A Comprehensive Guide to the Hospital Survey on Patient Safety Culture

Discover how the Hospital Survey on Patient Safety Culture (HSOPSC) empowers hospitals to assess and improve safety, teamwork, and management support. Unlock key insights to identify strengths, address gaps, and benchmark your performance. By enhancing safety culture, your organization can boost patient care and excel in surveys like Leapfrog, driving overall success.

⏰ 16 min read

Published on September 16, 2024

Understanding the Hospital Survey on Patient Safety Culture (HSOPSC)
Key Components of the AHRQ Hospital Survey on Patient Safety Culture (Version 2.0)
The Link Between Safety Culture and Overall Performance
Leapfrog Survey Questions about the Hospital Survey on Patient Safety Culture (HSOPSC or SOPS)
1. Key Leapfrog Requirements for Conducting the Survey on Patient Safety Culture
2. What Leapfrog Asks in Their Survey
Key Deadlines for the Leapfrog Hospital Survey (2024)
How ADN’s SOPS Service Can Help You Meet These Requirements
Integrating the Medical Office Survey on Patient Safety Culture or the SOPS Ambulatory Surgery Center Survey
Additional Resources

Ensuring a culture of safety within healthcare facilities is essential for delivering high-quality care. The Hospital Survey on Patient Safety Culture (HSOPSC), sometimes also referred to as the Hospital SOPS Survey, AHRQ SOPS Surveys, or HSOPSC Questionnaire, is a key tool for hospitals to assess their safety culture and identify areas for improvement. This guide provides an in-depth look at the requirements and best practices for conducting a survey on patient safety culture, including the implications for the Leapfrog Hospital Survey, to help quality leaders enhance patient safety culture in their organizations.

Understanding the Hospital Survey on Patient Safety Culture (HSOPSC)

The Hospital Survey on Patient Safety Culture (HSOPSC), developed by the Agency for Healthcare Research and Quality (AHRQ), is designed to help hospitals evaluate the safety culture in their facilities. It collects data on staff perceptions of patient safety, error reporting, communication openness, and management support for patient safety. By using this survey, hospitals can benchmark their performance, identify strengths and weaknesses, and foster an environment where patient safety is prioritized. Learn how ADN’s SOPS Service helps achieve these goals.

Key Components of the AHRQ Hospital Survey on Patient Safety Culture (Version 2.0)

The AHRQ Hospital Survey on Patient Safety Culture covers 10 critical areas:

Communication About Error: Staff are informed when errors occur, discuss ways to prevent errors, and are informed when changes are made.
Communication Openness: Staff speak up if they see something unsafe and feel comfortable asking questions.
Handoffs and Information Exchange: Important patient care information is transferred across hospital units and during shift changes.
Hospital Management Support for Patient Safety: Hospital management shows that patient safety is a top priority and provides adequate resources for patient safety.
Organizational Learning— Continuous Improvement: Work processes are regularly reviewed, changes are made to keep mistakes from happening again, and changes are evaluated.
Reporting Patient Safety Events: Mistakes of the following types are reported: (1) mistakes caught and corrected before reaching the patient and (2) mistakes that could have harmed the patient but did not.
Response to Error: Staff are treated fairly when they make mistakes and there is a focus on learning from mistakes and supporting staff involved in errors.
Staffing and Work Pace: There are enough staff to handle the workload, staff work appropriate hours and do not feel rushed, and there is appropriate reliance on temporary, float, or PRN staff.
Supervisor, Manager, or Clinical Leader Support for Patient Safety: Supervisors, managers, or clinical leaders consider staff suggestions for improving patient safety, do not encourage taking shortcuts, and take action to address patient safety concerns.
Teamwork: Staff work together as an effective team, help each other during busy times, and are respectful.

The Link Between Safety Culture and Overall Performance

Recent studies have demonstrated a strong link between a hospital’s culture of safety and its overall performance, including its score on the Centers for Medicare & Medicaid Services (CMS) Total Performance Score (TPS). A study published in the Health Care Management Review found that hospitals with a robust culture of safety tend to have higher CMS TPS. The study indicates that hospitals focusing on safety culture improvements not only enhance patient safety outcomes but also positively impact financial and operational performance metrics measured by CMS, such as readmission rates, patient satisfaction, and clinical outcomes (Health Care Management Review, 2024).

This relationship underscores the importance of investing in safety culture as a strategic priority. By aligning efforts to enhance safety culture with broader organizational goals, hospitals can achieve dual benefits: improved patient safety and higher CMS reimbursement rates, which are increasingly tied to quality performance.

Leapfrog Survey Questions about the Hospital Survey on Patient Safety Culture (HSOPSC or SOPS)

The Leapfrog Hospital Survey is a comprehensive assessment tool used by hospitals to evaluate their performance in various safety, quality, and efficiency measures. It covers a wide range of topics, including medication safety, intensive care unit staffing, maternity care, and patient safety practices, among others.

One of the critical areas that Leapfrog focuses on is the hospital’s culture of safety, which is captured under Section 6B: NQF Safe Practice #2 – Culture Measurement, Feedback, and Intervention.

Key Leapfrog Requirements for Conducting the Survey on Patient Safety Culture

Survey Administration:
- Tool Utilization: Hospitals are required to conduct a culture of safety survey using a nationally recognized tool, such as the AHRQ Hospital Survey on Patient Safety Culture, that has demonstrated validity, consistency, and reliability. The surveyed units must represent at least 50% of the total patient care provided within the hospital and encompass areas with high patient safety risks.
- Frequency: The survey must be conducted at least once every 24 months. The frequency ensures the hospital maintains consistent feedback on its safety culture. This interval also allows sufficient time for planning and implementing performance improvement initiatives, monitoring their impact, and evaluating progress before the next survey. By identifying trends over time, the hospital can make data-driven decisions to enhance patient safety and foster a culture of continuous improvement.
Reporting and Benchmarking:
- Results Presentation: Hospitals must compile and present the results of the culture of safety survey in a report that includes both hospital-wide and individual unit-level data, as applicable. This detailed breakdown allows for targeted interventions at the unit level and ensures that all staff members are aware of their specific areas for improvement.
- Benchmarking: Results should be benchmarked against external organizations, such as similar hospitals or others within the same health system. This comparative analysis helps hospitals understand their performance relative to peers and identify areas where they may lag behind or excel.
Accountability and Improvement:
- Actionable Feedback: Following the survey, senior administrative leaders must use the results to debrief relevant units and staff, ensuring that the feedback is actionable and leads to tangible improvements. Aggregate survey data should be used in debriefings to maintain the anonymity of respondents while fostering a culture of transparency and trust.
- Incorporating Survey Results in Performance Evaluations: The results of the survey should be integrated into the performance evaluation criteria for senior leadership. This integration helps ensure that leadership is accountable for improving the culture of safety within their organization.
Education and Resources:
- Staff Education Programs: Hospitals should conduct staff education programs tailored to the organization’s culture of safety survey results. These programs are essential for educating staff on aspects of improving safety culture based on the specific feedback gathered from the survey.
- Budget Inclusion: It is recommended that the costs associated with culture assessment and follow-up activities be included in the patient safety program budget. This financial planning ensures that sufficient resources are allocated to maintain and improve safety culture initiatives.

What Leapfrog Asks in Their Survey

Awareness

2.1) Within the last 24 months, in regard to culture measurement, our organization has done the following:
a. conducted a culture of safety survey of our employees using a nationally recognized tool that has demonstrated validity, consistency, and reliability. The units surveyed account for at least 50% of the aggregated care delivered to patients within the hospital and include the high patient safety risk units or departments. If “no” to question 2.1a, skip the remaining questions in Section 6B and continue to the next subsection. The hospital will be scored as “Limited Achievement.”	o Yes o No
b. portrayed the results of the culture of safety survey in a report, which reflects both hospital-wide and individual unit level results, as applicable.	o Yes o No
c. benchmarked results of the culture of safety survey against external organizations, such as “like” hospitals or other hospitals within the same health system.	o Yes o No
d. compared results of the culture of safety surveys across roles and staff levels.	o Yes o No
e. service line, midlevel managers, or senior administrative leaders used the results of the culture of safety survey to debrief at the relevant unit level, using semistructured approaches for the debriefings and presenting results in aggregate form to ensure the anonymity of survey respondents.	o Yes o No

Accountability

2.2) Within the last 24 months, in regard to accountability for improvements in culture measurement, our organization has done the following:
a. shared the results of the culture of safety survey with the board (governance) and senior administrative leadership in a formal report and discussion.	o Yes o No
b. included in performance evaluation criteria for senior administrative leadership both the response rates to the culture of safety survey and the use of the culture of safety survey results in the improvement efforts.	o Yes o No

Ability

2.3) Within the last 12 months, in regard to culture measurement, the organization has done the following (or has had the following in place):
a. conducted staff education program(s) on methods to improve the culture of safety, tailored to the organization’s culture of safety survey results.	o Yes o No
b. included the costs of culture measurement/follow-up activities in the patient safety program budget.	o Yes o No

Action

2.4) Within the last 12 months, in regard to accountability for improvements in culture measurement, our organization has done the following:
a. developed or implemented explicit, hospital-wide organizational policies and procedures for regular culture measurement.	o Yes o No
b. disseminated the results of the culture of safety survey widely across the institution, and senior administrative leadership held follow-up meetings with the sampled units to discuss the unit’s results and concerns.	o Yes o No
c. identified performance improvement interventions based on the culture of safety survey results, which were shared with senior administrative leadership and subsequently measured and monitored.	o Yes o No

Key Deadlines for the Leapfrog Hospital Survey (2024)

For healthcare organizations striving to achieve high standards of patient safety, adhering to the deadlines set by the Leapfrog Hospital Survey is crucial. Below are the key deadlines for the 2024 Leapfrog Hospital Survey:

Survey Launch Date:
- April 1, 2024: The survey opens, and hospitals can begin submitting their responses.
Submission Deadline:
- June 30, 2024: The last date for hospitals to submit their initial survey responses and any required CPOE Evaluation Tools.
Public Reporting Dates:
- July 12, 2024: Survey results available on the Hospital Details Page.
- July 25, 2024: Public reporting of survey results begins.
Late Submission and Performance Update Deadline:
- November 30, 2024: Serves as the Late Submission deadline and the last date for updates or corrections to previously submitted survey responses.
Corrections Deadline:
- January 31, 2025: The final deadline for hospitals to submit any corrections to their 2024 survey data.

How ADN’s SOPS Service Can Help You Meet These Requirements

ADN’s Survey on Patient Safety Culture (SOPS) service is designed to provide comprehensive support for hospitals, medical offices, and ambulatory surgery centers aiming to enhance their patient safety culture. Our service is tailored to meet the unique needs of your facility, ensuring that you not only comply with the Leapfrog Hospital Survey requirements but also foster a robust culture of safety.

Here’s how our SOPS service can help:

Survey Development: Our team builds the electronic AHRQ Survey on Patient Safety Culture™ (SOPS®) that is specifically customized for your facility. This ensures that the survey captures relevant data and aligns with your organization’s goals and requirements.
Distribution Strategy: ADN assists with the entire survey distribution process by providing communication templates and collaborating with your team to develop a survey timeline that suits your facility. We offer recommendations on survey duration, send times, incentive ideas, and more to maximize response rates. Throughout the survey period, ADN monitors and reports on overall facility and department-specific response rates, enabling you to adjust your internal survey promotions as needed to boost participation and completion rates.
Comprehensive Analytics Report: Within 30 days of the survey closure, our experts provide a detailed analytics report of your SOPS survey results. This report identifies your facility’s strengths and areas for improvement in patient safety culture at various levels, including overall facility performance by key areas and respondent characteristics. We also provide comparisons to the most recently available AHRQ SOPS databases, helping you understand how your organization measures up against national benchmarks.
Deep Dive Report: ADN takes your SOPS survey results further by identifying your facility’s top Opportunities for Improvement (OFIs) based on AHRQ patient safety comparators. We conduct in-depth analyses, including Question Item, Department/Clinic Level, and Staff Position Analyses, to uncover additional areas for focus. Our team provides recommended next steps for each OFI and suggests evidence-based practices, toolkits, articles, and other resources relevant to the identified areas of improvement. To ensure alignment with your organization’s goals, we work closely with your facility’s primary contact to understand current practices and recommend strategies that best fit your needs.
Senior Leadership Presentation: Recognizing the importance of engaging senior leadership, ADN offers a 20-30 minute slide presentation to explain and interpret the Comprehensive Analytics Report. This presentation is delivered virtually and tailored to your leadership team’s preferences, helping to effectively communicate the survey results and proposed strategies for improvement.

By choosing ADN’s SOPS service, your organization gains a trusted partner committed to enhancing your patient safety culture. From survey development and distribution to comprehensive analysis and leadership engagement, ADN provides the expertise and resources needed to drive meaningful improvements in safety culture and overall organizational performance.

Integrating the Medical Office Survey on Patient Safety Culture or the SOPS Ambulatory Surgery Center Survey

Building a culture of safety in healthcare extends beyond hospitals to include outpatient settings such as medical offices. The AHRQ Medical Office Survey on Patient Safety Culture (MOSOPS) and the SOPS Ambulatory Surgery Center Survey, developed by the Agency for Healthcare Research and Quality, provides valuable insights into safety culture in these environments.

Both the MOSOPS and the ASCSOPS assess several key areas, including teamwork, management/leadership support for patient safety, communication openness, organizational learning, and work pressure and pace. Conducting this survey enables medical offices to benchmark their performance, identify strengths and areas for improvement, and implement targeted strategies to enhance patient safety. A recent initiative involving 116 clinics further underscores the need to address safety culture in outpatient settings.

For hospitals looking to improve safety culture across all care settings, integrating MOSOPS or ASCSOPS with the Hospital Survey on Patient Safety Culture (HSOPSC) can provide a comprehensive view of safety culture throughout the organization. By addressing both inpatient and outpatient environments, healthcare organizations can create a unified approach to patient safety, leading to better outcomes and a stronger culture of safety overall.

ADN’s SOPS service is designed to help hospitals and medical offices meet the requirements of the Leapfrog Hospital Survey and foster a proactive approach to patient safety. With our tailored support, detailed analysis, and expert guidance, you can enhance your safety culture and achieve your organizational goals. Uncover the key advantages of safety culture surveys to drive meaningful improvements.