Flex Monitoring Team Briefing Paper No.

30

Promoting a Culture of Safety:

Use of the Hospital Survey on
Patient Safety Culture
in Critical Access Hospitals

April 2012
With funding from the federal Office of Rural Health Policy (PHS Grant No.
U27RH01080), the Rural Health Research Centers at the Universities of Minnesota,
North Carolina, and Southern Maine are cooperatively conducting a performance
monitoring project for the Medicare Rural Hospital Flexibility Program (Flex Program).

The monitoring project is assessing the impact of the Flex Program on rural hospitals
and communities and the role of states in achieving overall program objectives, including
improving access to and the quality of health care services; improving the financial
performance of CAHs; and engaging rural communities in health care system
development.

This report was prepared by Zachariah Croll, Andrew Coburn, and Karen Pearson,
University of Southern Maine. Questions regarding the report should be addressed to:
Zach Croll, zgagecroll@usm.maine.edu

http://flexmonitoring.org

University of Minnesota
Division of Health Services Research & Policy
420 Delaware Street, SE, Mayo Mail Code 729
Minneapolis, MN 55455-0392
612.624.8618

University of North Carolina at Chapel Hill

Cecil B. Sheps Center for Health Services Research
725 Martin Luther King Jr. Boulevard, CB #7590
Chapel Hill, NC 27599-7590
919.966.5541

University of Southern Maine

Muskie School of Public Service
PO Box 9300
Portland, ME 04104-9300
207.780.4435
 The Medicare Rural Hospital Flexibility Program

The Medicare Rural Hospital Flexibility Program (Flex Program), created by Congress in
1997, allows small hospitals to be licensed as Critical Access Hospitals (CAHs) and
offers grants to States to help implement initiatives to strengthen the rural health care
infrastructure. To participate in the Flex Grant Program, States are required to develop a
rural health care plan that provides for the creation of one or more rural health networks;
promotes regionalization of rural health services in the State; and improves the quality of
and access to hospital and other health services for rural residents of the State.

The core activity areas of the Flex Grant Program are: 1) support for quality
improvement in CAHs; 2) support for financial and operational improvement in CAHs; 3)
support health system development and community engagement, including the
integration of EMS into local and regional systems of care; and 4) conversion of eligible
rural hospitals into CAHs. States use Flex resources for performance management
activities, training programs, needs assessments, and network building. The Flex
Program is also beginning a new special project, the Medicare Beneficiary Quality
Improvement Project (MBQIP) focused on Medicare Beneficiary Health Status
improvement.

CAHs must be located in a rural area (or an area treated as rural); be more than 35
miles (or 15 miles in areas with mountainous terrain or only secondary roads available)
from another hospital or be certified before January 1, 2006 by the State as being a
necessary provider of health care services. CAHs are required to make available 24-
hour emergency care services that a State determines are necessary. CAHs may have a
maximum of 25 acute care and swing beds, and must maintain an annual average
length of stay of 96 hours or less for their acute care patients. CAHs are reimbursed by
Medicare on a cost basis (i.e., for the reasonable costs of providing inpatient, outpatient
and swing bed services).

The legislative authority for the Flex Program and cost-based reimbursement for CAHs
are described in the Social Security Act, Title XVIII, Sections 1814 and 1820, available at
http://www.ssa.gov/OP_Home/ssact/title18/1800.htm
Table of Contents

Introduction ........................................................................................................... 1

Organizational Safety Culture: What is it? ............................................................ 2

Is There Evidence that Safety Culture Affects Safety? ......................................... 3

Patient Safety Culture Surveys ............................................................................. 4

Methodological Concerns ..................................................................................... 5

The AHRQ Hospital Survey on Patient Safety Culture .......................................... 5

Promoting a Culture of Safety in Rural Hospitals .................................................. 8

Use of the AHRQ Culture Survey in Critical Access Hospitals .............................. 9

Rural Modifications to the Culture Survey ........................................................... 10

Strategies to Develop a Culture of Safety ........................................................... 11

Additional Resources and Tools to Enhance Patient Safety Culture .................. 12

References ......................................................................................................... 13
Introduction
This Briefing Paper is one in a series of Flex Monitoring Team reports that assess patient
safety and quality improvement initiatives appropriate for use by state Flex Programs and
Critical Access Hospitals (CAHs).

Over a decade ago, the Institute of Medicine (IOM) urged health care organizations to adopt
proven organizational models and strategies from other high-risk industries to minimize
error and reduce harm to patients.1 To promote a culture of safety and ensure safer systems
of care, the IOM emphasized the importance of developing clear, highly visible patient
safety programs that focus organizational attention on safety; use non-punitive systems for
reporting and analyzing errors; incorporate well-established safety principles such as
standardized and simplified equipment, supplies, and work processes; and establish proven
interdisciplinary team training programs for providers.1
The IOM also noted that, “the biggest challenge to moving toward a safer health system is
changing the culture from one of blaming individuals for errors to one in which errors are
treated not as personal failures, but as opportunities to improve the system and prevent
harm”.2 By developing a “systems” orientation to understanding and addressing medical
errors, hospitals can foster an organization-wide continuous learning environment where
members of the workforce feel comfortable reporting and discussing adverse events without
fear of reprisal.1,3

In recent years, consensus has emerged among patient safety experts that cultural attributes
such as leadership support, teamwork, communication, and fair and just culture principles
remain central to achieving high reliability and ensuring patient safety in health care
organizations.4-12

This Briefing Paper considers the use of patient safety culture surveys as a means to promote
organizational learning and build a culture of safety. To inform our work, we reviewed the
literature and convened a rural patient safety expert panel with representatives from federal
and state government and academia to share their experiences and offer guidance to CAHs.
Following a brief discussion of patient safety culture and the evidence base for safety culture

Panel members included Katherine Jones, PT, PhD, Assistant Professor in the Department of Physical
Therapy Education at the University of Nebraska; Paul Moore, DPh, Senior Health Policy Advisor at the
Federal Office of Rural Health Policy; Judy Tupper, MS, CHES, Managing Director of Population Health and
Health Policy at the Cutler Institute for Health and Social Policy and Director of the Maine Patient Safety
Collaborative; and Mary Sheridan, RN, Director of the Idaho State Office of Rural Health and Idaho Flex
Coordinator.

1
surveys, we provide an overview of the Agency for Healthcare Research and Quality’s
(AHRQ) Hospital Survey on Patient Safety Culture (Culture Survey) and its use in CAHs.

Organizational Safety Culture: What is it?

Hospital leaders face increasing pressure to cultivate an organizational culture of safety that
protects patients from medical error. However, the definitional ambiguity and breadth of
safety culture as a construct can make it difficult, if not daunting, to operationalize.13-15 In
developing the Culture Survey, AHRQ adopted the definition of safety culture used by the
Health and Safety Commission of Great Britain: “The safety culture of an organization is the
product of individual and group values, attitudes, perceptions, competencies, and patterns of
behavior that determine the commitment to, and the style and proficiency of, an
organization’s health and safety management. Organizations with a positive safety culture
are characterized by communications founded on mutual trust, by shared perceptions of the
importance of safety, and by confidence in the efficacy of preventive measures.”16

Reason and Hobbs suggest that rather than attempt a single comprehensive definition of
patient safety culture, it is often more useful to think of safety culture in terms of three
essential, interlocking attributes or components: (1) a just culture, (2) a reporting culture and
(3) a learning culture.17 They note that culture is further defined by what an organization is
(beliefs, attitudes and values), as well as what an organization does (structures, practices,
policies and controls). This interplay of beliefs, attitudes and values on the one hand and
structures, practices, policies and controls on the other raises the question of whether
changing culture is best addressed by changing beliefs or by modifying structures and
systems. Many organizations adhere to the “person model” of human error, which holds that
adverse events arise solely from the unreliability of human nature. Such organizations often
try to shift organizational values by naming, blaming and shaming perceived wrongdoers.
Alternatively, organizations can modify behavior by changing organizational policies and
practices, rather than directly attacking the collective attitudes, values, and beliefs of
employees (which are in fact a product of the prevailing organizational environment).17 That
is, introducing policies and practices that are seen to effectively modify behavior have a
tendency to bring actors’ values further into line with them. Acting and doing, and seeing
tangible results, can drive changes in thinking and believing, rather than the other way
around.

Establishment of a just culture is the first vital step in engineering a safer culture. While
employees will be disinclined to report errors and near misses in a wholly punitive culture, a
totally blame-free culture is equally undesirable given that some unsafe acts warrant
retribution. Importantly, leadership must strike a balance between the systems approach that
emphasizes organizational learning, and the need to retain personal accountability and

2
discipline.8,10,18-20 In the end, hospital leaders must hold individuals accountable for the
safety environment while also providing them with the security of knowing they will not be
blamed for system failures beyond their control.7 In short, formation of a just culture
requires the establishment of a zero tolerance policy for reckless conduct, counterbalanced
by a widespread confidence that unintended unsafe acts will generally go unpunished.

Cultivation of a reporting culture is the next critical step in creating a safer organizational
culture. Once a just culture is in place, the workforce should feel safer reporting errors and
near misses. However, important psychological and organizational barriers to reporting are
likely to remain. For example, people are naturally reluctant to confess mistakes and risk
blame or the possibility that reports will be kept on permanent record and held against them
in the future. Also, workers may be skeptical that reporting errors, particularly those that
reveal system weaknesses, will actually spur managerial actions that lead to meaningful
change. As a result, staff may come to believe that event reporting requires more time,
effort, and risk than it is worth. Potential strategies to overcome these barriers and support a
reporting culture include maintaining the confidentially of those who report adverse events;
granting partial indemnity against disciplinary procedure; separating the report collection
and analysis functions; and delivering timely feedback to the entire organization.17

Even with an effective incident and near miss reporting system in place, organizations must
also work to develop a learning culture to truly reap the benefits of institutional memory that
stem from the capacity to uncover and track safety risks.17 Drawing on the social science
literature on organizational learning,21 Reason & Hobbs highlight the distinction between
single-loop and double-loop learning.17 Organizations that engage in single-loop learning
review only the actions and take person-focused countermeasures such as naming, blaming,
shaming, and retraining. 17 In such cases, the organizational learning process stops and
solutions are restricted to disciplinary action and retroactive fixes. In contrast, organizations
that engage in double-loop learning approach adverse events as organizational learning
opportunities, challenging and transforming the basic assumptions that brought about the
unsafe act. Double-loop learning is the manifestation of a systems approach to
understanding human error, and can lead to systemic reforms rather than local repairs.
Organizations that use double loop learning are less preoccupied with who blundered than
with how and why the existing policies, practices, and safeguards failed to achieve the
desired results.17

Is There Evidence that Safety Culture Affects Safety?

A growing body of research demonstrates a positive relationship between organizational
culture and safety outcomes for both patients and employees. Mardon et al. found that
hospitals with enhanced patient safety culture had lower AHRQ Patient Safety Indicator

3
(PSI) scores for in-hospital complications and adverse events.22 Singer et al. and Rosen et al.
report a negative relationship between hospital safety culture and the PSIs, finding that
frontline employees’ perceptions about safety climate were more predictive of adverse
events than those of senior management, and individual psychological and interpersonal
measures of safety climate were more predictive of safety events than more distal
organizational and work unit factors.23,24 Huang et al. found that intensive care unit
employees’ perceptions of management and safety climate were negatively, albeit
moderately, associated with patient outcomes including mortality and length of stay.25
Additionally, hospitals with higher levels of group culture have been shown to experience
fewer patient falls resulting in injury26 and ICUs that report positive organizational climates
have lower rates of occupational injury and blood and body fluid exposures.27 In contrast,
hospitals with poorer organizational safety climate and higher workloads have demonstrated
an increased likelihood of employee needle-stick injuries.28

Hansen et al. found that hospitals with poorer safety climates had higher readmission rates
for acute myocardial infarction (AMI) and heart failure (HF).29 Typically, staff perceptions
of safety culture vary by management level and professional discipline, with senior
managers perceiving better safety culture than frontline employees,30-33 and physicians
perceiving better safety culture than nurses.31,34

Patient Safety Culture Surveys

The use of safety culture surveys to diagnose problem areas and effectively target
interventions to improve patient safety culture has been well documented. For example,
Sexton et al.35 report that a patient safety program designed to improve teamwork and safety
culture in a large cohort of intensive care units resulted in significant improvements in
overall mean safety climate scores, and McCarthy and Blumenthal highlight a hospital that
reduced ventilator-associated pneumonia by 84 percent and device-associated bloodstream
infections by 63 percent by using a range of strategies to strengthen its organizational
culture of safety.36

The rationale behind safety culture surveys is that organizations cannot change what they do
not measure. In order to achieve a culture of safety, hospitals and their employees must
understand the prevailing values, beliefs, norms, attitudes and behaviors with regard to
patient safety in their facility. As safety culture has become increasingly recognized as a
central factor in hospital quality and safety improvement efforts, culture surveys have also
gained prominence. While there are a number of patient safety culture measurement
tools,37,38 the AHRQ Culture Survey is among the most rigorously tested and well
established of these instruments.39 The survey has been psychometrically tested and
validated in a number of settings16,37,40,41 and is one of the only instruments that provides an

4
extensive comparative database that allows users to benchmark their organizational safety
culture against other units or hospitals.38

By administering a culture survey, health care organizations can establish baseline measures
of organizational safety culture, identify areas in need of improvement, and monitor the
impact of patient safety initiatives over time.9,42-44 They can also conduct internal and
external benchmarking to satisfy health system directives or regulatory requirements.9
Perhaps the greatest value of culture surveys is their ability to raise the profile of, and
promote conversations around, patient safety within health care organizations.45,46 In the
end, the usefulness of cultural assessment data depends greatly on the involvement of key
stakeholders, focused strategic planning, the use of effective data collection procedures, and
a commitment to meaningful change.9

Methodological Concerns
A number of studies have questioned the construct validity, rigor, and potential unintended
consequences of safety culture surveys.13,14,39,47-51 Others warn that because staff,
departmental, or hospital-level characteristics may account for differences in survey results,
caution should be exercised when using results to design and enforce rules, sanctions,
rewards and other organizational policies.50 Scott et al. argue that culture change policies
may yield a range of unintended and dysfunctional consequences.51 For example, in addition
to promoting constructive change, the emphasis on performance management may
encourage a focus on some areas to the detriment of others (particularly those which defy
quantification); complacency with quality improvement if the organization achieves a
satisfactory ranking; misrepresentation of the data through creative accounting or fraud; or
myopic concentration on short-term issues to the detriment of longer-term dynamics that
only show up in survey or other data over time.

The AHRQ Hospital Survey on Patient Safety Culture

The Survey Instrument

Released in 2004, the AHRQ Culture Survey was developed to promote a culture of safety
and quality improvement in U.S. hospitals.16 The Culture Survey is a diagnostic tool,
intended to be deployed in conjunction with targeted safety improvement strategies. Initial
administration of the survey allows hospitals to establish baseline data with future
reassessments facilitating measurement of changes in safety culture over time.

The Culture Survey examines the patient safety culture of an organization from the
perspective of hospital staff. It is intended for a range of different employees, including
frontline clinical and nonclinical staff, pharmacy and laboratory personnel, hospital-
employed physicians, and hospital supervisors, managers, and administrators. The survey

5
and accompanying toolkit provide hospital officials with the basic knowledge and tools
needed to conduct a safety culture assessment, as well as ideas for using the survey data.

The Culture Survey contains 42 items that measure 12 dimensions or composites of patient
safety culture, as well as two single-item outcomes questions that ask respondents to provide
an overall grade on patient safety for their work area and the number of adverse events they
have reported in the past year. Most items use 5-point Likert scales of agreement (“Strongly
disagree” to “Strongly agree”) or frequency (“Never” to “Always”) to measure staff
perceptions and attitudes. Respondents are also asked to provide limited background
demographic information about their work area, staff position, and whether they directly
interact with patients.41 The twelve composite measures include communication openness;
feedback and communication about error; frequency of events reported; handoffs and
transitions; management support for patient safety; non-punitive response to error;
organizational learning- continuous improvement; overall perceptions of patient safety;
staffing; supervisor/manager expectations and actions promoting safety; teamwork across
units; and teamwork within units.16

While the Culture Survey was designed to be used in different types of hospitals, the survey
form and feedback report templates are available as modifiable electronic files to allow
further customization of the survey. However, developers recommend making only those
changes that are absolutely necessary, as any modifications may affect the reliability and
validity of results and make comparisons with other hospitals difficult. The survey
emphasizes measurement at the unit level because staff members are typically most familiar
with the safety culture in their immediate work area. Small hospitals that do not have highly
differentiated units are advised to modify survey instructions or items that focus on the
“unit” to focus on the hospital as a whole.

Conducting the Survey

How the Culture Survey is administered is critical, both in terms of the resources needed and
the validity and reliability of the results. Careful planning is vital to ensure that hospitals
have the appropriate resources for administering the survey and analyzing and disseminating
the results. To ensure effective deployment of the Culture Survey, hospitals should engage
in a thorough planning process that takes into consideration available human and financial
resources, the desired scope and schedule of the project, and the in-house technical
capacities of the hospital. While rural hospitals in particular must carefully weigh resource
availability, they should also keep in mind that surveying a greater number of staff members
will increase the likelihood of achieving a representative sample of respondents.

6
Though it may add considerable expense to the project, the use of an outside vendor to
perform data collection and/or analysis can offer advantages. Vendors with expertise in
survey research can help hospitals obtain better quality results in a timelier manner, and
ensure the neutrality and credibility of the survey process. Importantly, staff may feel their
responses will be treated with greater confidentiality when reporting to an outside vendor.
Alternatively, hospitals that belong to a system may seek to involve their corporate
headquarters in a system-wide survey effort to lessen the human and financial resource
burden on their facility and impart a greater degree of confidentiality to the process. Either
way, hospitals will need to establish a project team whose responsibilities include selecting a
sample; establishing department-level contact persons; preparing survey materials;
distributing and receiving the survey; tracking responses and response rates; handling data
entry, analysis, and report preparation; and, where applicable, coordinating with and
monitoring an outside vendor. For hospitals that choose to administer the survey themselves,
Sorra and Nieva offer extensive guidance on coding, cleaning, and analyzing survey data as
well as producing summary reports.16

Notably, a member of our expert panel cautioned against outsourcing the survey process to a
third party, as hospitals may be less likely to “own” the intervention. That is, given the
survey’s potential to stimulate conversation and drive the quality improvement process, the
more hospital staff actively engages with the tool, the better. Panel members also
acknowledged the importance of having an experienced analyst helping to interpret results.
For example, staff members often think that they and their co-workers practice good
teamwork, scoring their work area highly during the baseline assessment. However,
following training people realize they didn’t understand the concepts as well as they thought
and, as a result, report lower perceptions of safety culture upon reassessment. Without an
analyst capable of explicating this dynamic, declining survey results may discourage
administrators from continuing what is actually an effective patient safety program.

Although the Culture Survey can be administered on-line, evidence suggests that web-based
surveys typically have lower response rates than paper-based surveys.52 Potential advantages
of a web-based approach includes simpler logistics vis-à-vis survey dissemination; minimal
need for data entry or cleaning; and the potential for faster data collection. Disadvantages
include the time needed to develop and test the web-based survey; limited internet or email
access among members of the sample group; and individual differences in computer literacy.

Comparing Results
AHRQ created the Hospital Survey on Patient Safety Culture User Comparative Database to
allow hospitals to compare survey results with those of other facilities; to support internal
assessment and learning during patient safety interventions; to help users identify areas of

7
strength and weakness vis-à-vis patient safety culture; and to provide a database that tracks
changes in patient safety culture over time. The 2012 report includes results from 1,128
hospitals and 567,703 hospital staff respondents, with trending data available for 650
hospitals that have administered the survey and submitted data on multiple occasions. The
database provides a “rolling” indicator by retaining data for up to 3.5 prior years and
replacing it as more recent data becomes available. The full report contains detailed
information on a range of hospital characteristics (e.g., bed size, teaching status, ownership
and control, geographic region) as well as respondent characteristics (e.g., work area, staff
position, and level of interaction with patients).53
Overall, characteristics of the hospitals included in the 2012 database are consistent with the
distribution of American Hospital Association-registered hospitals. Notably, the smallest
hospitals (6-24 beds) had the highest percent positive scores across all patient safety culture
composites (68%) while larger hospitals (400 beds or more) had the lowest (60%); hospitals
with 49 beds or less had the highest percentage of respondents who gave their work area a
patient safety grade of “excellent” or “very good” (80%) while larger hospitals again scored
the lowest (71%).
The four composites with the highest percent of positive responses in 2012 were teamwork
within units (80%), supervisor/manager expectations and actions promoting patient safety
(75%), organizational learning-continuous improvement (72%), and management support
for patient safety (72%). According to respondents, the areas with the most potential for
improvement were non-punitive response to error (44%), handoffs and transitions (45%),
and staffing levels (56%). For more on the 2012 User Comparative Database Report, visit:
http://www.ahrq.gov/qual/hospsurvey12/

Promoting a Culture of Safety in Rural Hospitals

To develop a culture of safety, hospitals must acknowledge the high-risk nature of their
work; establish a blame-free environment that supports reporting of adverse events and near
misses; encourage cross-discipline and cross-rank collaboration in seeking solutions to
patient safety problems; and allocate human and financial resources to address patient safety
concerns.54

Wakefield notes that senior leadership in rural facilities must demonstrate a strong
commitment to patient safety as shown in their business and strategic plans and, in addition
to allocating financial resources, they must help drive a fundamental cultural reorientation
to create an environment in which employees feel safe to report errors.3 This is especially
challenging in rural facilities given the typically small staff size and resultant lack of
anonymity.

8
While patient safety culture surveys are an important tool for promoting a culture of safety,
it is important that CAHs pursue a diversified strategy for improving patient safety. Coburn
et al. recommend that rural hospitals adopt a comprehensive patient safety program that
“sets measurable objectives, provides patient safety educational initiatives for employees,
and includes a system for reporting and responding to errors.” They advise hospitals to
develop protocols for root cause analyses (RCA); generate annual reports on errors;
document organizational response to errors; and highlight the safety programs implemented
to prevent similar adverse events in the future. In doing so, CAHs must adopt patient safety
initiatives that fit with the environmental context and needs of their facilities.55

Because many popular patient safety interventions are developed in large urban or teaching
hospitals, rural hospitals may face technological, staffing, financial and other organizational
constraints that inhibit their implementation.3,55,56 For example, many CAHs lack
sophisticated health information technology, a formal and structured quality improvement
process, or the level of financial and human resources needed to administer and analyze a
survey.57 Moreover, ensuring the anonymity of those who report adverse events can be a
challenge in the small professional communities typical of CAHs and other rural hospitals.
Finally, the lower census and limited service mix of rural hospitals often results in a low
volume of measurable events, making it difficult to reliably assess the safety environment
prior to and following patient safety interventions.45,58

Use of the AHRQ Culture Survey in Critical Access Hospitals

Despite the previously noted resource constraints on rural hospitals, the Culture Survey has
demonstrated its value to patient safety initiatives in CAHs. For example, the Tennessee
Rural Hospital Patient Safety Demonstration project used the Culture Survey in tandem with
two other patient safety interventions (use of personal digital assistants and the sharing of
emergency room protocols to facilitate the standardization of care) as part of a multi-
organizational effort to strengthen patient safety in eight small rural hospitals. The research
team coached participating hospitals on event reporting, the survey process, data
management and culture change, and administered the survey to all hospital employees
(including non-clinical staff) on three occasions during the two year study period.45,58

Following each round of surveys, participating hospitals were provided with both an
individualized hospital report and an aggregate report, allowing for internal and external
benchmarking and the identification of areas in need of improvement. In response to
preliminary results, all participating hospitals sought to develop non-blame, anonymous
error reporting systems and adopted a variety of continuous quality improvement techniques
including RCA, forced function, and surgical pause.45 Hospitals also began using control
charts to better understand system processes and monitor organizational process change;

9
increased board involvement in patient safety issues; encouraged greater collaboration and
communication among hospital staff; and began monitoring patient safety through walk-
arounds, medication counts and reporting, and evaluation of inventory discrepancies. 45
Upon redeployment of the survey, composite hospital results improved in nine of the
survey’s twelve dimensions, with the largest improvements in communication openness,
feedback and communication about errors, teamwork within areas, frequency of events
reported, and non-punitive response to errors.45,58

Rural Modifications to the Culture Survey

Jones and colleagues also demonstrate the effectiveness of the AHRQ Culture Survey in
planning, executing and evaluating targeted patient safety interventions in CAHs.59 The
authors conducted a rural-adapted Culture Survey in 24 CAHs to obtain baseline
assessments of their cultures of safety and stimulate dialogue about safety culture. The rural-
adapted version of the Culture Survey was modified to better fit the CAH environment and
ensure the anonymity of survey respondents. These demographic changes were also
incorporated into a customized data tool for entering and analyzing small hospital survey
results. The rural-adapted version of the Culture Survey is available from the Nebraska
Center for Rural Health Research website (http://www.unmc.edu/rural/patient-
safety/culture%20survey/culture-survey.htm).

The results were used to develop benchmarks and plan safety culture educational
interventions to address areas in need of improvement. In order to develop the hospitals’
organizational infrastructure for voluntarily reporting and analyzing medication errors, use
of the survey was coupled with training in MEDMARX®, an internet-based, anonymous
medication error-reporting program. Twenty-one of the CAHs participated in a second
round of surveys to evaluate the effectiveness of the MEDMARX® training, and 17 of these
hospitals engaged in a variety of other safety culture educational activities. In addition to
developing their reporting cultures, these hospitals established protocols for determining the
blameworthiness of unsafe acts (just culture); carried out teamwork training emphasizing
knowledge, skills and beliefs that support coordination within and across work areas
(flexible culture); and adopted a range of approaches to communicate about and learn from
errors, including Leadership WalkRounds™, unit/departmental safety briefings, aggregate
RCA of non-harmful events, and individual RCA of harmful errors (learning culture).59

Upon reassessment, the average scores on the 12 dimensions of the Culture Survey
increased for the 17 CAHs that participated in follow-up safety culture educational
activities; conversely, scores decreased among the four CAHs that chose not to participate
(except for the frequency of events reported dimension). The authors’ findings are consistent
with other research showing that perceptions of safety culture vary by work area and

10
position, with non-clinician management reporting more positive assessments than nurses
and providers actively engaged in patient care. Also, surgery and lab personnel reported
more positive perceptions of safety culture than acute/skilled care personnel in the same
organization, signifying the importance of microcultures within a single organization and the
impact of differences in safety culture training within health care professions.59

Once survey results have been obtained, organizations should perform internal and external
benchmarking; “drill down” on high and low scores to celebrate successes and prioritize
areas in need of improvement; share the findings to encourage dialogue about safety culture;
and explore participatory action plans that engage staff in system wide improvement
strategies.

Strategies to Develop a Culture of Safety

To develop a culture of safety, rural hospitals must acknowledge the high-risk nature of their
work; establish a just environment conducive to reporting adverse events; encourage cross-
discipline and cross-rank learning and collaboration; and allocate the necessary human and
financial resources to carry out patient safety initiatives.3,54

Leadership is pivotal in creating an organizational culture that values transparency,

communication, and mutual respect.60,61 Effective leadership is characterized by the ability
to project clear expectations for employee behavior and adapt to situational demands.62
Indeed, Sammer and colleagues note that “leaders must view linkages between
organizational culture, a rapidly changing workforce, and financial and quality success.”10
Leaders that promote workforce education and embed simple rules and behaviors can
improve attitudes around teamwork and safety climate, boost employee satisfaction, and
reduce turnover among staff.5

Other strategies to improve patient safety include implementation of situational briefing

models, pre- and post-surgical briefings, team huddles, critical event trainings and
simulations, standardized communication processes, conflict resolution, and leadership
walkrounds.5,60 Direct support from senior management, the board of directors, and
physician and nursing leadership can ease the burden on busy front line workers, provide a
broader organizational perspective on quality improvement efforts, and convey the status
and authority required to resolve problems that cross organizational boundaries.63

Similarly, State Flex Programs and Flex Coordinators can play a critical role in providing
the leadership and assistance needed by CAHs interested in the Culture Survey. In addition
to providing financial support, State Flex Programs can encourage the use of evidence-based

11
patient safety programs; offer technical assistance and training; facilitate administration and
analysis of the Culture Survey; assist with external benchmarking; and share findings across
CAHs.

Additional Resources and Tools to Enhance Patient Safety Culture

The following resources from the Agency for Healthcare Research and Quality (AHRQ),
the Institute for Healthcare Improvement (IHI), the Joint Commission and others can be used
to enhance hospital patient safety culture and improve the quality and safety of care.

2012 Hospital Survey on Patient Safety Culture User Comparative Database Report.
http://www.ahrq.gov/qual/hospsurvey12/
AHRQ Health Care Innovations Exchange. http://www.innovations.ahrq.gov/index.aspx
AHRQ Hospital Survey on Patient Safety Culture Adapted for Critical Access
Hospitals. http://www.unmc.edu/rural/patient-
safety/culture%20survey/AHRQ%20HSOPSC%20Rural%201107.pdf
AHRQ Quality Indicators Toolkit for Hospitals. http://www.ahrq.gov/qual/qitoolkit
Improving Patient Safety in Hospitals- A Resource List for Users of the AHRQ
Hospital Survey on Patient Safety Culture.
http://www.ahrq.gov/qual/patientsafetyculture/hospimpptsaf.htm
IHI Knowledge Center. http://www.ihi.org/knowledge/Pages/default.aspx
Patient Safety direct link:
http://www.ihi.org/explore/PatientSafety/Pages/default.aspx
Developing a Culture of Safety direct link:
http://www.ihi.org/knowledge/Pages/Changes/DevelopaCultureofSafety.aspx

Joint Commission Resources, The Essential Guide for Patient Safety Officers.
http://www.jcrinc.com/Books-and-E-books/patient-safety-officers-handbook/447/
Nebraska Center for Rural Health Research.
http://www.unmc.edu/rural/default.htm and/or:
http://www.unmc.edu/rural/patient-safety/default.htm

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