pilot Study

Value and Efficiency Supplemental Item Set 13 items that measure four composites Empowerment to Improve Efficiency (3 items) Efficiency and Waste Reduction (3 items) Patient Centeredness and Efficiency (3 items) Management Support for Improving Efficiency and Reducing Waste (4 items) Four overall rating items related to hospital performance 20

Pilot Test February August 2014 21

Hospital Respondents Hospital Staff Positions N (%) Nursing Staff 1,272 (34%) Other Clinical Staff 959 (26%) Other Support Staff 797 (21%) Department Managers, Senior Leaders 348 (9%) Medical Staff 197 (5%) 22

Results Value and Efficiency Composites % Positive Response Supervisor, Manager, or Clinical Leader Support for Improving Efficiency and Reducing Waste Patient Centeredness and Efficiency Efficiency and Waste Reduction Empowerment To Improve Efficiency 23

Results: Overall Quality Ratings 24

SOPS Updates and Products

SOPS TM Trademark Surveys on Patient Safety Culture (SOPS ) Hospital Survey Database participants cannot: Change the wording of the items or response options. Change the order of the items or response options. Delete one or more items. Add supplemental or custom questions within the core survey. 26

SOPS Database Schedule Upcoming Database Submissions 2018 Nursing Home June 1-21, 2018 Community Pharmacy October 1-21, 2019 2019 Hospital Medical Office 27

Action Planning Tool https://www.ahrq.gov/sops/quality-patient-safety/ patientsafetyculture/planningtool.html 28

Resource List https://www.ahrq.gov/sops/quality-patientsafety/patientsafetyculture/hospital/index.html 29

E-mail Updates www.ahrq.gov 30

Thank you! Additional questions or comments? E-mail: SafetyCultureSurveys@westat.com Phone: 1-888-324-9749 Website: https://www.ahrq.gov/sops 31