Using Culture in Your Organization

This article is an excellent read!  Patient safety culture and patient safety are the buzzwords these days, but what are some actions to help you improve your patient safety culture?

  • First, understand the culture of your organization. This is truly the foundation for prioritizing patient safety.
  • Involve your patients and their family members as active participants in their care. This helps increase their health literacy, which contributes to improved patient outcomes.
  • Reinforce that reporting events is necessary so you can continually evaluate and improve systems—-not to provide fuel to blame the healthcare providers. Providing a user-friendly reporting system that is integrated into your organization’s daily processes will increase the number of reported events and unsafe conditions.

To sum it up:  “In the long run, patient and workforce safety will not only be a moral imperative but will likely be critical to sustainability and essential to delivering on value.”   (Gary Kaplan, MD)

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Administering a Culture Survey


Why assess your culture?

You can improve what you measure. Without measuring, you have no way to know if you are improving.

These statements are especially true when it comes to assessing your culture. It may be easy to take a quick poll of staff and infer their perceptions to that of the rest of your organization’s employees, but there’s no certainty in your results. Using a standardized survey tool can provide measurable and meaningful feedback.

Another reason to assess your culture is because many regulatory and certifying bodies now require or recommend measurement of an organization’s patient safety culture. This is because they, too, recognize the clear connection between strong cultures with open communication and the effective implementation and sustainability of patient safety and quality improvement programs.

  • The Joint Commission
  • Leap Frog
  • CMS Merit-based Incentive Payment
    System (MIPS)
  • CMS Quality Assurance and Performance Improvement (QAPI)

The Center for Patient Safety has been administering culture assessments since 2010, and we understand the most successful organizations have a fine-tuned process for administering the survey and analyzing their results. In this article, we’ll discuss some of the most pertinent planning details when preparing to launch a survey. Subsequent articles will include diagnostic tips for evaluating your survey data.

While standard online survey templates may ease the burden of survey administration, there are four key areas that, if addressed upfront, can save time, resources, and frustration in the long run.

1. Which Tool.
The Center has always supported the Agency for Healthcare Research and Quality’s (AHRQ) Survey on Patient Safety (SOPS) tools though there are many other surveys that can provide a similar analysis. The SOPS tools have been developed for a multitude of healthcare provider types with specific, relevant questions asked, based on varying care settings, such as nursing homes, hospitals, ambulatory surgery centers, pharmacies and medical offices. These surveys have also been psychometrically tested and validated and are available in more than 40 languages.

2. Which Medium.
How do you normally administer surveys to your staff? Are they at ease with an online version, or are they most comfortable with a paper survey? While this seems like an insignificant question, it is quite important. If staff are fearful, they will hesitate to write unfavorable feedback on a paper survey because they think their handwriting will be recognized. However, they may also think the organization will track their online response back to them for purposes of punishment. Using a third party vendor often works best and creates a neutral environment for staff to respond. Consider offering a combination of online and paper surveys. Allow staff to take the survey in a confidential environment with varying options for submitting them. Providing options other than submitting them to their manager increases anonymity, resulting in truer results.

3. Custom Questions.
We often get question-happy when it comes to surveys. It’s efficiency at its finest: “While we have our staff’s attention, let’s just go ahead and ask a few more questions, like what they thought about the EHR implementation, their employee engagement for the year and what sport the organization should have at the next company picnic.” This is a big no-no. If you’re using a standardized survey, keep the list of questions short and relevant. The AHRQ SOPS ask about 45-50 questions and can take up to 15 minutes to complete. Limit additional questions to no more than five and keep it related to culture. More than five questions on an unrelated topic will cause confusion and create survey fatigue.

4. Promotion.
Staff won’t do something if they don’t know they need to do it. Put a little effort into marketing the survey and you’ll get a very valuable return. The more staff that take your survey, the more accurately your results will reflect the culture of your organization. This in turn gives you better data to analyze. Plan with your marketing department, do a search on Google, or harness your creativity to develop posters and email templates. Ask your CEO or President to write a brief memo about the value and importance of all staff taking the assessment and their desire to see honest feedback. Put a link to the survey on your Intranet; distribute surveys at a monthly staff meeting; offer a certificate for a free drink for turning in a completed survey; or host a pizza party if you reach your target response goal. These are small tokens of appreciation that can have a big impact on getting valuable insight.

In Summary 

Your time will be most efficiently spent analyzing the results and preparing action plans post-survey, so addressing these four areas upfront will remove many of the headaches that can go along with planning and administering a survey. If a third-party option is a better choice for you, please contact the Center for Patient Safety to discuss our custom options. We’ll even help in the analysis of your survey results. Find out more information about our survey services.

Diagnostic Error

By Michael Handler, MD, MMM, FAAPL
CPS Medical Director

As most of you know, the patient safety movement as we know it was started in 1999 with the report “To Err is Human” and was followed in 2001 by its second report, “Crossing the Quality Chasm.” The third report in that series was published in September, 2015 and that report, entitled “Improving Diagnosis in Health Care”, was another landmark report in patient safety and the culmination of many years of study of the important process of medical diagnosis.

Basically, this publication addresses in great detail the topic of diagnostic error. Diagnostic error is defined by the IOM as the failure to establish an accurate and timely explanation of the patient’s health problem(s) OR the failure to communicate that explanation to the patient. Although the definition is somewhat controversial in the scholarly circles, the implication of some type of discrepancy in diagnosis is the common denominator and can include over-diagnosis, under-diagnosis or misdiagnosis. And the prevalence is quite staggering. Errors of this type are estimated to be responsible for 40,000 to 80,000 deaths/year in this country. Seventeen percent of adverse events are related to diagnosis and 20% of readmissions are related to the wrong diagnosis. Five percent of primary care visits involve a preventable diagnostic error and ten patients are harmed every day in clinics or emergency departments. It is likely that most of us will experience at least one diagnostic error in our lifetime, sometimes with devastating consequences.

So, I know what you are thinking. It is always the other clinician—not me—who makes errors in diagnosis. In fact, fewer than 10% of physicians admit to one diagnostic error per year and some physicians deny ever making an error. So, what are some of the more common missed diagnoses? Well, missed CVA, epidural abscess, meningitis, sepsis, acute coronary syndrome, abdominal pain and failure to diagnose a cancer, to name a few. Professional liability carriers state that diagnostic errors are second in the number of closed claims and the highest category of average indemnity payment.

When you look at why diagnostic errors occur, you must look at patient variables, system variables and practitioner variables. Patient variables include the stage of disease, how it manifests, how it is described and when help is sought. System complexity includes discounted care, communication barriers, production pressure and difficult access to care and expertise. Finally, practitioner variables include knowledge and experience, access to patient data, tests, consults, skill in clinical reasoning and stress, distractions, mood and time to think. We must also understand the concepts of cognitive biases of providers which lead to error. These biases include such things as anchoring bias which means relying on your initial diagnostic impressions, despite subsequent information to the contrary. These types of biases can lead to errors which perpetuate themselves.

How can we reduce errors? There is not one clear answer, but we can implement processes such as double checks and checklists to reduce reliance on memory and accept feedback from other clinicians whether from physicians, nurses or other professionals. We must also remember to work on improving teamwork, communications and handoffs.

The IOM report concluded with several goals to improve diagnosis and reduce diagnostic error, and these span the entire health care spectrum:

  1. Facilitate more effective teamwork in the diagnostic process among professionals, patients and their families.
  2. Enhance health care professional education and training in the diagnostic process. Educators are being asked to be sure their curricula include skills in clinical reasoning, teamwork and communication.
  3. Ensure health information systems support patients and health care professionals in the diagnostic process. Special reference was made to the elimination of such things as copy and paste, meaningless alerts and templates from the record. Instead, health IT vendors should be encouraged to work together with users to ensure that health IT demonstrates usability, incorporates human factors knowledge and fits well with clinical workflow.
  4. Develop and deploy approaches to identify, learn from and reduce diagnostic errors and near misses and establish ways to provide systematic feedback to physicians and other providers in the system. The goal is to find specific actionable items in a root cause analysis and actually fix them.
  5. Establish a strong culture of safety that supports the diagnostic process and improvements in diagnostic performance.
  6. Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from errors and near misses.
  7. Develop a payment and health care delivery system that supports the diagnostic process and the final goal is to provide dedicated funding for research on the diagnostic process and errors.

So, what are some things that you can do to reduce the incidence of diagnostic errors?

  • Work together with all members of the healthcare team to identify, learn from and reduce diagnostic errors. This includes collaboration with all members of the team including physicians, nursing, pharmacy and all other possible sources of information to help with the right diagnosis.
  • Sharpen communication skills and improve handoff communication so that nothing is missed which may lead to the right answer.
  • Use the electronic health record as a communication tool and not copy and paste just to get the documentation done — make sure it is correct and true.
  • Be willing to accept suggestions and feedback from others, always keeping the best care of our patient top of mind.

The area of diagnostic error continues to be a very dynamic area in patient safety and many unanswered questions remain. We must continue to look for opportunities to help minimize these errors to help to keep all our patients safe.

MICHAEL HANDLER, MD, MMM, FAAPL, is the Medical Director for the Center for Patient Safety. He has been an OB/Gyn physician since 1985, operating private practices in Missouri through 2007. The last ten years Dr. Handler has served as house obstetric physician, medical director for quality improvement, and chief medical officer for several SSM Health hospitals in the St. Louis area. In early 2017 he accepted the position of chief medical officer for Amita Health Alexian Brothers Medical Center and Amita Health St. Alexius Medical Center in suburban Chicago. Dr. Handler earned his medical degree at University of Missouri-Kansas City School of Medicine. He completed his internship and residency in Obstetrics and Gynecology at St. Louis University Hospitals. He has a Master of Medical Management degree from Tulane University and is a fellow of the American College of Physician Executives.


The Center for Patient Safety has released the Summer Newsletter.  We’re certain you’ll find something of interest related to patient safety at your organization!  Download the full newsletter to read more on the PSO legal environment, upcoming events, best practices, and much more!  CPSNews – a publication for providers across the continuum of care – Download.

Do you have an EMS Patient Safety Plan?

While we have all heard the old saying, “do you plan to fail or fail to plan,” this short statement has likely influenced many people to re-evaluate a current process or situation in their life.  The specialty area of preventable harm or patient safety is gaining strong momentum in Emergency Medical Services, which has relied on another common old saying “do no harm”.   While the desire to do no harm has always been present in EMS, it isn’t until recently that coordinated efforts have come forward to inform, organize and delineate actionable plans and steps to reduce preventable harm at the organizational level.

The EMS Patient Safety Boot Camp is a great way to get started, or to improve your current patient safety journey.  An opportunity in beautiful, cool Denver is waiting for you!


Patient Safety Resources

Are you frustrated because others in your organization don’t seem to have the same passion or urgency to improve patient safety?  Limited resources and increasing financial pressures are driving the focus on patient safety down on the list of priorities.  It’s difficult to build a business case to support the importance of constantly improving patient safety.  Now there’s help!  The Institute for Healthcare Improvement and National Patient Safety Foundation recently published a resource to assist you – and it’s free!  Remember that improving patient safety is a journey, not an initiative.  Never give up!

Press Release: EMS Medical Advisor


Brian Froelke, M.D., is named first EMS Medical Advisor at the Center for Patient Safety.

Download the Press Release

Jefferson City, Mo. – The Center for Patient Safety (CPS) announced that Brian Froelke, M.D., an emergency medicine physician at Washington University School of Medicine in St. Louis, has been named the center’s first Emergency Medical Services Medical Advisor. CPS is a national organization, based in Missouri, dedicated to promoting healthcare safety through a reduction in medical errors.

For more than 10 years, CPS has worked to improve safety for both patients and healthcare providers by fostering a culture that encourages healthcare workers to quickly report medical errors so they can be quickly addressed and prevented in the future. CPS was also one of the first organizations in the nation to be certified as a Patient Safety Organization (PSO), which offers federal confidentiality protections to healthcare workers for reporting medical errors. Additionally, CPS was the first in the nation to provide EMS PSO services, including sharing and learning opportunities with EMS providers based, in part, on the collection of data on adverse events.

“Onboarding an EMS Medical Advisor is a logical next step, and Dr. Froelke is an obvious first choice for this position. He has long been involved with CPS and is a recognized EMS leader with a passion for patient safety,” said Alex Christgen, Executive Director of CPS. “We are delighted that he is joining CPS in a voluntary role as Medical Advisor to our EMS services.”

EMS, as a profession, is called to change in light of new laws and a healthcare system that is placing more emphasis on patient safety improvements. To meet new expectations, the advancement of safety in EMS must be a focal point of leadership across the nation.

Dr. Froelke, an assistant professor of emergency medicine, is board-certified in emergency medicine and emergency medicine EMS. As EMS Medical Advisor, he will engage leadership and support CPS by conducting activities and supporting programs that improve and promote patient safety efforts nationally and internationally among air and ground medical transport services. He also will advise the CPS team on current and long-term safety objectives as well as provide education and awareness opportunities among the EMS healthcare community.

Dr. Froelke noted, “The Center for Patient Safety is a national leader in the field of EMS, and I look forward to working with this group to improve the culture of safety for patients and healthcare providers. The participation of the center’s member EMS agencies and medical directors is a key step toward improving our systems and reducing preventable medical errors. Analysis of data on adverse events has already lead to real-world solutions and initiatives that have improved patient care. I believe this partnership, with the support of an academic medical center like Washington University School of Medicine, will strengthen these endeavors.”

“We are excited to welcome Dr. Froelke,” said Lee Varner, Patient Safety Director at CPS. “He brings a wealth of knowledge and experience from his diverse background in EMS including many roles and projects that have spanned the regional, state and national level.  Dr. Froelke’s experience, coupled with his desire to improve EMS patient safety, will add an exciting level of expertise to the CPS team.

CPS Safety Culture Assessment

“I am very impressed with the reports. I know my leadership team will be thrilled to have the individual reports by their division. This
has been a very positive experience for me.”

“We love the Center’s patient safety culture survey feedback reports. The department level reports give a level of granularity we
were lacking with previous surveys.”

The Center focuses heavily on culture to support patient safety improvement. A punitive environment discourages open communication of events and near misses, creating a barrier to learning about the mistakes that are occurring.

The Center has been administering the AHRQ Surveys on Patient Safety (SOPS) since 2011. Since then, we have administered hundreds of thousands of surveys and provided survey support, feedback reports, and consultation to hundreds of organizations.

A select group of 42 hospitals were selected from the 2016 database. These organizations were selected based on their activity level and extended use of the Center’s resources and services for PSO participation, webinar attendance, resource usage, and consulting. An analysis of their patient safety culture scores are compared to the national compare database from AHRQ. More than 14,000 surveys were analyzed.

  • 7 dimensions were equal to or higher than the 50th AHRQ Percentile
  • “Nonpunitive Response to Error” ranked in the 75th AHRQ Percentile
  • 23 questions were equal to or higher than the 50th AHRQ Percentile
  • “We are actively doing things to improve patient safety” ranked in the 90th AHRQ Percentile

The top strengths for these organizations align with the top strengths from the 2016 AHRQ Hospital Compare Database:

However, the areas with potential for improvement, or the lowest scoring dimensions, indicate variation in two of the composite scores:

The Center has had a long history with a focus on creating a nonpunitive environment. The dimension includes the question “Staff worry that mistakes they make are kept in their personnel file.” The higher score for the composite “Nonpunitive Response to Error” is statistically significant (>5%). Compared to the national average, the organizations in our select group are in the 75th percentile nationally.  While most of the respondent emographics for the hospitals included in the Center’s summary align with the AHRQ Compare Database, it is worth noting:

  • 15% of staff indicated they report 11-20 event reports per year; 29% indicated they report 3-5 events per year (statistically significant variation from AHRQ National Compare Database)
  • Higher numbers of reports suggest an environment that supports open communication without a fear of retribution or punishment.

Additional notes:

  • 85% of respondents had direct patient care
  • 41% of staff worked 1-5 years in the current work area
  • 36% of staff worked 1-5 years in the current hospital; 13% worked 21 years or more in the current hospital
  • 44% of staff indicated they were a Registered Nurse

Click here to download the full data report.

Interested in receiving reports like this for your organization’s departments or locations? Request a no obligation price estimate with a summary of the Center’s survey administration services.

CPS Releases PSO Report: #CultureForward

The Center for Patient Safety, a Patient Safety Organization (CPS PSO), is pleased to present this report summarizing some of the information we are learning from the collaborative participation of healthcare providers across the country.

Please note throughout this report, each contracted provider with the CPS PSO participates voluntarily. Each participating organization may elect to report different types of patient safety events, or they may elect to only submit information about the least or most severe cases, therefore, analysis of PSO data is always conducted with this understanding. Benchmarks and rates are unattainable without having a complete data set, so the information in this report is intended to offer a snapshot of the trends and findings from the thousands of events we have collected from hospitals, long-term care organizations, health systems, home health, emergency medical services, and medical offices.

We hope you find value in the information we have provided in this report. If you are not yet participating with a PSO, please contact CPS and we would be happy to help you with your selection process. All PSOs are different and it is important that you find the one that best meets your needs. As a reminder, organizations can participate with more than one PSO. We would encourage you to do so if there are beneficial offerings to your organization. Some PSOs are specific to, for example, children’s hospitals, while others may be specific to Pharmacies. CPS works across the continuum of care and is positioned to help you achieve your greatness.

I encourage you to review this report and compare the findings to patient safety concerns at your own organization. Contact me or any member of the team for information about how we can support your organization as an extension of your quality or safety department. We want you to be successful!

Download the Report

Patient Safety Boot Camp Now Available for EMS

Patient Safety Boot Camp Now Available for EMS

There’s lots of talk in the EMS world about patient safety and patient culture, but few resources to assist agencies in improving their culture and moving forward.

The Center for Patient Safety (CPS) has taken action. Based on similar work done in the acute setting several years ago, we have developed a day-long Patient Safety Bootcamp for EMS professionals.

Attendees will learn the basics of the science of patient safety, human factors, error reduction, process improvement and measurement. Presentations are in TED talk style, with “work-out” discussion sessions after each topic for attendees to analyze how their agency is fairing relative to the presented topic. Tools such as fishbone, root cause analysis, prioritization matrices and action plans are used throughout the day.

The goal is for each participant to leave the boot camp with either the start or refinement of a patient safety plan. Presenters are safety specialists with many years of experience in patient safety and quality improvement.

I encourage EMS personnel to consider this unique opportunity to dive in to patient safety!


JULY 25:  , BRANSON, MO Preconference workshop- MISSOURI EMS EXPO

  • Special guest speaker: TBA

AUGUST 2: Tomball, TX –Greater Houston area

  • Hosted by- Northwest Community Health
  • Special guest speaker: TBA

AUGUST 23-24: DENVER, CO as part of the National EMS Safety Summit


  • Special guest speaker: TBA


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.