Composite Results and Comparative Statistics Report ... · collaboration with the Regional Managers...
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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
Patient Safety Culture Survey Composite Results and Comparative Statistics
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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
Patient Safety Culture Survey Composite Results and Comparative Statistics
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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.
Patient Safety Culture Survey Composite Results and Comparative Statistics
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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.
Patient Safety Culture Survey Composite Results and Comparative Statistics
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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
* This question was itemised as Q17 for Single and Group Hospitals and as Q15 for Pilot Hospitals.
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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
* This question was itemised as Q15 for Single and Group Hospitals and as Q13 for Pilot Hospitals.
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
* This question was itemised as Q14 for Single and Group Hospitals and as Q12 for Pilot Hospitals.
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.
Note: % Calculations exclude missing values.
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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%.
Note: % Calculations exclude missing values.
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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)
% Positive % Neutral % Negative
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)
% Positive % Neutral % Negative
Note: % Calculations exclude missing values and may not sum to 100% due to rounding.
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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
Dimension and Questions
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)
% Positive % Neutral % Negative
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
Dimension and Questions
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)
% Positive % Neutral % Negative
Note: % Calculations exclude missing values and may not sum to 100% due to rounding.
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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
Dimension and Questions
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)
% Positive % Neutral % Negative
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
Dimension and Questions
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)
% Positive % Neutral % Negative
Note: % Calculations exclude missing values and may not sum to 100% due to rounding.
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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
Dimension and Questions
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)
% Positive % Neutral % Negative
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
Dimension and Questions
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)
% Positive % Neutral % Negative
Note: % Calculations exclude missing values and may not sum to 100% due to rounding.
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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
Dimension and Questions
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)
% Positive % Neutral % Negative
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
Dimension and Questions
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)
% Positive % Neutral % Negative
Note: % Calculations exclude missing values and may not sum to 100% due to rounding.
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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
Dimension and Questions
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)
% Positive % Neutral % Negative
Note: % Calculations exclude missing values and may not sum to 100% due to rounding.
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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
%
Note: % Calculations exclude missing values and may not sum to 100% due to rounding.
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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
Note: % Calculations exclude missing values and may not sum to 100% due to rounding.
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
Note: % Calculations exclude missing values and may not sum to 100% due to rounding.
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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.
Note: % Calculations exclude missing values.
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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 %
Less than 1 year 152 5
1 - 5 years 593 18
6 - 10 years 941 29
11-15 years 849 26
16-20 years 268 8
21 years or more 451 14
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 %
Less than 1 year 92 7
1 - 5 years 180 13
6 - 10 years 388 28
11-15 years 357 26
16-20 years 153 11
21 years or more 197 14
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)
Less than 1 year 134 11
1 - 5 years 268 21
6 - 10 years 303 24
11-15 years 275 22
16-20 years 123 10
21 years or more 151 12
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 %
Less than 1 year 99 3
1 - 5 years 570 16
6 - 10 years 855 23
11-15 years 816 22
16-20 years 536 15
21 years or more 765 21
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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