Stage 1: Develop the project rationale and plan

Before you decide to undertake a safety and quality improvement project focusing on patient safety culture it is important to consider engagement from senior leadership, the resources required to undertake the project and the cultural maturity of the organisation.

Is senior leadership engaged?

Buy-in from leadership is critical to the success of these types of projects. Without this support it can be challenging to get staff to complete the survey and even more challenging to get support for initiatives identified through the survey.

Do you have the resources to take action?

Measuring culture without taking action on the information collected can be detrimental to culture and can make future work in this area more challenging. There should be sufficient resources to undertake the project in its entirety including feeding back the information and the implementation improvement strategies.

Is the organisation ready?

Insights into the culture of a hospital can be gained from existing information such as exit interviews, retention rates, complaints and error reporting (low levels may indicate an issue). The approach to measurement will depend on the level of cultural maturity. For cultures with very low maturity and a lack of trust, asking staff about their experiences and perspectives through a survey can be ineffective and potentially harmful to the culture. Staff may fear the information will be attributed to them or have a sense that nothing will be improved as a result of the work. Alternative approaches may need to be considered to improve the culture before it is measured using a standardised tool.

Before starting the project it is critical to consider and articulate what you want to achieve. Consider the project as a complete improvement cycle; not just the measurement component of the work. This will help to implement the project in a way that leads to improvement.

The project may have multiple objectives. Measurement of patient safety culture can be used to:

• Raise staff awareness about patient safety
• Identify strengths and areas for improvement to target interventions 
• Evaluate the cultural impact of patient safety initiatives and interventions. 

Other considerations when developing your project are:

• Is the focus of the work on the unit, department, hospital or a group of hospitals? 
  
  Culture varies and can be influenced at a unit, department or whole of organisation level. There may be a particular area within the hospital where concerns have been raised –  for example through broader organisational surveys, other safety measures or direct feedback. The project can be set up to focus on this area or as a hospital-wide initiative.
• Are there specific aspects of patient safety culture that have been identified as an issue? 
  
  Insights into the culture of a hospital can be gained from a range of sources such as organisational surveys, exit interviews, retention rates, incident investigations and complaints. These may identify specific areas of focus. Identifying these areas early will inform decisions about which survey to use and if additional questions should be added.

Resources

Key to an effective project are a clear budget and a realistic schedule. It is also important to consider your available resources at an early stage; not only to administer the survey but also to analyse the data, communicate the results, undertake action planning and implement change.  

Reflective questions:

• How much funding and/or resources are available to conduct this project?
• How will you engage staff across the organisation?
• Who within the hospital is available to work on this project?
• What is the availability of the project team?
• When do we need to have the results completed and available?
• Are there any aspects that we need external help with?

Scope

The scope of your work will reflect the project objectives and resources. While measuring the culture of the whole hospital is ideal, it is resource intensive to undertake the complete improvement cycle. Measuring culture without taking action on the information collected can be detrimental to the culture of the hospital and to any future surveys of staff. Where resources are limited, there may be a need to prioritise work for a specific department or use a sample of staff.

Establish a project team responsible for planning and managing the project through to implementation of the action plan.

Engaging people from across the hospital will support shared ownership of the work and engagement in the outcomes. Identifying the project team and key stakeholders is important regardless of whether you conduct the survey in-house or in partnership with an external vendor.

The team will include the following roles, one person may need to take on multiple roles. Engaging this team early and sharing the work load of the project will help to encourage high participation rates and engagement in the process.

Online surveys

The Commission recommends that surveys of patient safety culture are administered online as this offers advantages including:

• There are no surveys or cover letters to print, survey packets to assemble, postage or mailing envelopes to arrange, or completed paper surveys to manage
• The responses are automatically entered into a dataset, so separate data entry is not needed
• The task of data cleaning is reduced by validation checks built into the online survey.

Increasing access and response rates

Providing access to complete the online survey at the hospital will help increase your response rates and ensure that the project is inclusive of all staff. Options for this include:

• Dedicated computer booths where staff can complete the survey
• Access to tablets with the survey
• One-off events to promote the project where there are laptops/tablets available to complete the survey.

Combine with paper based surveys

Some hospitals may choose to use paper-based surveys to support data collection for a small number of hard to reach staff. Where paper-based surveys are used, they should be marked in the dataset.

Combining online and paper-based surveys (a multi-modal approach) can be used to capitalise on the advantages of online surveys, while increasing response rates in hard to reach groups. However, this approach can add a level of complexity to data collection, calculating response rates and reporting. Results from paper-based surveys and online surveys will need to be independently checked and validated before both sets of data are consolidated.

The survey can either be confidential or anonymous. When making the decision consider your hospitals privacy policy, how previous surveys have been conducted and the level of trust.

A confidential survey is one where the survey administrators can link survey responses to individuals, but assurances and processes are in place to ensure that identifiable data will not be released to anyone.

An anonymous survey is one where no identifiers are used to link survey responses to individuals.

The table below outlines the pros and cons of confidential and anonymous surveys.

You may consider using an outside vendor for all or selected aspects of the project. For example you might choose to administer and send out the survey internally, but use an outside vendor for data analysis and reporting. 

If you engage an external vendor:

• Provide a written outline of the work requirements. Make tasks, expectations, deadlines, and deliverables clear and specific. Include information on the requirements of the survey platform, data storage and reporting requirements
• Ensure you stipulate that the data remain the property of the hospital and what will be done with the data at the end of the project – including your expectations for the provision of the raw data file and deletion of the data by the vendor. 

If your organisation is implementing a survey across multiple hospitals - try to hire one vendor for all hospitals. This will lead to consistent data collection methods and make comparison easier and there are likely to be economies of scale.  

Careful planning of the timing of the project will ensure it runs smoothly without undue stress on the project team. Consider the timing of the project carefully. Consider the other events in the hospitals calendar such as public holidays, other staff surveys and accreditation. A draft timeline is provided in the project plan template. This timeline is provided as a guide only and should be updated taking into consideration your project team’s resources.

The key tasks in the project are outlined below. In planning the project it is useful to assign these tasks to members of the team or an external vendor:

• Planning and budgeting - Determine the scope of the project given the available resources, plan project tasks, and monitor the budget
• Establishing contact people - Assign points of contact to support survey administration, maintain open communication throughout the project, and provide assistance
• Preparing publicity materials - Create fliers, posters, email and intranet messages to announce and promote the survey in the hospital, plan when these will occur
• Programming the web survey instrument - Design the instrument, program the survey, and pre-test the instrument
• Distributing and promoting the survey - Distribute email invitations and reminder emails over the data collection period. Actively promote the survey and provide access for staff to complete the survey while at work
• Calculating preliminary response rates - Monitor survey returns and calculate preliminary response rates
• Handling data cleaning, analysis, and report preparation - Review survey data for errors in electronic data files, conduct data analysis, and prepare reports of the results
• Distributing and discussing feedback results with staff - Disseminate results broadly to increase their usefulness, target feedback to meet stakeholder needs
• Developing action plans - Investigate and understand the results to develop a plan for improvement. This may require additional information from interviews, focus groups or observation
• Monitoring the implementation of the interventions and feedback on the action - Keep staff and executive informed on the progress of the interventions.

Additional tasks for paper based surveys include:

• Preparing paper survey materials - Print surveys, prepare postage-paid return envelopes and labels and assemble these components for survey distribution
• Distributing and receiving paper survey materials - Distribute surveys and reminder notices and handle receipt of completed surveys
• Data entry and cleaning - Enter paper-based surveys, conducting spot checks and combining the datasets from paper based and electronic collections.