Stage 4: Feedback, action planning and improvement strategies

Feedback is key to a patient safety culture project. Ideally, feedback should be provided broadly – to management, administrators, boards of directors, committees, and staff—either directly during meetings or through communication tools such as email, intranet sites, posters, presentations or newsletters. The more broadly the results are disseminated, the more useful the information is and the more likely respondents will feel that taking the survey was worthwhile.

A lack of feedback to staff can have detrimental effects on culture and can impact engagement in future surveys and quality improvement activities.

Increasingly, results are able to be fed back through electronic tools which allow users to interrogate the data by different demographics in the survey. These can be useful for engaging managers and staff with the data. As with paper reports, any online tools should not report on groups with less than five responses.

A survey of patient safety culture should be seen as a starting point for further, targeted, discussions with hospital staff. Interviews, focus groups and direct observation can be used to verify or deepen your understanding of the survey data or find out more about an issue identified in the survey data.

You may also consider triangulation with other data sources already accessible to your hospital. For example:

• Other safety and quality measures
• Incident reports
• Retention rates
• Complaints and compliments
• Broader organisational culture surveys
• Workplace health and safety data
• Exit surveys.

Developing actions for improvement are a crucial part of conducting a patient safety culture improvement project. For effective action planning you will need leadership support, board engagement and an action planning team. Your action planning team should be multidisciplinary, including at least one senior leader and key stakeholders that will be impacted by any change initiative.

Tips for effective action planning include:

• Hold multidisciplinary focus groups with a mix of staff with different roles, expertise, skills and perspectives to develop the action plan
• Focus on the shared goal of improving patient safety
• Send a summary of the survey findings before the focus group highlighting both areas that need improvement and areas where the hospital is doing well
• Focus on a limited number of achievable actions – not all change needs to be drastic, focus on something small and feasible first
• Ensure there is engagement with senior leadership and staff throughout the process.

An action plan is an essential part of any quality improvement process. It documents the your goals, approach to improvement, who is responsible, what resources are required, your timeline and how you will measure progress. 

There are a range of action planning tools available. The Agency for Healthcare Research and Quality (AHRQ) has developed an Action Planning Tool to support use of the survey results from the Hospital Survey on Patient Safety Culture (HSOPS 2.0). It provides step-by-step guidance to help survey users develop an action plan to improve patient safety culture and an action plan template your hospital can use. 

Outcomes of the action planning and progress against the plan should be fed back to hospital staff. 

Based on the results of the survey analysis and action planning process, improvement strategies can be implemented to enhance the patient safety culture at your hospital. Consider what would work in your hospital and engage staff throughout the process. 

Improving patient safety culture can be challenging and it can be difficult to know where to start. Small changes can be helpful but in some cases larger changes may be required. Additional resources may be required to undertake change programs, including support from external experts or additional internal resources. Long term commitment from senior leadership is important to ensure momentum and resources are maintained.

A range of resources are available on potential improvement strategies:

• AHRQ has compiled a list of practice resources to improve patient safety culture and patient safety in hospitals. While this resource list is not exhaustive, it is designed to give initial guidance to hospitals seeking information about patient safety initiatives. The list is arranged by the composites in the HSOPS 2.0
• The Manchester Patient Safety Framework (MaPSaF) is a tool to help healthcare organisations reflect on their progress in developing a safety culture. The MaPSaF can be used to evaluate a specific intervention or reflect on the current safety culture to develop suggestions for improvement in a workshop
• The Commission’s Communicating for Safety resource portal provides a range of resources which could be used to support improvements in communication and handover.

Continuous effort is required to change and improve culture.  For this reason, it is important that continuous monitoring is conducted and the action plan is evaluated. Progress can be tracked against a range of measures such as staff turnover, complaints, error reporting and annual organisational culture surveys. Qualitative approaches such as focus groups and interviews can also be useful to monitor progress between surveys.

Formal measurement of patient safety culture is recommended every two to three years. This allows sufficient time for work from the previous improvement projects to impact on the culture of the organisation.

Each time the survey is conducted, the findings must be distributed back to participants. Each report should compare to previous rounds of data collection, indicating if there has been any improvement in the hospitals patient safety culture.