Composite Results and Comparative Statistics Report ... · collaboration with the Regional Managers for Quality and Patient Safety, piloted the ‘National Patient Safety Culture

Patient Safety Culture Survey Composite Results and Comparative Statistics

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Patient Safety Culture Survey of Staff in Acute Hospitals

Composite Results and Comparative Statistics Report

April 2015


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Table of Contents Executive Summary 3

1.0 Purpose and Use of this Report 8

2.0 Introduction 8

3.0 Survey Administration 10

4.0 Respondents Characteristics 12

5.0 Composite Results 14

5.1 Main Findings 15

5.2 Dimensions 17

5.3 Clinical Governance Development 27

5.4 Open Disclosure 29

6.0 Comparative Statistics 31

6.1 Description and Interpretation 31

6.2 Comparative Tables 33

7.0 Action Planning for Improvement 37

8.0 References 38

9.0 List of Figures 39

10.0 List of Tables 39

11.0 List of Appendices 40

Appendix A: Adapted AHRQ Survey Tool 41

Appendix B: Respondent Characteristics 54

Appendix C: Clinical Governance Development Index Score 56


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Executive Summary

Quality and safety has been a major focus in healthcare over the last ten years and internationally

significant efforts have been made to incorporate this as an integral part of all health systems. How health

staff feel about patient safety at their hospital is an important part of assessing and changing the culture

within the organisation (Nieva, V.F., Sorra, J. 2003). Without understanding the culture within an

organisation, across all staff groups, and at every level of the organisation, it is difficult to improve systems

and ensure that robust quality and patient safety processes are implemented effectively.

Much attention has been given to focusing on improving healthcare services and service user (patient)

outcomes, whilst this is commendable and should always be a priority; still more work needs to be done

with healthcare providers, namely, the staff who are employed to deliver this care of the safest and highest

quality. Optimum patient care should encompass compassion and caring (Report of the Mid Staffordshire

NHS Foundation Trust Public Inquiry, 2013), but compassion and caring also apply to the way we treat

team members (ward and wider inter disciplinary teams) in the workplace. Hence, healthcare staff must

engage with service users, other team members and also the healthcare organisation in which they work

(Macleod and Clarke, 2009).

Being expected to do more with less, has left some staff feeling demoralised, having no voice in their

organisations and feeling increasingly stressed, in some cases ‘burnt out’. It is precisely during these very

difficult times that leaders and managers within the healthcare organisations, need to motivate inspire and

engage their staff to be the best they can be. However, this will only happen within a culture of trust and

transparency, staff must feel they are valued, respected, that their voices are heard and that their opinions

count. These are the principles of staff engagement ( NHS Employers, 2011).

In 2012, the Quality and Patient Safety Directorate now the Quality Improvement Division (QID) in

collaboration with the Regional Managers for Quality and Patient Safety, piloted the ‘National Patient Safety

Culture Survey for Staff in Acute Hospitals’ in five hospitals. The survey tool used was an adapted version

of the Agency for Health Care Research (United States (US)) ‘Hospital Survey on Patient Safety Culture’

(AHRQ 2004). Following this pilot, the tool was further refined and the survey was rolled out as a national

project in 2013. In order to facilitate hospitals as much as possible, it was necessary to divide the national

project up into five phases which commenced in June 2013 and continued through to March 2014.

Each participating hospital received its own survey report. This assessment of a hospital’s patient safety

culture should assist the hospital in meeting the National Standards for Safer Better Healthcare (HIQA

2012) and enable the hospital to incorporate its survey findings into any quality improvement plans being

developed to meet the requirements of the National Standards for Safer Better Healthcare.


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In order to meet further information requirements, data from 41 participating hospitals and 4,700

respondents were merged into one composite database and analysed. This Composite Results and

Comparative Statistics Report presents this analysis in the form of overall results and comparative

measures, so as to enable each hospital to compare its results with those of other hospitals. The Quality

Improvement Division is committed to providing the integral support within the overall system to enable

hospitals tom address comparative culture outcomes.


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MAIN FINDINGS:

Areas of Strength

The three areas of strength i.e. the three multi-question dimensions with the highest percent positive

responses were:

Teamwork Within Units/Departments (Staff support each other, treat each other with respect and work

together as a team)

79%

Organisational Learning – Continuous Improvement (There is a learning culture in which mistakes

lead to positive changes and changes are evaluated for effectiveness)

70%

Supervisor/Manager Expectations & Actions Promoting Patient Safety (Supervisor/Manager

consider staff suggestions for improving patient safety, praise staff for following patient safety procedures, and do not

overlook patient safety problems)

67%

The same three areas of strengths across 653 hospitals in the US were identified in the AHRQ’s User

Comparative Database Report for 2014.

Areas with Potential for Improvement

The three areas with the most potential for improvement i.e. the three multi-question dimensions with the

lowest percent positive responses were:

Non Punitive Response to Error (Staff feel that their mistakes and event reports are not held against them)

47%

Handoffs and Transitions (Important patient care information is transferred across hospital units/departments and during shift changes)

42%

Staffing (There are enough staff to handle the workload and work hours are appropriate to provide the best care for

patients)

40%

The AHRQ’s User Comparative Database Report for 2014 identifies the same three areas with the most

potential for improvement.


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Clinical Governance is defined as ‘a framework through which healthcare teams are accountable for the

quality, safety and satisfaction of patients in the care they deliver.’ (Gauld et al. 2011).

The Clinical Governance Development Index Score was determined from an additional series of

questions, included with the AHRQ Survey, and the average across the hospitals was:

Clinical Governance Development Index Score (measures the extent to which a healthcare

organisation is working to develop clinical governance)

47%

This is on a par with baseline results from the 2011 New Zealand study that developed the index.


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Dimensions 1-12

The average % positive responses for the multi-question dimensions range from 40% to 79%. AHRQ

results range from 44% to 81%.

Average % Positive Response by Dimension

79%

70%

67%

60%

60%

57%

56%

53%

52%

47%

42%

40%

1.Teamwork within

Wards/Departments

3.Organisational

Learning - Cont inuous

Improvement

2.Supervisor/M anager

Expectat ions & Act ions

7.Communicat ion

Openness

8.Frequency of Incidents

Reported

9.Teamwork Across

Wards/Departments

6.Feedback &

Communication about

Error

5.Overall Percept ions of

Pat ient Safety

4.M anagement Support

for Pat ient Safety

12.Non Punit ive

Response to Error

11.Handoffs & Transit ions

10.Staff ing

Dimension 13 - Overall Grade on Patient Safety

65% of respondents graded patient safety on their wards/departments positively (as ‘Excellent’ or ‘Very

Good’) and 7% graded it negatively (as ‘Poor’ or ‘Failing’). The AHRQ equivalents were 76% and 5%

respectively.

Dimension 14 - Number of Events Reported

67% of respondents had completed and submitted an incident report within the past year. The equivalent

for US hospitals is 44% (AHRQ).


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1.0 Purpose and Use of this Report This Composite Results and Comparative Statistics Report provides:

• Composite survey results for all participating hospitals;

• Comparative statistics to enable each hospital to compare its results with those of other hospitals;

• Assistance for hospitals in internal assessment and in their learning of the patient safety

improvement process;

• Assistance for hospitals in identifying their areas of strengths and areas for improvement in

patient safety culture.

2.0 Introduction

Quality and safety has been a major focus in healthcare over the last ten years and internationally

significant efforts have been made to incorporate this as an integral part of all health systems. How health

care staff feel about patient safety at their hospital is an important part of assessing and changing the

culture within the organisation (Nieva, V.F., Sorra, J. 2003). Without understanding the culture within an

organisation, across all staff groups, and at every level of the organisation, it is difficult to improve systems

and ensure that robust quality and patient safety processes are implemented effectively.

A significant review of the available international ‘patient safety culture survey tools’ were explored and

surveys applicable to many health service areas were considered. The multitude of available survey tools in

itself indicates the lack of synergy within healthcare safety culture improvement, as no one tool has

transpired to be the very best. It was agreed by the pilot project group that the survey that best met the

needs within Irish healthcare was the ‘Agency for Healthcare Research and Patient Safety Culture Surveys’

(2004). This was supported by Halligan and Zecevic (2011), who reviewed 12 different survey tools, of

which the following four were the most commonly cited: the ‘Agency for Healthcare Research and Quality

(AHRQ)’s Hospital Survey on Patient Safety Culture (2003)’; ‘Safety Attitudes Questionnaire (2003)’;

‘Patient Safety Climate in Healthcare Organisations Survey (2007)’; ‘Modified Stanford Patient Safety

Culture Survey Instrument (2009)’. The ‘Agency for Healthcare Research and Quality (AHRQ)’s Hospital

Survey on Patient Safety Culture’ was adapted to the Irish healthcare setting, through minor changes in

terminology, and with the addition of specific questions on ‘Clinical Governance Development’ and ‘Open

Disclosure’. The inclusion of Clinical Governance questions were drawn from the New Zealand Clinical

Governance Development Index (CGDI, 2011) and the Clinical Governance Development Programme

(HSE, 2012). The ‘Open Disclosure’ questions were obtained from the ‘Open Disclosure’ project,

established in 2010.


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In 2012, the Quality and Patient Safety Directorate now the Quality Improvement Division (QID) in

collaboration with the Regional Managers for Quality and Patient Safety, piloted the ‘National Patient Safety

Culture Survey for Staff in Acute Hospitals’ in five hospitals. Following this pilot, the tool was further refined

and the survey was rolled out as a national project in 2013. In order to facilitate hospitals as much as

possible, it was necessary to divide the national project up into five phases which commenced in June 2013

and continued through to March 2014.

The purpose of undertaking such a survey is to assess and understand the culture of all staff within

organisations; to raise awareness of the many areas of quality and patient safety that need to be

considered within an organisation; to give organisations information of their staff perceptions of patient

safety issues, which in turn enables the organisation to focus on areas that need to be considered for

improvement. Undertaking an exercise of assessing the culture within the organisation also gives staff an

opportunity to openly express their views, thus influencing the specific areas for which the hospital may

subsequently decide to develop quality improvement plans. The survey will also enable an organisation to

assess how existing processes and systems pertaining to patient safety have been implemented, and

evaluate their effectiveness from a staff viewpoint. By conducting the survey there is generally more

communication within the organisation around the topics contained in the survey and this in turn results in

greater awareness amongst staff for all aspects of quality and patient safety.

The QID was also keen to assist hospitals in meeting the National Standards for Safer Better Healthcare

(HIQA 2012), and by assessing the culture within their organisations, this would enable hospitals to

incorporate the findings of the survey into any quality improvement plans being developed to meet the

requirements of the National Standards for Safer Better Healthcare.


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3.0 Survey Administration

The national roll-out of the ‘National Patient Safety Culture Survey for Staff in Acute Hospitals’ commenced

in June 2013. As with the pilot in 2012, the survey was open to all hospital staff with both electronic and

paper based survey tools available for use. In order to facilitate hospitals as much as possible, it was

necessary to divide the national project up into five phases which continued right through to the end of

March 2014, Table 1. Two hospitals are excluded from the table - one agreed to participate but no

responses were received from it and the other one refused to facilitate the survey and did not participate at

all. A total of 43 hospitals participated in the survey.

Table 1: Survey Period and Numbers of Participating Hospitals in each Phase

Phase

Survey Period

Number of

Participating

Hospitals

Pilot Beginning of June 2012 to End of July 2012 5

Phase 1 End of June 2013 to End of August 2013 18

Phase 2 Beginning of September 2013 to End of October 2013 9

Phase 3 End September 2013 to End of November 2013 5

Phase 4 End of October 2013 to Beginning of December 2013 3

Phase 5 Beginning of February 2014 to End of March 2014 3

Data from 41 participating hospitals and 4,700 respondents were merged into one composite database and

analysed. In line with an AHRQ criterion, two hospitals with fewer than 10 respondents were excluded.

Table 2 presents the average and range across these 41 hospitals and 4,700 respondents.

Table 2: Average and Range of Responses Across Hospitals

Average Minimum Maximum

Number of Respondents per Hospital 115 12 523

Hospital Response Rate (%) 13 1 39

The majority of hospitals, 29, provided their staff with the option of completing the questionnaire using

either the paper or the electronic version of the survey tool, Table 3. The average response rates for the

‘Paper Only’ and ‘Either’ hospitals were on a par and significantly higher than the equivalent rate for ‘Web

Only’ hospitals.


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Table 3: Numbers and Percentages of Hospitals and Respondents by Survey Tool

Average Hospital

Response Rate

Survey Tool N % N % %

Paper Only 9 22 937 20 14

Web Only 3 7 223 5 3

Either 29 71 3,540 75 14

Total 41 100 4,700 100 13

Hospitals Respondents


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4.0 Respondent Characteristics

The main characteristics of the 4,700 database respondents were:

• 51% were nurses/midwives;

• 80% had direct interaction with patients;

• 30% had been working in their current wards/departments for 1-5 years and another 30%

for 6-10 years; and

• 77% worked 20-39 hours per week.

Tables 4 to 7 provide detailed breakdowns for the respondent characteristic questions that were applicable

to all hospitals.

Table 4: Numbers and Percentages of Respondents and Staff Census Headcount by Staff Position

Staff Position * N % N %

Medical/Dental 300 7 6,373 13

Nursing/Midwifery 2,326 51 20,934 42

Health & Social Care Professionals 764 17 5,774 12

General Support Staff 376 8 5,679 11

Management/Administration 641 14 7,376 15

Other Patient & Client Care 134 3 3,634 7

TOTAL 4,541 100 49,770 100

Missing Values 159

Overall Total 4,700

Staff Census Headcount**Respondents

* This question was itemised as Q16 for Single and Group Hospitals and as Q14 for Pilot Hospitals.

** Source: HR Management Information as appropriate to the survey months.

Table 5: Numbers and Percentages of Respondents by Direct Interaction with Patients

Direct Interaction with Patients * N %

Yes 3,648 80

No 909 20

TOTAL 4,557 100

Missing Values 143

Overall Total 4,700

Respondents



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Table 6: Numbers and Percentages of Respondents by Years Worked in Current Ward/Department

Years Worked in Current Ward/Department * N %

Less than 1 year 442 10

1 - 5 years 1,376 30

6 - 10 years 1,372 30

11 - 15 years 882 19

16 - 20 years 253 6

21 years or more 239 5

TOTAL 4,564 100

Missing Values 136

Overall Total 4,700

Respondents


Table 7: Numbers and Percentages of Respondents by Hours Worked per Week

Hours Worked per Week * N %

Less than 20 hours 217 5

20 - 39 hours 3,555 77

40 - 59 hours 694 15

60 - 79 hours 108 2

80 hours or more 15 0

TOTAL 4,589 100

Missing Values 111

Overall Total 4,700

Respondents


The other respondent characteristics questions varied, depending on whether the hospital was part of a

hospital group or not or was a pilot hospital, and their breakdowns are provided in Appendix B.


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5.0 Composite Results

This section provides results from analysis of the composite database

for twelve Patient Safety Culture dimensions with multiple questions:

1. Teamwork within Wards/Departments (4 questions)

2. Supervisor/manager Expectations & Actions Promoting Patient Safety (4 questions)

3. Organisational Learning – Continuous Improvement (3 questions)

4. Hospital Management Support for Patient Safety (3 questions)

5. Overall Perceptions of Patient Safety (4 questions)

6. Feedback and Communications about Error (3 questions)

7. Communication Openness (3 questions)

8. Frequency of Incidents Reported (3 questions)

9. Teamwork Across Hospital Wards/Departments (4 questions)

10. Staffing (4 questions)

11. Hospital Handoffs and Transitions (4 questions)

12. Non Punitive Response to Error (3 questions);

for two further Patient Safety Culture dimensions with a single question.

13. Overall Grade for Patient Safety (1 question)

14. Number of Events Reported (1question);

for Clinical Governance Development; and

for Open Disclosure.

Composite results are reported as averages of the 41 individual hospitals’ results so that equal weight is

given to each hospital’s results. This methodology is necessary for the purposes of this survey as the

patient safety culture pertains collectively to a hospital, not to individual respondents.


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5.1 Main Findings

Areas of Strength (Dimensions 1-12) : The three areas of strength i.e. the dimensions with the highest

percent positive responses were:

Teamwork Within Units/Departments (Staff support each other, treat each other with respect and work

together as a team)

79%

Organisational Learning – Continuous Improvement (There is a learning culture in which mistakes

lead to positive changes and changes are evaluated for effectiveness)

70%

Supervisor/Manager Expectations & Actions Promoting Patient Safety (Supervisor/Manager

consider staff suggestions for improving patient safety, praise staff for following patient safety procedures, and do not

overlook patient safety problems)

67%

The same three areas of strengths across 653 hospitals in the US were identified in the AHRQ’s User

Comparative Database Report for 2014.

Areas with Potential for Improvement (Dimensions 1-12): The three areas with the most potential for

improvement i.e. the three dimensions with the lowest percent positive responses were:

Non Punitive Response to Error (Staff feel that their mistakes and event reports are not held against them)

47%

Handoffs and Transitions (Important patient care information is transferred across hospital units/departments

and during shift changes)

42%

Staffing (There are enough staff to handle the workload and work hours are appropriate to provide the best care for

patients)

40%

The AHRQ’s User Comparative Database Report for 2014 identifies the same three areas with the most

potential for improvement.

Note: % Calculations exclude missing values.


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Clinical Governance is defined as ‘a framework through which healthcare teams are accountable for the

quality, safety and satisfaction of patients in the care they deliver.’ (Gauld et al. 2011).

Clinical Governance Development Index Score: This was determined from an additional series of

questions, included with the AHRQ Survey, and its average across hospitals was:

Clinical Governance Development Index Score (measures the extent to which a healthcare organisation is working to develop clinical governance)

47%

This is on a par with baseline results from the 2011 New Zealand study that developed the index.



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5.2 Dimensions

Figure 1 illustrates the results for the first twelve multi-question dimensions (in descending order) with

AHRQ comparisons and is followed by the percent positive responses to the other two single-question

dimensions.

Figure 1: Average % Positive Response by Dimension

with AHRQ comparisons

79%

70%

67%

60%

60%

57%

56%

53%

52%

47%

42%

40%

81%

73%

76%

62%

66%

61%

67%

66%

72%

44%

47%

55%

1.Teamwo rk wit hin

W ards/ D ep art ment s

3 .Organisat ional

Learning - C ont inuo us

Impro vement

2 .Supervisor/ M anag er

Expect at ions & A ct ions

7.Co mmunicat ion

Openness

8 .Freq uency o f

Incident s R epo rt ed

9 .Teamwo rk Acro ss

W ards/ D ep art ment s

6 .F eed back &

C o mmunicat ion ab out

Erro r

5.Overal l Percep t io ns

of Pat ient Saf et y

4 .M anagement Sup port

f o r Pat ient Saf et y

12 .No n Punit ive

Respo nse t o Error

11.Hand of f s &

Transit io ns

10 .St af f ing

PSCS AHRQ

Dimension 13 - Overall Grade on Patient Safety

65% of respondents consider patient safety on their wards/departments as excellent (19%) or very good

(46%) (Figure 14). The AHRQ reported a combined 76% with 33% as excellent and 43% as very good.

Dimension 14 - Number of Events Reported

67% of respondents had completed and submitted an incident report within the past year (Figure 15). The

AHRQ equivalent was 44%.



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The following series of figures, Figures 2 to 13, provides % Positive, % Neutral and % Negative responses

for each dimension and for each question within a dimension. The % Positive category is determined by

‘Agree’, ‘Strongly Agree’, ‘Most of the Time’ and ‘Always’ responses to positively worded questions and by

’Disagree’, ‘Strongly Disagree’, ‘Never’ and ‘Rarely’ responses to reverse worded questions (as indicated

by the letter ‘R’). The converse of this determines the % Negative category while ‘Neither’ and

‘Sometimes’ responses fall into the % Neutral category. Equal weight is given to each question within a

dimension so the % responses for the dimension as a whole are calculated as the average of the

questions’ responses.

Dimension 1 Teamwork within Wards/Departments

Description Staff support each other, treat each other with respect, and work together as a team

Figure 2: % Responses to Teamwork within Wards/Departments

Dimension and Questions

79

87

83

81

63

9

6

8

8

13

13

8

9

11

24

DIMENSION

1. People support one another in this

ward/department (4a)

2. When a lot of work needs to be done quickly,

we work together as a team to get the work

3. In this ward/department people treat each

other with respect (4d)

4. When one area in this ward/department gets

really busy, others help out (4k)

% Positive % Neutral % Negative

Note: % Calculations exclude missing values and may not sum to 100% due to rounding.


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Dimension 2 Supervisor/Manager Expectations and Actions Promoting Patient Safety

Description Supervisor/Manager consider staff suggestions for improving patient safety, praise staff for

following patient safety procedures, and do not overlook patient safety problems.

Figure 3: % Responses to Supervisor/Manager Expectations and Actions

Promoting Patient Safety Dimension and Questions

67

60

69

64

74

16

18

14

19

14

17

22

16

17

12

DIM ENSION

1. M y line manager says a good word when he/she sees a job

done according to established patient safety procedures (5a)

2. M y line manager seriously considers staff suggestions for

improving patient safety (5b)

R3. Whenever pressure builds up, my line manager wants us to

work faster, even if it means taking shortcuts (5c)

R 4. M y line manager overlooks patient safety problems that

happen over and over (5d)


1

Dimension 3 Organisational Learning - Continuous Improvement

Description Mistakes have led to positive changes and changes are evaluated for effectiveness

Figure 4: % Responses to Organisational Learning - Continuous

Improvement Dimension and Questions

84

66

60

17

10

21

21

13

6

13

19

70DIMENSION

1. We are actively doing things to improve patient

safety (4f)

2. Mistakes have led to positive changes here (4i)

3. After we make changes to improve patient

safety we evaluate their effectiveness (4m)




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Dimension 4 Management Support for Patient Safety Description Hospital management provides a work climate that promotes patient safety and shows that

patient safety is a top priority

Figure 5: % Responses to Management Support for Patient Safety


65

53

39

17

14

21

16

30

21

26

45

52DIMENSION

1. Hospital management provides a work

environment that promotes patient safety (9a)

2. The actions of hospital management show

that patient safety is a top priority (9h)

R 3. Hospital management seems interested in

patient safety only after an incident happens (9i)


2

Dimension 5 Overall Perceptions of Patient Safety

Description Procedures and systems are good at preventing errors and there is a lack of patient safety

problems

Figure 6: % Responses to Overall Perceptions of Patient Safety


53

54

68

49

42

17

16

18

15

18

30

30

14

35

40

DIMENSION

1. Patient safety is never sacrificed to get more work

done (4o)

2. Our procedures and systems are good at preventing

errors from happening (4r)

R 3. It is just by chance that more serious mistakes

don't happen around here (4j)

R 4. We have patient safety problems in this

ward/department (4q)




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Dimension 6 Feedback and Communication about Error

Description Staff are informed about errors that happen, given feedback about changes implemented,

and discuss ways to prevent errors

Figure 7: % Responses to Feedback and Communication about Error


56

39

64

66

24

29

23

21

19

32

13

13

DIMENSION

1. We are given feedback about changes put

into place based on incident reports (6a)

2. We are informed about errors that happen in

this ward/department (6c)

3. In this ward/department, we discuss ways to

prevent errors from happening again (6e)


3

Dimension 7 Communication Openness

Description Staff freely speak up if they see something that may negatively affect a patient and feel

free to question those with more authority

Figure 8: % Responses to Communication Openness


60

73

46

62

26

20

29

28

14

7

10

25

DIMENSION

1. Staff will freely speak up if they see something

that may negatively affect patient care (6b)

2. Staff feel free to question the decisions or

actions of those with more authority (6d)

R 3. Staff are afraid to ask questions when

something does not seem right (6f)




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Dimension 8 Frequency of Incidents Reported

Description 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

Figure 9: % Responses to Frequency of Incidents Reported


60

53

53

74

21

24

23

17

19

23

24

9

DIMENSION

1. When a mistake is made, but is caught and

corrected before affecting the patient, how often

is this reported? (7a)

2. When a mistake is made, but has no potential

to harm the patient, how often is this reported?

(7b)

3. When a mistake is made that could harm the

patient, but does not, how often is this reported?

(7c)


Dimension 9 Teamwork Across Wards/Departments

Description Hospital wards/departments cooperate and coordinate with one another to provide the best

care for patients

Figure 10: % Responses to Teamwork Across Wards/Departments


57

59

69

38

61

21

22

20

21

21

22

18

11

41

18

DIMENSION

1. There is good cooperation among hospital

wards/departments that need to work together

(9d)

2. Hospital wards/departments work well

together to provide the best care for patients (9j)

R3. Hospital wards/departments do not

coordinate well with each other (9b)

R4. It is often unpleasant to work with staff from

other hospital wards/departments (9f)




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Dimension 10 Staffing

Description There are enough staff to handle the workload and work hours are appropriate to provide

the best care for patients

Figure 11: % Responses to Staffing


40

26

40

60

32

18

9

24

23

16

42

65

36

17

51

DIMENSION

1. We have enough staff to handle the workload (4b)

R 2. Staff in this ward/department work longer hours

than is best for patient care (4e)

R 3. We use more agency/temporary staff than is

best for patient care (4g)

R 4. We work in 'crisis mode' trying to do too much,

too quickly (4n)


Dimension 11 Handoffs and Transitions

Description Important patient care information is transferred across hospital wards/departments and

during shift changes

Figure 12: % Responses to Handoffs and Transitions


42

36

51

35

45

27

25

26

22

34

32

40

23

42

21

DIMENSION

R 1. Things 'fall between the cracks' when

transferring patients from one ward/department

to another (9c)

R 2. Important patient care information is often

lost during shift changes (9e)

R 3. Problems often occur in the exchange of

information across hospital wards/departments

(9g)

R 4. Shift changes are problematic for patients in

this hospital (9k)




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Dimension 12 Non Punitive Response to Error

Description Staff feel that their mistakes and incident reports are not held against them and that

mistakes are not kept in their personnel file

Figure 13: % Responses to Non Punitive Response to Error


47

49

52

42

21

22

16

24

32

30

32

34

DIMENSION

R 1. Staff feel like their mistakes are held against

them (4h)

R 2. When an incident is reported, it feels like

the person is being reported, not the problem

(4l)

R 3. Staff worry that mistakes they make are kept

in their personnel file (4p)




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Dimension 13 - Overall Grade of Patient Safety (Question 8)

Nearly two-thirds of respondents, 65%, provided a positive response (those responses that were

considered ‘excellent’ or ‘very good’) to the question on patient safety for their ward/department (Figure 14).

Figure 14: % Responses to Overall Grade on Patient Safety

19

46

28

61

0

20

40

60

80

100

Excellent Very good Acceptable Poor Failing

Grade

%



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Dimension 14 - Number of Events Reported (Question 10)

Just over two-thirds of respondents, 67%, had completed and submitted at least one incident report within

the past year (Figure 15).4


Figure 15: % Responses to Number of Events Reported

33 29

18

10 10

0

20

40

60

80

100

None 1 - 2 3 - 5 6 - 10 11+

Number of Reports

%


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5.3 Clinical Governance Development

One adaptation of the AHRQ survey tool for the Irish context was to include questions to determine staff

perceptions in relation to Clinical Governance Development.

Clinical Governance is:

‘a framework through which healthcare teams are accountable for the quality, safety and

satisfaction of patients in the care they deliver.’

In determining clinical governance development questions to be included in the survey, questions were

drawn from the New Zealand Clinical Governance Development Index (CGDI, 2011). This incorporated

clinical governance structures; how quality and safety are incorporated into clinical governance;

responsibility and accountability; and the involvement of patients and families. Two additional questions

were also included pertaining to whether staff had received education or training in relation to clinical

governance, and also whether patients and families are involved in improving quality and safety.

Table 8: % Reponses to Clinical Governance Development Questions

Don't

Yes No Know

Question 11 (Q17 for Pilot Hospitals) % % %

11a. Have you had any clinical governance education or training? 40 46 14

11b. To your knowledge, has your hospital established a clinical governance

structure that ensures a partnership between clinicians and management?49 9 42

Great Some No Don't

Extent Extent Extent Know

Question 12 (Q18 for Pilot Hospitals) % % % %

12a. To what extent do you believe that quality and safety is the goal of every clinical

initiative in your hospital? 40 50 3 7

12b. To what extent do you believe that quality and safety is the goal of every

management/administrative initiative in your hospital?33 54 6 8

12c. To what extent are clinicians in your hospital involved as full active participants

in all governance decision making processes?17 49 7 26

12d. To what extent are clinicians in your hospital involved in a partnership with

management with shared decision making, responsibility and accountability?17 48 8 27

12e. To what extent has your hospital sought to identify clinical leaders? 20 36 8 35

12f. To what extent has your hospital sought to give responsibility to your team for

clinical service decision making in your clinical area?17 43 14 27

12g. To what extent do staff in this hospital involve patients and families in improving

quality and patient safety?15 46 15 23



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Each hospital’s CGDI score is based on the combined responses to seven questions, Q11b and Q12a-f,

per individual respondent (see Appendix C for further information on how the score is calculated). It gives

an indication of staff perception of the extent of the clinical governance development for the hospital. Of

note is that the percentages of negative responses (‘No Extent’) are lower than the percentages of positive

responses (‘Great Extent’, ‘Some Extent’) for Q 12a-f. The composite score for database hospitals was

47%.


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5.4 Open Disclosure

Within the survey additional questions were presented in relation to ‘Open Disclosure’ in order to determine

the perceptions of staff to ‘Open Disclosure’.

Open disclosure is

’ An open consistent approach to communicating with patients when things go wrong in healthcare.

This includes expressing regret for what has happened, keeping the patient informed, providing

feedback on investigations and the steps taken to prevent a recurrence of the adverse event’.

(Australian Commission on Safety and Quality in Health care, 2008)

Four specific questions were included in the survey tool and the composite % positive responses are

shown in Figure 16. Positive responses are defined as ‘Most of the Time’ or ‘Always’ for Question 7d and

as ‘Strongly Agree’ or ‘Agree’ for Questions 9l to 9n.

Figure 16: % Positive Responses to Open Disclosure Questions *

94

51

43

48

0 20 40 60 80 100

7d. When a mistake is made that caused harm to a

patient how often is this reported?

9l. Hospital management and clinicians support and

engage in open disclosure w ith patients/their support

person following an adverse event

9m. Following an adverse event staff are supported by

the organisation in relation to their needs

9n. Hospital management support and promote a

culture of open disclosure/communication within the

organisation

%

* The five Pilot Hospitals are excluded as their open disclosure questions are not compatible with those re-configured for the national roll-out.



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In considering the ‘Open Disclosure’ responses it is important to take cognisance of the following patient

safety dimensions that were presented earlier in the report:

Management Support for Patient Safety

Feedback and Communication about Error

Communication Openness

Non Punitive Responses to Error

Overall Grade on Patient Safety


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6.0 COMPARATIVE STATISTICS

The tables in this section are provided so that each hospital can compare its results with the database

average and it can position its results relative to the distribution of results for all database hospitals. These

are only relative comparisons though, so even if a hospital’s result is well positioned there may still be room

for improvement in a particular area within the hospital. For that reason, these comparative statistics should

be used to supplement hospitals’ own efforts toward identifying areas of strength and areas on which to

focus improvement efforts.

6.1 Description and Interpretation

Rather than establishing statistically significant results which may or may not be meaningful, the AHRQ

recommends the use of a 5 percentage points difference as a rule of thumb when comparing an

individual hospital’s result (score) with the database’s average (mean). Thus, if an individual hospital’s

score is 5 percentage points greater or less than the database average then that hospital can consider itself

to be ‘better’ or ‘worse’ than the database average. If it is not, then the hospital should consider itself as

being on a par with the average.

Percentiles are used to indicate the distribution of scores across all database hospitals thereby enabling

an individual hospital to position itself within that distribution. Hospital scores were ranked from lowest to

highest and then they were divided into 100ths i.e. percentiles. Consequently, a specific percentile value

shows the percentage of hospitals that scored at or below that specific value. For example, the 10th

percentile is the score where 10% of hospitals scored the same or lower, the 25th percentile is the score

where 25% of hospitals scored the same or lower etc.


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Only the more commonly used percentiles are presented in this report. Definitions and interpretations of the

reported comparative statistics are provided in Table 9a.

Table 9a: Description and Interpretation of Comparative Statistics

Statistic Interpretation

Average Mean of hospitals’ scores

Minimum Lowest hospital score

10th

percentile

10% of hospitals scored the same or lower (representing the lowest scoring hospitals) or. 90% of hospitals scored higher

25th percentile

25% of hospitals scored the same or lower (representing the lower scoring hospitals) or. 75% of hospitals scored higher

50th percentile (median) The median is the middle value in the distribution of

scores so 50% of hospitals scored the same or lower and 50% scored higher

75th percentile

25% of hospitals scored higher (representing the higher scoring hospitals) or 75% of hospitals scored the same or lower

90th percentile

10% of hospitals scored higher (representing the highest scoring hospitals) or 90% of hospitals scored the same or lower

Maximum Highest hospital score

Table 9b is provided as a data source for examples of how to make valid hospital comparisons by

interpreting the statistics correctly. It is recommended that an individual hospital would

(i) compare its score with the database average by using the 5 percentage points rule of thumb; and

(ii) position its score relative to the percentile scores provided.

Example 1): i) A comparison of an individual hospital’s average % positive response of 86% for the

Teamwork within Wards/Departments dimension with the database average of 79% would mean that it is

better than the database average as the former is more than 5 percentage points higher than the latter. (ii)

Furthermore, and as highlighted in red in Table 9b, an examination of the percentile scores indicates that

the individual hospital is among the highest scoring hospitals (the top 10% of hospitals) as its 86% result

exceeds the 90th percentile score of 85%.

Example 2) a) A hospital with a 77% average could consider itself as being on a par with the database

average of 79% as the 5 percentage points criterion is not satisfied. b) Interpretation of the distribution of

scores across hospitals, and as highlighted in blue in Table 9b, locates the individual hospital in the lower

half of the distribution (less than the 50th percentile) but it’s better than the lower scoring hospitals (greater

than the 25th percentile).


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Table 9b: Interpretation of Comparative Statistics for Examples

Minimum 10th

%tile

25th

%tile

75th

%tile

90th

%tile

79% 67% 69% 75% 79% 82% 85% 92%

Average

Percentiles

Maximum50th

%tile

6.2 Comparative Tables

Tables 10-15 provide comparative statistics for the percentage positive responses or scores for each

dimension; each dimension question; the CDGI score; and each Open Disclosure question.

Table 10: Comparative Statistics for % Positive Responses to Dimensions 1-12

Minimum 10th

%tile

25th

%tile

50th

%tile

75th

%tile

90th

%tile

Maximun

1.Teamwork within Wards/Departments 79% 67% 69% 75% 79% 82% 85% 92%

2.Supervisor/Manager Expectations & Actions 67% 33% 58% 62% 67% 72% 77% 82%

3.Organisational Learning - Continuous Improvement 70% 57% 59% 64% 70% 76% 79% 92%

4.Management Support for Patient Safety 52% 28% 37% 42% 50% 61% 72% 77%

5.Overall Perceptions of Patient Safety 53% 38% 44% 46% 51% 61% 64% 79%

6.Feedback & Communication about Error 56% 37% 46% 51% 55% 61% 70% 79%

7.Communication Openness 60% 46% 51% 55% 60% 65% 70% 76%

8.Frequency of Incidents Reported 60% 47% 51% 56% 60% 64% 67% 86%

9.Teamwork Across Wards/Departments 57% 34% 43% 48% 56% 65% 73% 77%

10.Staffing 40% 24% 30% 32% 38% 46% 50% 60%

11.Handoffs & Transitions 42% 19% 25% 33% 41% 49% 61% 76%

12.Non Punitive Response to Error 47% 30% 38% 42% 46% 53% 60% 72%

Average

Percentiles

Dimension


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Table 11: Comparative Statistics for % Positive Responses to Dimensions 1-12 Questions

DIMENSION & QUESTIONMinimum 10th

%tile

25th

%tile

50th

%tile

75th

%tile

90th

%tile

Maximum

1.Teamwork within Wards/Departments

4a. People support one another in this ward/department87% 73% 80% 83% 86% 92% 95% 100%

4c. When a lot of work needs to be done quickly, we work together as a

team to get the work done 83% 64% 77% 80% 82% 88% 91% 94%

4d. In this ward/department, people treat each other with respect81% 61% 71% 75% 82% 88% 93% 98%

4k. When one area in this ward/department gets really busy, others

help out 63% 42% 54% 56% 63% 69% 74% 86%

2. Supervisor/Manager Expectations & Actions Promoting Patient Safety

5a. My line manager says a good word when he/she sees a job done

according to established patient safety procedures 60% 43% 47% 53% 62% 68% 71% 75%

5b. My line manager seriously considers staff suggestions for improving

patient safety 69% 36% 60% 64% 69% 76% 81% 85%

5c. Whenever pressure builds up, my line manager wants us to work

faster, even if it means taking shortcuts (R) 64% 36% 53% 58% 66% 69% 78% 84%

5d. My line manager overlooks patient safety problems that happen

over and over (R) 74% 15% 68% 70% 75% 79% 82% 92%

3.Organisational Learning - Continuous Improvement

4f. We are actively doing things to improve patient safety84% 65% 76% 79% 84% 88% 93% 100%

4i. Mistakes have led to positive changes here66% 52% 57% 62% 64% 72% 76% 87%

4m. After we make changes to improve patient safety, we evaluate their

effectiveness 60% 16% 46% 50% 60% 67% 79% 100%

4.Management Support for Patient Safety

9a. Hospital management provides a work environment that promotes

patient safety 65% 31% 47% 55% 64% 76% 86% 91%

9h. The actions of hospital management show that patient safety is a

top priority 53% 25% 36% 43% 50% 63% 73% 93%

9i. Hospital management seems interested in patient safety only after

an incident happens (R) 39% 14% 25% 30% 38% 50% 58% 63%

5.Overall Perceptions of Patient Safety

4o. Patient safety is never sacrificed to get more work done54% 34% 39% 46% 52% 58% 69% 76%

4r. Our procedures and systems are good at preventing errors from

happening 68% 48% 59% 60% 67% 73% 81% 92%

4j. It is just by chance that more serious mistakes don't happen around

here (R) 49% 19% 36% 40% 46% 60% 63% 78%

4q. We have patient safety problems in this ward/department (R)42% 18% 31% 34% 37% 48% 57% 75%

6.Feedback & Communication about Error

6a. We are given feedback about changes put into place based on

incident reports 39% 17% 25% 33% 37% 45% 56% 67%

6c. We are informed about errors that happen in this ward/department64% 39% 51% 56% 63% 69% 78% 93%

6e. In this ward/department, we discuss ways to prevent errors from

happening again 66% 46% 56% 60% 66% 72% 81% 86%

Average

Percentiles


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DIMENSION & QUESTIONMinimum 10th

%tile

25th

%tile

50th

%tile

75th

%tile

90th

%tile

Maximum

7.Communication Openness

6b. Staff will freely speak up if they see something that may negatively

affect patient care 73% 58% 60% 67% 72% 79% 83% 93%

6d. Staff feel free to question the decisions or actions of those with

more authority 46% 31% 35% 41% 46% 53% 57% 67%

6f. Staff are afraid to ask questions when something does not seem

right (R) 62% 33% 52% 56% 62% 67% 70% 78%

8.Frequency of Incidents Reported

7a. When a mistake is made, but is caught and corrected before

affecting the patient, how often is this reported? 53% 34% 43% 46% 53% 58% 63% 83%

7b. When a mistake is made, but has no potential to harm the patient,

how often is this reported? 53% 39% 43% 48% 53% 57% 65% 75%

7c. When a mistake is made that could harm the patient, but does not,

how often is this reported? 74% 63% 66% 70% 72% 76% 83% 100%

9.Teamwork Across Wards/Departments

9d. There is good cooperation among hospital wards/departments that

need to work together 59% 34% 43% 48% 59% 69% 78% 93%

9j. Hospital wards/departments work well together to provide the best

care for patients 69% 41% 55% 60% 68% 78% 83% 93%

9b. Hospital wards/departments do not coordinate well with each other

(R) 38% 13% 20% 27% 39% 48% 57% 65%

9f. It is often unpleasant to work with staff from other hospital

wards/departments (R) 61% 42% 44% 56% 60% 70% 76% 78%

10.Staffing

4b. We have enough staff to handle the workload26% 7% 14% 18% 23% 34% 42% 47%

4e. Staff in this ward/department work longer hours than is best for

patient care (R) 40% 21% 28% 30% 39% 46% 52% 67%

4g. We use more agency/temporary staff than is best for patient care

(R) 60% 36% 43% 52% 63% 68% 73% 89%

4n. We work in "crisis mode" trying to do too much, too quickly (R)32% 14% 19% 24% 30% 39% 50% 80%

11.Handoffs & Transitions

9c. Things "fall between the cracks" when transferring patients from

one ward/department to another (R) 36% 12% 17% 24% 36% 43% 57% 78%

9e. Important patient care information is often lost during shift changes

(R) 51% 30% 35% 43% 47% 58% 69% 88%

9g. Problems often occur in the exchange of information across

hospital wards/departments (R) 35% 6% 16% 26% 34% 44% 55% 69%

9k. Shift changes are problematic for patients in this hospital (R)45% 13% 28% 34% 43% 52% 68% 77%

12.Non Punitive Response to Error

4h. Staff feel like their mistakes are held against them (R)49% 30% 36% 43% 48% 53% 61% 80%

4l. When an incident is reported, it feels like the person is being

reported, not the problem (R) 52% 10% 40% 45% 48% 59% 69% 100%

4p. Staff worry that mistakes they make are kept in their personnel file

(R) 42% 26% 31% 37% 40% 44% 55% 64%

Average

Percentiles

Table 12: Comparative Statistics for % Positive Response to Dimension 13 - Overall Grade

on Patient Safety

Minimum 10th

%tile

25th

%tile

50th

%tile

75th

%tile

90th

%tile

Maximum

65% 51% 52% 57% 64% 72% 77% 91%

Average

Percentiles

Table 13: Comparative Statistics for % Positive Response to Dimension 14 – Number of

Events Reported

Minimum 10th

%tile

25th

%tile

50th

%tile

75th

%tile

90th

%tile

Maximum

67% 47% 56% 59% 66% 74% 80% 92%

Average

Percentiles


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Table 14: Comparative Statistics for Clinical Governance Development Index Score

Minimum 10th

%tile

25th

%tile

50th

%tile

75th

%tile

90th

%tile

Maximum

47% 35% 40% 43% 46% 49% 55% 63%

Average

Percentiles

Table 15: Comparative Statistics for % Positive Responses to Open Disclosure Questions *

Minimum 10th

%tile

25th

%tile

50th

%tile

75th

%tile

90th

%tile

Maximum

7d. When a mistake is made that caused harm to a

patient how often is this reported?94% 80% 88% 91% 94% 97% 100% 100%

9l. Hospital management and clinicians support and

engage in open disclosure with patients/their support

person following an adverse event 51% 20% 33% 42% 48% 62% 70% 83%

9m. Following an adverse event staff are supported by

the organisation in relation to their needs43% 25% 27% 34% 38% 56% 61% 75%

9n. Hospital management support and promote a

culture of open disclosure/communication within the

organisation 48% 23% 33% 39% 47% 55% 67% 70%

Open Disclosure Question Average

Percentiles

* The five Pilot Hospitals are excluded from these average calculations as their open disclosure questions are not compatible with those re-configured for the national roll-out


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7.0 Action Planning for Improvement

In reviewing the responses to the survey the Quality and Patient Safety Division suggests that hospitals

review all the data in this report and discuss and share the results with staff within their organisations. In

reviewing the findings of this survey the results may assist hospitals in developing some of their quality

improvement plans to meet the requirements of the National Standards for Safer Better Healthcare. Where

processes, policies, guidelines and quality improvement initiatives are available, these should be reviewed,

and where appropriate quality improvement plans developed to support the implementation of these.

The delivery of survey results is not the end point in the survey process; it is just the beginning. Often, the

perceived failure of surveys to create lasting change is actually due to faulty or non-existent action

planning or survey follow-up.

Seven steps of action planning are provided to give hospitals guidance on the next steps to take to turn their

survey results into actual patient safety culture improvement:

1. Understand your survey results.

2. Communicate and discuss the survey results.

3. Develop focused action plans.

4. Communicate action plans and deliverables.

5. Implement action plans.

6. Track progress and evaluate impact.

7. Share what works.


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8.0 References

AHRQ (2012). Hospital Survey on Patient Safety Culture. Data Entry and Analysis Tool.

Gauld, R, et al (2011) The clinical governance development index: results from a New Zealand study

Halligan, M., Zecevic, A. (2011). Safety culture in healthcare: a review of concepts, dimensions, measures

and progress. Quality Safety in Healthcare 2011.

HIQA, (2012). National Standards for Safer Better Healthcare. Dublin: Health Information Quality Authority.

Macleod, D and Clarke, N. (2009). Engaging for success: enhancing performance through employee engagement. London, UK: Department for Business Innovation and Skills

National Health Service (NHS) Employers (2011). Engaging your staff: the NHS staff engagement resource. Supporting you to increase staff engagement in your organisation. Retrieved 9

th October 2012

from http://www.nhsemployers.org/EmploymentPolicyAndPractice/Staff-engagement-toolkit

Nieva, A.F, Sorra, J. (2003) Safety Culture assessment: a tool for improving patient safety in healthcare

organizations. Quality and Safety in Health Care.

Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013). Chaired by Robert Francis QC. London: The Stationary Office

Sorra J, Famolaro T, Yount ND, 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.

Sorra J.S, Nieva., V, F, Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract

No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Healthcare Research and

Quality. September 2004.


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9.0 List of Figures

Figure 1: Average % Positive Response by Dimension with AHRQ comparisons

Figure 2: % Responses to Teamwork within Wards/Departments

Figure 3: % Responses to Supervisor/Manager Expectations & Actions Promoting Patient

Safety

Figure 4: % Responses to Organisational Learning – Continuous Improvement

Figure 5: % Responses to Hospital Management Support for Patient Safety

Figure 6: % Responses to Overall Perceptions of Patient Safety

Figure 7: % Responses to Feedback and Communication about Error

Figure 8: % Responses to Communication Openness

Figure 9: % Responses to Frequency of Incidents Reported

Figure 10: % Responses to Teamwork across Wards/Departments

Figure 11: % Responses to Staffing

Figure 12: % Responses to Hospital Handoffs & Transitions

Figure 13: % Responses to Non Punitive Response to Error

Figure 14: % Responses to Overall Grade on Patient Safety

Figure 15: % Responses to Number of Events Reported

Figure 16: % Positive Responses to Open Disclosure Questions

10.0 List of Tables

Table 1: Survey Period and Numbers of Participating Hospitals in each Phase

Table 2: Average and Range of Responses Across Hospitals

Table 3: Numbers and Percentages of Hospitals and Respondents by Survey Tool

Table 4: Numbers and Percentages of Respondents and Staff Census Headcount by Staff Position

Table 5: Numbers and Percentages of Respondents by Direct Interaction with Patients

Table 6: Numbers and Percentages of Respondents by Years Worked in Current Ward/Department

Table 7: Numbers and Percentages of Respondents by Hours Worked per Week

Table 8: % Responses to Clinical Governance Development Questions

Table 9a: Description and Interpretation of Comparative Statistics

Table 9b: Interpretation of Comparative Statistics for Examples

Table 10: Comparative Statistics for % Positive Responses to Dimensions 1-12

Table 11: Comparative Statistics for % Positive Responses to Dimensions 1-12 Questions

Table 12: Comparative Statistics for % Positive Response to Dimension 13

Table 13: Comparative Statistics for % Positive Response to Dimension 14

Table 14: Comparative Statistics for Clinical Governance Development Index Score

Table 15: Comparative Statistics for % Positive Responses to Open Disclosure Questions


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11.0 List of Appendices

Appendix A: Adapted AHRQ Survey Tool for Individual hospitals and the Hospital Groups

Appendix B: Respondent Characteristics

Appendix C: Clinical Governance Development Index Score


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A review of available international ‘culture survey tools’ were explored and surveys applicable to many

health service areas were considered. It was agreed that the survey that best met the needs within Irish

healthcare was the survey tool developed by the ‘Agency for Healthcare Research’ (US). The Agency for

Healthcare Research ‘Hospital Survey on Patient Safety Culture’ (AHRQ 2004) was adapted to the Irish

healthcare setting, through minor changes in terminology, and with the addition of specific questions on

‘Clinical Governance Development’ and ‘Open Disclosure’, which are two initiatives currently being

developed and implemented. The inclusion of Clinical Governance questions were drawn from the New

Zealand Clinical Governance Development Index (CGDI, 2011) and the Clinical Governance Development

Programme (HSE, 2012). The ‘Open Disclosure’ questions were obtained from the ‘Open Disclosure’

project, established in 2010.

Appendix A: Adapted AHRQ Survey Tool


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Appendix A: Adapted AHRQ Survey Tool


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National Patient Safety Culture Survey for Staff in Acute Hospitals

Hospitals Group

Instructions

This survey asks for your opinions about patient safety issues, medical error, and adverse event reporting in your hospital and will take about 15 minutes to complete.

To mark your answer, just put an X in the box: X

If you are working in more than one organisation please respond for the hospital where you work the most hours (i.e. base hospital)

Please answer all questions. Please ensure you answer questions 1-3 in order that survey analysis may be completed.

DEFINITIONS The following definitions are from the revised HSE Incident Management Policy 2012 (draft)

Patient Safety - the avoidance and prevention of patient injuries or adverse events resulting from the processes of health care delivery (AHRQ).

Incident - an event or circumstance which could have, or did lead to unintended and/or unnecessary harm (WHO 2009 and DoH 2010) and includes adverse events and near misses. Incidents can be clinical or non-clinical. Incidents include complaints which are associated with harm that may be caused by acts or omissions on the part of the HSE and as such these complaints are service user reported incidents.

Adverse event - an incident which results in harm.

Near misses - an incident which could have resulted in harm, but did not either by chance or timely intervention.

Clinical Governance - the system through which healthcare teams are accountable for the quality, safety and satisfaction of patients in the care they deliver.

Clinical Leader - is a competent professional involved in providing direct and indirect clinical care, who enables oneself and influences others to improve.

Clinical Leadership - is about driving service improvement and the effective management of teams to provide excellence in patient care.

Clinicians - for the purpose of this survey 'clinicians' encompasses in its broadest context all clinical staff.

Open Disclosure - is 'an open, consistent approach to communicating with patients when things go wrong in healthcare. It includes expressing regret for what has happened, keeping the patient informed, providing feedback on any investigations and the steps taken to prevent a recurrence of the adverse event'. (The Australian Commission on Safety and Quality in Health Care).

'Sorra J.S., Nieva V.F. Hospital Survey on Patient Safety Culture. (Prepared by Westat, under Contract No. 290-96-0004). AHRQ Publication No. 04-0041. Rockville, MD: Agency for Health Research and Quality. September 2004. Adapted to the Irish Healthcare Setting by the Quality and Patient Safety Directorate, Health Service Executive, 2012.'


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SECTION H:

Clinical Governance Development

The benefit of clinical governance rests in improved patient experiences and better outcomes in terms of quality and safety.

Don't

11. Think about your service... Yes No Know

a. Have you had any clinical governance education or training? (please tick one)

1 2 3

b. To your knowledge, has your hospital established a clinical governance structure that ensures a partnership between clinicians and management? (please tick one)

1 2 3

12. Think about your service, read each question and indicate... A great Some No Don't

extent extent extent Know

a. To what extent do you believe that quality and safety is the goal of every clinical initiative in your hospital? (please tick one)

1 2 3 4

b. To what extent do you believe that quality and safety is the goal of every management/administrative initiative in your hospital? (please tick one)

c. To what extent are clinicians in your hospital involved as full active participants in all governance decision making processes? (please tick one)

d. To what extent are clinicians in your hospital involved in a partnership with

management with shared decision making, responsibility and accountability? (please tick one)

e. To what extent has your hospital sought to identify clinical leaders? (please tick one)

f. To what extent has your hospital sought to give responsibility to your team for clinical service decision making in your clinical area? (please tick one).

g. To what extent do staff in this hospital involve patients and families in improving quality and patient safety? (please tick one)

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

SECTION I: Background Information This information will help in the analysis of the survey results.

13.a How long have you worked in a Hospital Group?

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

13.b How long have you worked in the individual hospitals prior to the establishment of the Hospitals Group?

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

13.c Is your post a new Hospital Group post?

Yes

No


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APPENDIX B: RESPONDENT CHARACTERISTICS

Table B1 provides a breakdown of the numbers of years worked in their current hospital for a subset of

respondents i.e. those working in single (i.e. hospitals not part of a group) and pilot hospitals.

Table B1: Numbers and Percentages of Respondents by Years Worked in Current Hospital – Single and Pilot Hospitals Only

Years Worked in Current Hospital * N %


1 - 5 years 593 18

6 - 10 years 941 29

11-15 years 849 26

16-20 years 268 8


TOTAL 3,254 100

Missing Values 54

Overall Total 3,308

Respondents from Single

and Pilot Hospitals

* This question was itemised as Q13 for Single Hospitals and as Q11 for Pilot Hospitals.

Respondents from group hospitals were asked three different questions in relation to their service, Table

B2:

Table B2: Numbers and Percentages of Respondents by Years Worked in Hospital Group, Years Worked in Individual Hospitals

and New Hospital Group Post– Group Hospitals Only


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Years Worked in Hospital Group (Q13a) N %


1 - 5 years 180 13

6 - 10 years 388 28

11-15 years 357 26

16-20 years 153 11


TOTAL 1,367 100

Missing Values 25

Overall Total 1,392

Years Worked in Individual Hospitals Prior to the

Establishment of the Hospital Group (Q13b)


1 - 5 years 268 21

6 - 10 years 303 24

11-15 years 275 22

16-20 years 123 10


TOTAL 1,254 100

Missing Values 138

Overall Total 1,392

New Hospital Group Post (Q13c)

Yes 218 17

No 1,038 83

TOTAL 1,256 100

Missing Values 136

Overall Total 1,392

Respondents from

Group Hospitals

Table B3 provides breakdown details for the years worked in current speciality/profession for respondents

from single and group hospitals only.

Table B3: Numbers and Percentages of Respondents by

Years Worked in Current Speciality/Profession – Single and Group Hospitals Only

Years Worked in Current Speciality/Profession? (Q18) N %


1 - 5 years 570 16

6 - 10 years 855 23

11-15 years 816 22

16-20 years 536 15


TOTAL 3,641 100

Missing Values 133

Overall Total * 3,774

Respondents from Single

and Group Hospitals

* Responses from Pilot Hospitals are excluded as an incorrect version of their question (Q16) appeared on

the survey forms.


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Appendix C: Clinical Governance Development Index Score The index is based on the combined responses to 7 survey questions, i.e. Q11b and Q12 a – f. For pilot hospitals the corresponding questions were Q17b and Q18 a - f. For Question 11b, a score of 1 was assigned to a ‘yes’ response and zero (0) for ‘no’ and ‘don’t know’ responses. For Questions 12 a -f, scores of 2,1,0 (zero) was assigned to responses of ‘great extent’, ‘some extent’ and ‘no extent’ respectively. These scores are assigned and summed on an individual respondent basis.* The index score for the hospital was calculated as the average of the summed scores expressed as a percentage. * A respondent who didn’t reply to any of these questions is excluded from calculations.


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Documents

Composite Results and Comparative Statistics Report ... · collaboration with the Regional Managers for Quality and Patient Safety, piloted the ‘National Patient Safety Culture