Measures of patient safety culture

Information on measuring patient safety culture including the Australian Hospital Survey on Patient Safety Culture.

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Approaches to measurement

Patient safety culture can be measured through surveys of hospital staff, qualitative measurement (focus groups, interviews), ethnographic investigations or a combination of these. Surveys of hospital staff are the most common way of measuring patient safety culture. The experience and perspectives of all hospital staff are important. Clinical and non-clinical staff observe different aspects of how the hospital works and have the potential to identify what is going well and what could be done better.

Patient safety culture should not be measured in isolation but forms one component of a comprehensive measurement and improvement system. The Commission has produced a suite of indicators that complement patient safety culture measurement, such as, complications acquired while in hospital, accreditation outcomes, mortality, patient-reported experience and outcome measures and serious in-hospital incidents.

Regardless of the measurement approach taken, the most important part of the project is ensuring the results a fed back at multiple levels and the information gathered is used to implement improvements.

Recommended measures

The Commission has developed a toolkit to support patient safety culture measurement and improvement. The project identified an existing survey – the Hospital Survey on Patient Safety Culture Version 2 (HSOPS 2.0). This survey was selected as it measures the most contemporary view of patient safety culture, measures the key aspects of patient safety culture, is easy to complete and can be implemented in a range of hospital types. The Australian modification of this survey was validated and tested in public and private Australian hospitals.

The Commission recommends that hospitals use the Australian Hospital Survey on Patient Safety Culture Version 2 (A-HSOPS 2.0) to measure patient safety culture.

There are a range of other surveys and measurement tools that can be used to systematically measure patient safety culture that are in use in Australia. Hospitals can also gather complementary information on patient safety culture through existing data sources and qualitative methods. While generic employee engagement surveys can provide useful information to support this process, they focus on multiple areas and do not provide detailed information on patient safety culture. 

A-HSOPS 2.0

The HSOPS was developed by the US Agency for Health Research and Quality in 2004, with an updated version released in 2019. The survey is utilised internationally and is designed to measure staff opinions about patient safety issues, medical errors, and safety event reporting.  

The HSOPS 2.0 was selected by the Safety Culture Measurement Expert Advisory Group as the most suitable survey for measurement of patient safety culture in both public and private Australian hospitals. The Commission developed the Australian version of the survey based on the advice of the expert advisory group, tested these modifications through cognitive testing and undertook a pilot of the survey in nine hospitals. 

The A-HSOPS 2.0 offers a survey that has been:

  • Assessed as the a suitable validated survey for use in Australian hospitals
  • Modified for the Australian setting 
  • Shortened to be user-friendly to promote uptake while keeping sufficient detail to be actionable
  • Piloted in the Australian hospitals and found to be valid and reliable for use.

Structure

The survey includes a total of 35 questions. There are 26 items across nine composites, they are:

  1. Supervisor, manager, or clinical leader support for patient safety (3 items)
  2. Teamwork (3 items)
  3. Communication/openness (3 items)
  4. Reporting patient safety events (2 items)
  5. Organisational learning- continuous improvement (3 items)
  6. Communication about error (3 items)
  7. Hospital management support for patient safety (3 items)
  8. Response to error (3 items)
  9. Handovers and information exchange (3 items).

The remaining nine questions are:

  • Two overarching items (rating of patient safety for their unit/work area, and likelihood to recommend their unit/work area to a friend or family member)
  • One open-ended item
  • Six demographic items.

Validation in Australia

The A-HSOPS 2.0 has been validated in nine hospitals from across Australia. The pilot included three private and six public hospitals.

Supporting resources

  • Survey form - Complete a short form to download the A-HSOPS 2.0
  • Technical specification – Provides guidance for survey administrators in Australian hospitals on best practice implementation of the A-HSOPS 2.0
  • Web based toolkit – Steps through the process of undertaking a quality improvement project using the A-HSOPS 2.0 as an example.

Other tools used in Australia

In addition to the A-HSOPS 2.0, there are two other tools that are used in Australia. They are the:

  • Safety Attitudes Questionnaire (SAQ) – short version
  • Manchester Patient Safety Framework (MaPSAF).

Both of these tools have been used in Australian hospitals and provide a view of the key elements of patient safety culture. SAQ has been validated in South Australia and Victoria. MaPSAF, while resource intensive, provides an opportunity to measure, and improve on, patient safety culture concurrently. While the A-HSOPS 2.0 is recommended, hospitals may continue using these other tools to meet their needs or understand trends in patient safety culture over time. Information on each of these tools is provided below.

The literature review and environmental scan provides a comprehensive list of alternative tools available. Other surveys may be appropriate where the focus of the measurement is on a particular speciality or setting or if the aim of the project is to focus on a specific element of patient safety culture in more detail.

Safety Attitudes Questionnaire (SAQ)

The SAQ was developed in 2004 by researchers at the University of Texas in the US and continues to be widely used to measure patient safety culture.

Structure

The full version of the questionnaire includes 60 items, of which 30 items are standard and identical across all settings. The generic SAQ Short-form version, includes the 30 standard items from the full SAQ, plus an additional six items, and three demographic items, providing a total of 39 items.

The survey is comprised of six factors:

  1. Teamwork Climate
  2. Safety Climate
  3. Job Satisfaction
  4. Perceptions of Management
  5. Working Conditions
  6. Stress Recognition.

Validation and use in Australia

The Staff Survey on Patient Safety was developed by South Australia Health who worked with researchers to adapt the SAQ. This survey was used in a state-wide study in 2009[i] and repeated in some SA Local Health Networks in 2013.

The Safety Climate Survey was developed by the Victorian Managed Insurance Authority and the Victorian Quality Council who worked with an consultants to adapt the SAQ. This survey was piloted in six hospitals in 2010. They also developed a guide for use and a range of templates to support implementation. 

The modifications of the SAQ continue to be used in Australia to monitor patient safety culture and measure the impact of improvement projects.

Manchester Patient Safety Framework (MaPSaF)

The MaPSaF was designed specifically for use in the UK’s National Health Service in 2009.[ii] The MaPSaF provides a different approach to assessing patient safety culture. Rather than collecting information from a survey, the MaPSaf uses a card sorting activity and facilitated discussion to support units to understand their culture.

The implementation is ideally facilitated by a person within the healthcare organisation and teams who have a lead role in the patient safety agenda, rather than by a professional facilitator. The framework includes an improvement process that is designed to involve frontline staff in seven steps to assess and improve safety culture within their work unit. The seven steps are:

  1. Safety culture
  2. Lead and support staff
  3. Integrated risk management
  4. Promote incident reporting
  5. Involve patients and the public
  6. Learn and share lessons
  7. Implement solutions.

Structure

The framework is presented as a grid for organisations to assess themselves against five levels of maturity in nine or ten dimensions of safety culture. This allows the generation of a profile of the patient safety culture in terms of areas of relative strength and challenge, which can be used to identify issues for change and improvement.

The ten dimensions are:

  1. Overall commitment to continuous improvement
  2. Priority given to patient safety
  3. System errors and individual responsibility /perception of causes of incidents
  4. Recording incidents and best practice
  5. Evaluating incidents and best practice
  6. Learning and effecting change
  7. Communication about safety issues
  8. Personnel management and safety issues
  9. Staff education and training about safety
  10. Team working around safety issues.

The five levels of maturity are (E=most mature):

  1. Pathological: why waste time on patient safety?
  2. Reactive:  we take it seriously and do something after an incident
  3. Bureaucratic or Calculative:  we have systems in place to manage patient safety
  4. Proactive: we are always on the alert thinking about safety issues that might emerge
  5. Generative: managing patient safety is an integral part of everything we do.

Validation and use in Australia

The MaPSaF has been evaluated in a hospital setting overseas[iii]. While MaPSaF has not been validated in Australia, it is widely used and well regarded in Australia as an integrated measurement and improvement strategy.

[i] Öhrn A, Rutberg H, Nilsen P. Patient safety dialogue: evaluation of an intervention aimed at achieving an improved patient safety culture. Journal of patient safety. 2011 Dec 1;7(4):185-92.

[ii] Parker D. Managing risk in healthcare: understanding your safety culture using the Manchester Patient Safety Framework (MaPSaF). Journal of nursing management. 2009 Mar;17(2):218-22.

[iii] Braithwaite J, Westbrook MT, Pirone C, Robinson P, Robinson M, Michael S. Staff Survey on Patient Safety. Adelaide, SA: Communio and Centre for Healthcare Resilience and Implementation Science, UNSW for the South Australian Council for Safety and Quality in Health Care and South Australian Department of Health; 2009.

Complementary measures and information sources

There are a range of other sources of information that can provide insights into the patient safety culture of a hospital. These can be examined alongside survey data or be monitored between surveys to track progress.

Other safety and quality indicators HR measures Other sources
  • Complications acquired while in hospital
  • Incidents
  • Accreditation outcomes
  • Patient outcomes
  • Patient-reported experience and outcome measures
  • Absenteeism
  • Turnover
  • Staff complaints
  • Workplace health and safety data
  • Exit surveys
  • Complaints and complements from patients
  • Broader organisational culture surveys
  • Outcomes of incident investigations

A-HSOPS 2.0

The HSOPS was developed by the US Agency for Health Research and Quality in 2004, with an updated version released in 2019. The survey is utilised internationally and is designed to measure staff opinions about patient safety issues, medical errors, and safety event reporting.  

The HSOPS 2.0 was selected by the Safety Culture Measurement Expert Advisory Group as the most suitable survey for measurement of patient safety culture in both public and private Australian hospitals. The Commission developed the Australian version of the survey based on the advice of the expert advisory group, tested these modifications through cognitive testing and undertook a pilot of the survey in nine hospitals. 

The A-HSOPS 2.0 offers a survey that has been:

  • Assessed as the a suitable validated survey for use in Australian hospitals
  • Modified for the Australian setting 
  • Shortened to be user-friendly to promote uptake while keeping sufficient detail to be actionable
  • Piloted in the Australian hospitals and found to be valid and reliable for use.

Structure

The survey includes a total of 35 questions. There are 26 items across nine composites, they are:

  1. Supervisor, manager, or clinical leader support for patient safety (3 items)
  2. Teamwork (3 items)
  3. Communication/openness (3 items)
  4. Reporting patient safety events (2 items)
  5. Organisational learning- continuous improvement (3 items)
  6. Communication about error (3 items)
  7. Hospital management support for patient safety (3 items)
  8. Response to error (3 items)
  9. Handovers and information exchange (3 items).

The remaining nine questions are:

  • Two overarching items (rating of patient safety for their unit/work area, and likelihood to recommend their unit/work area to a friend or family member)
  • One open-ended item
  • Six demographic items.

Validation in Australia

The A-HSOPS 2.0 has been validated in nine hospitals from across Australia. The pilot included three private and six public hospitals.

Supporting resources

  • Survey form - Complete a short form to download the A-HSOPS 2.0
  • Technical specification – Provides guidance for survey administrators in Australian hospitals on best practice implementation of the A-HSOPS 2.0
  • Web based toolkit – Steps through the process of undertaking a quality improvement project using the A-HSOPS 2.0 as an example.

Other tools used in Australia

In addition to the A-HSOPS 2.0, there are two other tools that are used in Australia. They are the:

  • Safety Attitudes Questionnaire (SAQ) – short version
  • Manchester Patient Safety Framework (MaPSAF).

Both of these tools have been used in Australian hospitals and provide a view of the key elements of patient safety culture. SAQ has been validated in South Australia and Victoria. MaPSAF, while resource intensive, provides an opportunity to measure, and improve on, patient safety culture concurrently. While the A-HSOPS 2.0 is recommended, hospitals may continue using these other tools to meet their needs or understand trends in patient safety culture over time. Information on each of these tools is provided below.

The literature review and environmental scan provides a comprehensive list of alternative tools available. Other surveys may be appropriate where the focus of the measurement is on a particular speciality or setting or if the aim of the project is to focus on a specific element of patient safety culture in more detail.

Safety Attitudes Questionnaire (SAQ)

The SAQ was developed in 2004 by researchers at the University of Texas in the US and continues to be widely used to measure patient safety culture.

Structure

The full version of the questionnaire includes 60 items, of which 30 items are standard and identical across all settings. The generic SAQ Short-form version, includes the 30 standard items from the full SAQ, plus an additional six items, and three demographic items, providing a total of 39 items.

The survey is comprised of six factors:

  1. Teamwork Climate
  2. Safety Climate
  3. Job Satisfaction
  4. Perceptions of Management
  5. Working Conditions
  6. Stress Recognition.

Validation and use in Australia

The Staff Survey on Patient Safety was developed by South Australia Health who worked with researchers to adapt the SAQ. This survey was used in a state-wide study in 2009[i] and repeated in some SA Local Health Networks in 2013.

The Safety Climate Survey was developed by the Victorian Managed Insurance Authority and the Victorian Quality Council who worked with an consultants to adapt the SAQ. This survey was piloted in six hospitals in 2010. They also developed a guide for use and a range of templates to support implementation. 

The modifications of the SAQ continue to be used in Australia to monitor patient safety culture and measure the impact of improvement projects.

Manchester Patient Safety Framework (MaPSaF)

The MaPSaF was designed specifically for use in the UK’s National Health Service in 2009.[ii] The MaPSaF provides a different approach to assessing patient safety culture. Rather than collecting information from a survey, the MaPSaf uses a card sorting activity and facilitated discussion to support units to understand their culture.

The implementation is ideally facilitated by a person within the healthcare organisation and teams who have a lead role in the patient safety agenda, rather than by a professional facilitator. The framework includes an improvement process that is designed to involve frontline staff in seven steps to assess and improve safety culture within their work unit. The seven steps are:

  1. Safety culture
  2. Lead and support staff
  3. Integrated risk management
  4. Promote incident reporting
  5. Involve patients and the public
  6. Learn and share lessons
  7. Implement solutions.

Structure

The framework is presented as a grid for organisations to assess themselves against five levels of maturity in nine or ten dimensions of safety culture. This allows the generation of a profile of the patient safety culture in terms of areas of relative strength and challenge, which can be used to identify issues for change and improvement.

The ten dimensions are:

  1. Overall commitment to continuous improvement
  2. Priority given to patient safety
  3. System errors and individual responsibility /perception of causes of incidents
  4. Recording incidents and best practice
  5. Evaluating incidents and best practice
  6. Learning and effecting change
  7. Communication about safety issues
  8. Personnel management and safety issues
  9. Staff education and training about safety
  10. Team working around safety issues.

The five levels of maturity are (E=most mature):

  1. Pathological: why waste time on patient safety?
  2. Reactive:  we take it seriously and do something after an incident
  3. Bureaucratic or Calculative:  we have systems in place to manage patient safety
  4. Proactive: we are always on the alert thinking about safety issues that might emerge
  5. Generative: managing patient safety is an integral part of everything we do.

Validation and use in Australia

The MaPSaF has been evaluated in a hospital setting overseas[iii]. While MaPSaF has not been validated in Australia, it is widely used and well regarded in Australia as an integrated measurement and improvement strategy.

[i] Öhrn A, Rutberg H, Nilsen P. Patient safety dialogue: evaluation of an intervention aimed at achieving an improved patient safety culture. Journal of patient safety. 2011 Dec 1;7(4):185-92.

[ii] Parker D. Managing risk in healthcare: understanding your safety culture using the Manchester Patient Safety Framework (MaPSaF). Journal of nursing management. 2009 Mar;17(2):218-22.

[iii] Braithwaite J, Westbrook MT, Pirone C, Robinson P, Robinson M, Michael S. Staff Survey on Patient Safety. Adelaide, SA: Communio and Centre for Healthcare Resilience and Implementation Science, UNSW for the South Australian Council for Safety and Quality in Health Care and South Australian Department of Health; 2009.

Complementary measures and information sources

There are a range of other sources of information that can provide insights into the patient safety culture of a hospital. These can be examined alongside survey data or be monitored between surveys to track progress.

Other safety and quality indicators HR measures Other sources
  • Complications acquired while in hospital
  • Incidents
  • Accreditation outcomes
  • Patient outcomes
  • Patient-reported experience and outcome measures
  • Absenteeism
  • Turnover
  • Staff complaints
  • Workplace health and safety data
  • Exit surveys
  • Complaints and complements from patients
  • Broader organisational culture surveys
  • Outcomes of incident investigations
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