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.

PSO Legal Update: A new focus on reporting

The Center for Patient Safety’s staff has been fielding a lot of questions about what information can be protected under the Patient Safety and Quality Improvement Act and how that relates to reporting to the PSO.  The basic rules have not changed, but there is some new focus on reporting, which is the touchstone for all the definitions in the Act and the Final Rule.  So, this explanation will start at the beginning.  

The Act defines Patient Safety Evaluation System (PSES) as “the collection, management, or analysis of information for reporting to… a patient safety organization.”  The PSES can collect, manage and analyze; it need not just gather information and report it in its “virgin” form.  Inside the PSES, information can be aggregated, sorted, evaluated or otherwise processed as part of the organization’s patient safety activities.  

The Act has a two-prong definition of Patient Safety Work Product (PSWP).  The first prong is information “assembled or developed by a provider for reporting to a patient safety organization and… reported to a patient safety organization.  AHRQ refers to this as the “reporting pathway.”  That information needs to be gathered for purposes of reporting and actually reported.  The language itself does not address non-reported material.

The second prong of the PSWP definition, though, is the source of much value for PSO participants, as it is what protects the actual work within their PSES.  The Act also defines as PSES items “which identify or constitute the deliberations or analysis of, or identify the fact of reporting pursuant to, a patient safety evaluation system.”  To meet this definition, the PSES must conduct some deliberation and analysis of information that it has acquired.  And since the purpose of the PSES is to develop reportable information, the deliberations and analysis must take place in the course of (and generate material related to) synthesizing reported material.

CPS does not believe this means that ONLY information reported to the PSO can be protected.  We do, however, recommend that our participants only try to protect information that comes into the PSES or is developed within the PSES as part of a process that leads to reports to the PSO.  Those reports can be in the form of Common Data Format reports, root cause analysis that you send to a PSO or information that is functionally reported in connection with some actual reporting.  (If you have questions about functional reporting, you should contact CPS.)  And remember, you can meet the reporting requirement by sending your PSO PSWP or non-PSWP.  So, if you need to share a part of your RCA with a regulator, you can still report it and protect the process that developed it.  The point of reporting is to share your learning with others.

CPS staff will continue to remind our participants of the importance of reporting.  We don’t know how much is enough, but we know that an absence of reporting will lead to an absence of protection.

CPS Releases Annual Report

The last two years were a rollercoaster of change! But the passionate team of staff at the Center for Patient Safety (CPS) was on onboard to embrace all of the changes and use them as a rare opportunity to step back and look at where we were, and consider closely the direction we wanted to go. We found our way back to our roots of doing what we do best: helping providers improve patient safety. And we’re back at it, stronger than ever with innovative new programs and an enhanced mission. Our core competency remains our ability to support providers across the continuum of care in a non-punitive environment.

While the journey in a non-profit organization is arduous, it is unequivocally rewarding. Our team members face pressures of minimal resources, financial constraints and high expectations, but their ideals and commitment to patient safety never waiver. They are passionate about what they do and it shows in the way they amaze and inspire the individuals and groups that we work with every day. We were excited about the ability to rediscover our organization over the last year, but we also knew the next critical objective was to secure funding. I know, through inroads and allies with many individuals and organizations, we have a bright and sustainable future.

At this time, I would like to personally thank all of the supporters and healthcare providers we have had the pleasure of working with throughout 2016. You are the promise we have for our patients and the inspiration we have for one another. You are the result of hard work and dedication. You are the reason I look forward to going to the office every day! You are a Rock Star!

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National Time Out Day

Today The Joint Commission and the Association of periOperative Registered Nurses are celebrating National Time Out Day with a theme of “Be a Time Out SUPER HERO”

Support a safety culture
Use The Joint Commission’s Universal Protocol and AORN Surgical Checklist
Proactively reduce risk in the OR
Effect change in your organization
Reduce harm to patients

Have frank discussions about hazardous situations
Empower others to speak up when a patient is at-risk
Respect others on the surgical team
Openly seek opportunities for improving patient safety

In 1999 a landmark report was published by the Institute of Medicine bringing awareness to medical errors, such as wrong site and wrong person surgeries. Today, 17 years later, despite increased awareness, we are still seeing these types of errors occur, though they are greatly decreased.  The “Timeout” is a last line mechanism which addresses communication and ensures that the entire surgical team (from surgeon to nurse to anesthesiologist) is fully engaged. They should be aware of the procedure they are performing, the location and the person and every person on the team should feel empowered to speak up should they see something that could potentially cause harm to the patient.

As the majority of medical errors are not due to “bad people” but rather systems, processes and human factors, take some time today and review your policy and procedure regarding safe surgical practices. Pull in members of your surgical team also to ensure that the policy as written is being followed in practice and if not, figure out what the barriers are that resulted in a work-around being developed. And lastly, make certain your resources are up to date.






National Time out Day

It’s June 14 – National Time out Day!  It’s not too late to bring focus to this very important step of every invasive procedure or surgery.  Learn how the AORN has adopted the “Super hero” theme to remind everyone to pause to ensure the safest possible outcome for each patient.  Click here to learn more.

Zero Harm

Zero Harm – that’s the goal for every health care provider!  The only way to achieve this is for patient safety to be embedded into your culture.  That means  organizational leaders make it a priority by “walking the walk and talking the talk”. The culture must change the providers’ thinking from “it’s a known complication” or “it sometimes happens” to “not on my shift!”  Recently the American College of Healthcare Executive and the National Patient Safety Foundation released a whitepaper which provides guidance and tools to advance your organization’s culture of safety.   Whether you are just beginning your journey or are attempting to sustain levels of improvement, click here to downlad the guide which will be useful in directing your efforts and evaluating your success along your journey to zero harm. 


A Need for Speed

By: Lynnette Torres, Quality Improvement Manager for Memorial Hospital of Carbondale

Sepsis – a dreaded word for patients, families and health care providers alike. Sepsis is an infection caused by microorganisms or germs (usually bacteria) invading the body. It can be limited to a particular body region or be widespread in the bloodstream.

Addressing the Challenge
In addition to outcomes, the Agency for Healthcare Research and Quality lists sepsis as the most expensive condition treated in U.S. hospitals, costing more than $24 billion in 2013 increasing on average annually by 11.9%. It has been estimated that if the U.S. as a whole achieved earlier sepsis identification and evidenced based treatment, there would be 92,000 fewer deaths annually, 1.25 million fewer hospital days annually, and reductions in hospital expenditures of over $1.5 billion.2 Research has shown that mortality from sepsis increases 7% every hour that treatment is delayed. As many as 80% of sepsis deaths could be prevented with rapid diagnosis and treatment.3 Understanding this severity, Memorial Hospital of Carbondale, Illinois, began addressing the sepsis
challenge several years before it became a focus for the Centers for Medicare Services (CMS). A multi-disciplinary improvement team began studying sepsis, and realized how much more difficult and unique it is to meet all the requirements than the previously required core measures from CMS.

Making it Easier
The team began working on revising all order sets that are used for patients who may be septic, including the required measures of the Sepsis Bundle: blood cultures, lactic acid, antibiotics, fluid resuscitation, and vasopressors. A Kaizen project focused on the work flow for septic patients as well as components of the evidenced-based sepsis care bundle. Revised sepsis order sets for patients in triage, the ED and inpatient nursing units now include the required measures. These changes make it easier to ensure the proper care is provided in a timely manner. All nursing staff, hospitalists and ED physicians were educated on the sepsis requirements and new order sets. One-on-one education was provided when necessary. “Cheat sheets” and guides for sepsis care were created for physicians and nursing staff. The sepsis care path was laminated and placed on computers as a visual reminder. A checklist was created for nurses and physicians in the ED; these checklists double as a hand-off tool to communicate the continuum of care between providers.

Memorial has concurrent and retrospective nurse abstractors in the Quality Department. The concurrent abstractor reviews the patients who meet sepsis criteria daily, along with tracking use of the sepsis order sets.  Order set compliance data is shared with the providers.

“There are approximately 750,000 new sepsis cases each year in the US, with at least 210,000 fatalities. As medicine becomes more aggressive, with invasive procedures and immunosuppression, the incidence of sepsis is likely to increase even more. Reducing mortality due to severe sepsis requires an organized process that guarantees the early recognition of sepsis along with the uniform and consistent application of evidence-based practices.”

Moving Forward
The team continues to meet and seek ways to simplify the order sets to increase compliance. One of the challenges is missing the required lactic acid timeframe for admitted patients who have the first blood drawn in the ED but are not in their inpatient room when the Lab phlebotomists go to draw for the second order. The phlebotomists now place a sign above the bed indicating that they have been there, asking nurses to please contact the Lab so the second draw may be done in a timely manner.

The Results
Since the sepsis core measure is “all or nothing” for compliance, it is a challenge. However, the results at Memorial Hospital are consistently improving. Use of the revised sepsis order sets started in the low teens and has increased to about 65%. Total compliance with the Sepsis Bundle has increased to the mid-50’s. The team continues to meet every other week and gather input from the ED physicians and hospitalists to address the challenges, one of which is early recognition of sepsis so the timeframes can be met.

For More Information
Lynnette Torres is the Quality Improvement Manager for Memorial Hospital of Carbondale. For more information, including the tools used by Memorial Hospital of Carbondale, contact Lynette at 618-549-0721 Ext. 65472 or 618-684-3156 Ext. 55610. Memorial Hospital of Carbondale is a 140-bed tertiary care hospital, serving as the flagship hospital for Southern Illinois Healthcare and regional center for the 16-county southern Illinois region.

Six Book Recommendations for Leaders

At last week’s National Patient Safety Foundation Congress Don Berwick, MD, senior fellow at the Institute for Healthcare Improvement, recommended six books for all leaders to read in the next year to move patient safety forward:

  1. “The Fifth Discipline” by Peter Senge
  2. “The Improvement Guide: A Practical Approach to Enhancing Organizational Performance” by Gerald Langley, Ronald Moen, Kevin Nolan, Thomas Nolan, Clifford Norman and Lloyd Provost
  3. “Overcoming Organizational Defenses: Facilitating Organizational Learning” by Chris Argyris
  4. “Managing the Unexpected: Resilient Performance in an Age of Uncertainty” by Karl Weick and Kathleen Sutcliffe
  5. “The Design of Everyday Things” by Don Norman
  6. “Human Error” by James Reason

Identifying and Learning from Clinical Errors in Pre-hospital Care

A recent article in JEMS magazine by Dr. Mark E.A. Escott raises the important issue of patient safety in EMS. In the article, Dr. Escott highlights several key areas as he outlines the complexity of EMS while pointing out some of the barriers to greater patient safety.

Dr. Escott writes “EMS systems must choose to prioritize patient safety by directing resources to detecting and identifying when we make mistakes and developing monitoring systems, clinical oversight and performance improvement programs to mitigate these clinical errors”.

No matter where you are on the patient safety journey please read this article and share it with others as a call to action to reduce preventable harm in EMS.

Wed, May 10, 2017
By Mark E.A. Escott, MD, MPH, FACEP
JEMS Magazine

To read the full article go to https://www.jems.com/administration-and-leadership/identifying-and-learning-from-clinical-errors-in-prehospital-care/.

Safer Patient Care: One organization at a time
Over the last twelve years, the Center for Patient Safety (Center) has established itself as a nationally recognized leader with thousands of clients in 38 states. Our mission is to provide creative culture solutions to improve patient safety. We do this by focusing on preventing, learning, and protecting using a hands-on approach whereby we function as an extension of the patient safety and quality departments for the organizations with which we work. This allows participating organizations to have a direct connection to our patient safety experts as well as access to the latest information on industry trends and resources.
The Center works across the continuum of care and, therefore, has a unique set of staff with diverse experiences from large, multi-state hospital and health systems to EMS to Home Health and LTC, including risk and quality, clinical experience, legal and regulatory experience.
This year, as we continue to expand, the CPS Team invites you to join us. Every one of our clients is different, so we work directly with each one to identify strengths and weaknesses in the journey to safer and higher quality care. We help each organization in their unique journey to safer care.
We have several key initiatives underway that are receiving interest from the healthcare community nationwide. I encourage you to take a look and let us know if you have any questions: www.centerforpatientsafety.org
  • Safety Culture Surveys
  • PSO Services
  • Patient Safety Boot Camps
  • Consultation and Education
  • Improvement Planning
  • Culture Training
  • Resources
CPS can handle any or all of your patient safety needs at an affordable price. 
I encourage you to reach out with questions or ask about any of services that may be of value to you and your organization.


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.