AHRQ Releases SOPS Action Planning Resource

ActionPlanningThe Agency for Healthcare Research and Quality has issued an Action Planning Tool to complement their suite of safety culture survey assessments.

The tool is meant to be used after the survey has been administered and the results have been collected. The tool helps users define goals, process measures, and initiatives to be implemented, including a framework for determining who will lead the initiatives, how resources will be distributed, and strategy planning for potential barriers.

Find out more and download the report at AHRQ.gov.

Interested in surveying your organization? CPS can save you time and resources by administering the survey for your organization.  Find out more about CPS survey services.

Culture Measurement as Key Improvement Tool

A success story from Cox Health

The survey of patient safety culture has become a key improvement tool for CoxHealth, a health system across 5 campuses with 954 licensed beds. CoxHealth spans 83 clinics and serves 25 counties across southwestern Missouri. They have used the survey administered by the Center for Patient Safety (CPS) since 2010. All clinicians in the inpatient and outpatient settings as well as the clinics and EMS agency are encouraged to participate. While participation is a challenge, it has steadily increased over the years to 47% average due to improved communication. The surveys are discussed in the corporate newsletter as well as at leader meetings. Senior leaders discuss the surveys with staff during their regular rounding and encourage participation.

Download this article in the full Fall 2015 Newsletter.


Survey results are aggregated and distributed by CPS, including department level reports for those units large enough to ensure anonymity. Vice presidents and department leaders are responsible for discussing results at staff meetings and identifying opportunities for improvement. Departments using the TeamSTEPPS module use the survey results to identify needs and focus education. Rachel Wells, Patient Safety Officer, advised, “The survey is used as a tool. It helps open the door for us to guide patient care departments and can assist them in focusing their priorities.”


There have been many successes at CoxHealth!

  • The Radiation Oncology department had significant improvement, going from zero survey areas scoring above the 90th percentile, to seven survey areas above the 90th percentile in the last survey.
  • The overall non-punitive response to error score was above the 90th percentile in 2014, which shows a high level of staff trust with management. Patient safety culture has been nurtured as management is supportive and consistently improves processes when opportunities are identified. Jeff Robinson, Radiation Oncology Director, reveals, “Safety Surveys tend to turn the invisible into the visible. Once we saw where we are at, we came together to make the needed improvements.”
  • Cox Monet Hospital stands out as a benchmark within the system. It is a critical access hospital, and the staff’s access to senior leaders is outstanding. When opportunities for patient safety improvement are identified, teams work together to make improvements, which are communicated across the hospital to close the loop. The system is working to replicate this workflow model across all facilities.


Wells’ words of advice based on her experience with the culture surveys: “Patient safety is a journey and the survey is a tool to measure our progress and help us focus along the way. Doing the survey once is not enough. It needs to be routinely offered to see how we’re doing.”

Congratulations to CoxHealth for their focus and improvements in patient safety!


For more information, contact the CoxHealth Office of Patient Safety at 417-269-6589.

Aligning Culture with the Strategic Plan

A success story from SSM Health

Patient safety is a top priority for SSM Health, which owns and operates 20 hospitals, more than 60 outpatient care sites, a pharmacy benefit company, an insurance company, two nursing homes, comprehensive home care and hospice services, a technology company and two Accountable Care Organizations in four states. SSM Health has used the patient safety culture surveys to measure its progress and identify areas for improvement since 2007. While all hospital staff was surveyed in early years, SSM Health limited the survey to caregivers and added home care and long-term care facilities in 2014. Its many medical group practices across all four states were added in 2015 utilizing the medical practice survey tool. All caregivers are now encouraged to share their opinions about patient safety by completing the survey administered by the Center for Patient Safety (CPS).

Download this article in the full Fall 2015 Newsletter.


Participation in the 2015 survey increased to 62.9%, with some units achieving 100% participation. When asked why participation has steadily increased over the years to such a high level, Debby Vossenkemper, System Director/Patient Safety Officer, credited a consistent senior leader focus with leadership accountability, survey communication process and a strong rollout process. “Our caregivers as well as leaders are serious about improving patient safety,” Vossenkemper said. “Action is taken based on input from the front-line caregivers. In addition, we have a process to systematically communicate within each department details about the surveys, review department specific improvements from prior surveys and distribute the surveys to leaders through the use of a communication tool kit”. “Our System CEO, Bill Thompson, sent a letter in January to all employees setting expectations and explaining that the patient safety survey and employee partnership survey are closely aligned and equally important. Our System Vice President of Patient Safety and Quality, Dr. Kevin Johnson, sent a similar message to all clinicians. System Communications and Human Resources are also very involved in the process, which makes a big difference.” The weekly participation reports by department from CPS were also instrumental in driving up participation, enabling SSM Health to meet its participation goal.

“The Center for Patient Safety has been a pleasure to work with on the safety surveys – this is our second year of doing so. Nothing is too much to ask and it’s always done with a smile! Changes to customize the surveys and reports for SSM Health made a huge difference to our staff’s buy-in.”
– Debby Vossenkemper, System Director/Patient Safety Officer


Survey results are aggregated by CPS, who provides reports at the department level. This is helpful, as similar services across the system can compare results with each other. A toolkit including the results, a primer on how to read them and comparisons with previous survey results is distributed to all senior and clinical leaders. Leaders are expected to review, and discuss with their teams, improvements that have been made based on the staff’s input from previous surveys. In addition, the results are shared with senior leaders and System/Regional/Entity Patient Safety Councils to ensure a consistent understanding of the results across the organization and by facility. The top improvement opportunities are identified, and teams of front-line staff develop action plans, which are aligned with the organization’s strategic plan and goals. Each department is expected to have a patient safety goal which is posted on a SharePoint website for transparency across SSM. Each facility’s senior leadership team defines an action plan related to two areas of focus related to the survey results which is reviewed quarterly at the Patient Safety Quality Council. In addition, the action plan addresses both areas of focus related to patient safety and employee partnership.


While each facility selects areas of improvement based on its specific results, during the prior survey cycle the hand-off process between units, especially between the Emergency Department and nursing floors, was identified as an opportunity in several of the entities. Therefore, CQI teams are working to further study and improve the handoff process. Last year, one hospital identified an opportunity to increase its event reporting rate to better understand where and why events or near-misses were occurring. This year they celebrated a 28% increase! The senior leadership team “owned” the event report goal and made it happen by reinforcing the goal in various ways, including conversations during senior leader rounding, No Harm Team meetings and distribution of talking points, and daily safety briefs.


Vossenkemper shared two learnings from SSM’s survey experiences: First, identify one or two areas that need improvement and drive change, as opposed to trying to improve everything at once. Second, use quality improvement techniques to achieve incremental improvement and set stretch goals to achieve results. Congratulations to SSM Health for their focus and successes in improving patient safety!


Contact Debby Vossenkemper at [email protected] or 314-989-2197.

AHRQ Releases ASC Patient Safety Culture Survey

The Agency for Healthcare Research and Quality (AHRQ) has added a new healthcare provider survey to their suite of surveys. The latest release is the ambulatory surgery services (ASC) survey. In general, the AHRQ surveys are designed to measure the culture of an organization. The survey captures opinions and attitudes of staff, while the results of the survey can locate cultural strengths and weaknesses. Often the survey is part of an improvement initiative that involves surveying every 12-18 months in order to gauge improvements over time.

AHRQ defines ASCs as facilities 1) where patients have surgeries, procedures, and treatments and are not expected to need an inpatient stay, and (2) that have been certified and approved to participate in the Centers for Medicare & Medicaid Services’ ASC program.

Interested in finding out more about the ASC patient safety culture survey? Check out resources on AHRQ’s website.

AHRQ Medical Office Survey on Patient Safety Culture – Success Stories

To prevent adverse events from occurring, the Agency for Healthcare Research and Quality (AHRQ) recommends you measure your patient safety culture.   AHRQ’s patient safety culture surveys provide feedback on your organization’s communication, teamwork, patient safety, leadership, and staff engagement.   The results can be used to measure your current culture and provide insight into the most effective methods to improve the patient safety culture at your healthcare organization.   The survey is available for medical offices, LTC, hospitals, and pharmacies.

AHRQ recently hosted a webinar, discussing the results of the 2014 Medical Office User Comparative Database Report.   On the webinar, survey users also shared how they have successfully applied the survey results to improve patient safety culture at their medical offices.   View the recording.

For more information about the Medical Office Survey on Patient Safety Culture, visit AHRQ or learn more about the Center for Patient Safety’s survey services.

Center releases Fall 2014 EMS PSO Newsletter

Fall EMS 2014The latest newsletter from the Center for Patient Safety has been released. The Fall 2014 EMS PSONews contains information on the recently released PSO Safety Alert and EMS Safety Watch, articles on the legal environment to help maximize federal protections from the PSO, patient safety culture topics, and much more!   Download the newsletter or view on Issuu.

CPS attends Air Medical Transport Conference in Nashville

The Center for Patient Safety (CPS) recently exhibited at the Air Medical Transport Conference (AMTC) in Nashville, Tennessee.  This exciting opportunity allowed us to meet with industry leaders, experts, and providers in air medical services. The conference brought a wide group of these attendees to the exhibit hall with  new and innovative equipment and technology. CPS enjoyed sharing information about our services with air and ground EMS during breaks.

Many people were not familiar with the services available from a Patient Safety Organization (PSO), like the Center for Patient Safety.   Many states do not have peer review protection for their quality and safety work, but, by participating with a PSO, federal protection is available for safety and quality work. A PSO offers a safe way to share adverse events, near misses, and unsafe conditions. We all learn in different ways, but we can agree learning by our mistakes can be costly. Working with a PSO offers the opportunity to report errors in a safe way so we can learn from each other to help prevent future events.

Many of the programs and sessions at the conference addressed culture issues. Just Culture reshapes our understanding of accountability, the role of the system, and the role of human behavior. This allows us to distinguish human behaviors and develop a consistent way to establish a safe environment by managing the system and behavior. As we shift the way we think, act, and react, we are beginning to change the culture in EMS.   Just Culture is not a one day event; it’s the starting point for an organization’s journey as they shape their future course.

If you would like more information please contact us.

AHRQ webinar to present Medical Office Survey Highlights

The 2014 Medical Office User Comparative Database Report, released earlier this year, will be summarized by the Agency for Healthcare Research and Quality (AHRQ) via webinar on Tuesday, September 16, from 1-2pm EDT. Survey administration experiences and implemented improvement initiatives will be provided from the perspective of a system with more than 200 medical offices as well as a a federally qualified rural health center clinic. Register for this webinar.

The Center for Patient Safety (CPS) fully supports this diagnostic tool to measure your patient safety culture. If you are interested in administering the survey in your medical offices, let CPS provide you with an estimate., or learn more about CPS survey administration.


Strategy for a National EMS Culture of Safety

Almost a year later – have you read it yet?

It’s been almost a year since once of the most important safety and culture documents has been released. The Center for Patient Safety encourages you to read the Strategy for a National EMS Culture of Safety and support discussion with your peers.

Culture surveys are gaining ground

SOPS Rings_webCulture surveys are gaining ground and the results are encouraging.

Each year, we see more and more healthcare organizations come to the Center for Patient Safety for culture surveying services. Our services include response reports that analyze the culture at the organizational level as well as the unit level (where applicable).   This allows for analysis at the sub-culture level which undoubtedly exists within every unit and contributes to the organization’s overall culture. Each unit receives their own culture analysis that includes direct access to resources to assist unit managers and human resources implement improvements.   Additionally, survey administration from the Center includes two survey cycles in order to obtain a baseline and follow-up.   In 2013, the Center administered the AHRQ Survey on Patient Safety (SOPS) to thousands of healthcare staff in more than 60 hospitals and provided hundreds of unit-level response rate reports.

The Results

From 2012 to 2013, hospitals participating with the Center that were actively involved in patient safety efforts and implemented changes based on their baseline survey analysis saw positive changes. These changes related to improvements in teamwork, communication and implementation of a “just” culture. Overall, the Center for Patient Safety saw improvements that included: (more…)


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

Read More


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.