Team of doctors discussing a patient safety dashboard

National Healthcare Safety Dashboard: A New Tool to Protect Patient Safety

The National Healthcare Safety Dashboard is a groundbreaking tool empowering hospital leaders with real-time insights into patient safety data. By aggregating crucial metrics from AHRQ and CMS, it enables hospitals to benchmark performance and enhance patient safety outcomes. Learn how this innovative dashboard drives harm reduction and supports national safety goals, positioning hospitals at the forefront of patient safety excellence.

6 min read

Table of Contents

Hospital leaders, compliance directors, and institutional safety advocates now have a powerful patient safety dashboard at their fingertips. The innovative National Healthcare Safety Dashboard serves as a robust hospital patient safety dashboard designed to assess, analyze, and improve hospital safety data. Developed through the collaboration of federal agencies and private partners, this dashboard will help hospitals benchmark their performance against the current state of patient and workforce safety.

Background on the Patient Safety Dashboard

Launched in December 2024, the National Healthcare Safety Dashboard is a comprehensive tool that focuses on some of the most consequential hospital safety data metrics impacting patient safety nationwide. By aggregating data from four key sources, this hospital patient safety dashboard provides granular details on specific safety events, clinical indicators, and patient survey responses across four broad categories.

Three of the four dashboard categories are sourced from the Agency for Healthcare Research and Quality (AHRQ), and the other one comes from the Centers for Medicare and Medicaid Services (CMS). The four data sources include:

  • Hospital Patient Safety Indicators (AHRQ).
  • Hospital Medicare Adverse Events (AHRQ).
  • Hospital Reporting Program Safety Measures (CMS).
  • Surveys on Patient Safety Culture (SOPS) Hospital Survey (AHRQ).

While the patient safety dashboard currently focuses on hospital-based metrics, AHRQ officials have indicated plans to expand its scope to ambulatory settings and nursing homes. This hospital patient safety dashboard is a creation of the National Action Alliance for Patient and Workforce Safety (NAA), a collective of federal agencies and private partners formed within AHRQ in 2023 that seeks to meet the stated goals of AHRQ’s National Advisory Council to reduce patient and workforce harm by 50% by 2026.

The NAA supports five primary tactics to meet national goals in reducing patient safety adverse events and “help all healthcare systems strengthen their patient and workforce safety outcomes.” The five aims include:

  • Conducting self-safety assessments to assess a baseline measure of performance.
  • Empowering patient feedback to steer strategic aims (e.g., allowing patients’ safety concerns to flow into facilities’ event reporting systems).
  • Redesigning the workplace and team units to support workforce safety.
  • Strengthening the training of all workforce members in safety competencies.
  • Promoting research, learning, and process-sharing (e.g., harm reduction strategies) across networks.

The hospital safety data aggregated by the NAA is essential for tracking progress and measuring improvements in Adverse Events in Hospitals and other key indicators. “The National Healthcare Safety Dashboard is one approach to tracking our progress on patient and workforce safety nationally using measures prioritized by national programs,” the NAA states.

A Closer Look at the Data

Each of the four key data sources that comprise this patient safety dashboard contains sub-elements that delve into the latest national measures – providing a benchmark that facilities can use as they start on, or continue, their journey to enhanced harm reduction. In all cases, the charts and tables present the latest available federal data. The following section provides a closer look at the primary data categories and their sub-elements.

Hospital Patient Safety Indicators

This category includes more than a dozen condition- or event-related safety indicators, as follows:

  • Death rate in low-mortality diagnosis related groups (DRGs) (PSI-02)
  • Pressure ulcer rate (PSI-03)
  • Iatrogenic pneumothorax rate (PSI-06)
  • Central venous catheter-related bloodstream infection rate (PSI-07)
  • In-hospital fall with hip fracture rate (PSI-08)
  • Postoperative hemorrhage or hematoma rate (PSI-09)
  • Postoperative acute kidney injury requiring dialysis rate (PSI-10)
  • Postoperative respiratory failure rate (PSI-11)
  • Perioperative pulmonary embolism or deep vein thrombosis rate (PSI-12)
  • Postoperative sepsis rate (PSI-13)
  • Postoperative wound dehiscence rate (PSI-14)
  • Abdominopelvic accidental puncture or laceration rate (PSI-15)
  • Birth trauma rate – injury to neonate (PSI-17)

If you navigate through the data sets, you’ll find overall risk stratification levels for the various safety indicators. For instance, the post-operative sepsis rate shows a rolling national risk level from the period between 2016 and 2021, during which time facilities saw a significant reduction in post-op sepsis rates, decreasing from five cases per 1,000 discharges to about three-and-a-half cases per 1,000. Users can also mine the data further, stratifying the data based on patient variables (e.g., age group, expected payer, patient sex).

Facilities like ADN’s clients using the Clinical Benchmarking System have access to this type of benchmarking data already.

Hospital patient safety indicators

Hospital Medicare Adverse Events

One of the briefer data sets on the Safety Dashboard, the adverse events page shows two levels of stratification: patients with at least one adverse event during hospitalization; and total adverse events per 1,000 discharges. In both cases, the number of events showed favorable progress between 2021 and 2022, the latest year of available data. The cumulative number of adverse events per 1,000 discharges, for instance, fell from about 83.6 to 71.1.

Adverse events were identified using AHRQ’s Quality and Safety Review System (QSRS) to abstract information from hospital records. Measures include composite adverse event rates.

Hospital Medicare adverse events (QSRS program)

CMS Hospital Reporting Program Safety Measures

The safety performance data segment of the dashboard contains seven sub-elements, from hospital-associated infections to surgical site infections and complications. This portion of the dashboard contains some of the most recent data available, ending in calendar year 2024. The full list covers:

  • Central-line associated bloodstream infections: Intensive care unit plus select wards (HAI-1)
  • Catheter-associated urinary tract infections: ICU only (HAI-2)
  • Surgical site infection: Colon surgery (HAI-3)
  • Surgical site infection: Abdominal hysterectomy (HAI-4)
  • Death for surgical inpatient with serious treatable complications (PSI-04)
  • Complications for hip/knee replacements (COMP-HIP-KNEE)
  • Appropriate care for severe sepsis/septic shock (SEP-1)

Safety measures from CMS hospital reporting programs

Surveys on Patient Safety Culture (SOPS) Hospital Survey

Based on the SOPS data tool, the dashboard’s survey-based data covers 11 composite measures, and compares survey results year-over-year. The SOPS tool assesses “provider and staff perceptions of patient safety culture.” Within the dashboard, the covered measures include:

  • Communication about error.
  • Communication openness.
  • Handoffs and information exchange.
  • Hospital management support for patient safety.
  • Organizational learning – continuous improvement.
  • Reporting patient safety events.
  • Response to error.
  • Staffing and workplace.
  • Supervisor, manager or clinical leader support for patient safety.
  • Teamwork.
  • Unit/work area patient safety rating.

Hospital patient safety culture survey

Managing SOPS More Efficiently

To help hospitals manage SOPS data more effectively, ADN offers a dedicated Survey on Patient Safety Culture (SOPS) Service. This service simplifies the process of gathering and analyzing SOPS data by providing clear, consistent methods for collecting staff feedback and generating detailed reports. Using ADN’s SOPS Service enables hospitals to better understand their patient safety culture and systematically identify areas for improvement.

Self-Assessment: A Place to Start

As part of the NAA’s efforts, the workgroup recommends that all healthcare systems committed to improving safety for patients (and workforce) begin with a self-assessment. The NAA directs hospital leaders to the Institute for Healthcare Improvement’s (IHI) downloadable self-assessment tools (also available as an online tool).

The updated 2024 version of the IHI’s self-assessment tool aligns with national frameworks, including those of the NAA, CMS’ National Quality Strategy and others. The self-assessment is offered for individual evaluations or broader, team-based assessments, and both versions are available at the IHI website.

As the NAA’s Safety Dashboard gains traction and grows in the coming years, hospital leaders can turn to the data deposits to discern national trends and their organization’s status in the ongoing quest for enhanced safety.

doctor explaining patient handoff template

Patient Handoff Example Templates: An Executive Guide to Safer Transitions

Poor patient handoffs are a silent risk to healthcare quality, often leading to preventable errors, prolonged stays, and costly consequences. This guide for executives dives into proven handoff strategies like I-PASS and SBAR, showing how hospital leaders can streamline transitions of care and improve outcomes. Learn how ADN’s patient safety event reporting application can help track handoff-related issues and drive meaningful improvements across your organization.

12 min read

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Hospital executives nationwide are continually searching for ways to enhance quality improvement in healthcare. One key area often overlooked—but crucial to mitigating patient handoff errors—is the standardized patient handoff process. By refining patient handoff communication, healthcare leaders can strengthen patient safety, support staff efficiency, and improve overall organizational performance.

Patient Handoff Example

What Is a Patient Handoff and Why It Matters to Executives

Patient handoffs in patient care—sometimes referred to as “handovers”—involve transferring key information about a patient’s medical status, ongoing treatments, and relevant clinical details from one healthcare provider or team to another. These transitions occur frequently:

  • Shift changes between nursing or physician teams
  • Inter-departmental moves (e.g., from ICU to step-down units)
  • Inter-facility transfers (e.g., from a rural hospital to a tertiary care center)

Key Stat: The Joint Commission estimates that miscommunication during care transitions is a leading contributor to patient safety events—including preventable harm and higher readmission rates. “Joint Commission data indicate inadequate handovers are a factor in 80% of all adverse events, which include wrong-site, wrong-procedure, or wrong-patient surgeries; treatment delays; medication errors; and falls,” according to a 2018 study on communication’s effect on patient safety.

For hospital directors and VPs, these errors directly impact metrics such as patient satisfaction (HCAHPS scores), value-based reimbursement, and accreditation readiness.

How Patient Handoff Errors Affect Hospitals

When a patient handoff fails—due to incomplete, untimely, or misinterpreted information—the potential harm ranges from minor complications to serious sentinel events. This risk multiplies with the high frequency of handoffs in patient care.

  • Financial Impact: Medical errors and extended lengths of stay can lead to increased costs and reduced reimbursements.
  • Accreditation and Legal Risks: Agencies like The Joint Commission may cite communication lapses in accreditation reviews, and litigation risks rise when errors occur.
  • Reputation and Patient Satisfaction: Communication failures undermine patient trust and often negatively influence HCAHPS scores.

“Patient handoffs involve a structured communication process where the receiving caregiver ideally has the opportunity to ask questions and clarify details to fully understand the patient’s condition,” said Elizabeth Mort, MD, vice president and chief medical officer at The Joint Commission. “Healthcare professionals are deeply committed and work to ensure that patients’ needs are met, and optimal care is delivered. Regrettably, some of the important clinical detail can be lost during the transfer or transition of a patient to another healthcare provider for ongoing care.”

The Joint Commission suggests hospitals choose the patient handoff template that best fits their environment, but it emphasizes staff training, complete documentation, and cultural competency to prevent handoff communication breakdowns.

I-PASS vs. SBAR: Selecting a Patient Handoff Template

I-PASS: A Comprehensive, Evidence-Based Framework

I-PASS is a validated patient handoff tool designed to reduce medical errors and improve communication across multiple points of care. It was developed through a multi-institutional collaboration that sought to unify best practices from leading academic medical centers.

The acronym I-PASS stands for:

  1. Illness Severity:
    Providers categorize the patient’s current status (e.g., stable, unstable, or requiring close monitoring) to quickly convey the level of urgency.
  2. Patient Summary:
    A concise overview of the patient’s chief complaint, diagnosis, and brief hospital course. This may include relevant medical history and any major interventions already performed.
  3. Action List:
    Specific tasks to be completed by the incoming caregiver—such as ordering tests, following up on lab results, or administering medications. Clear accountability prevents important to-dos from being overlooked.
  4. Situation Awareness/Contingency Planning:
    Potential issues to watch out for and predefined plans to address them (e.g., “If the patient spikes a fever, initiate a sepsis workup”). Proactively sharing “what-ifs” helps avoid delays when complications arise.
  5. Synthesis by Receiver:
    The handoff recipient paraphrases the information and clarifies any uncertainties. This “teach-back” step ensures mutual understanding and encourages collaborative problem-solving.

Why It Works:

  • Evidence-Based: Multiple peer-reviewed studies show that adopting I-PASS can significantly reduce preventable errors, particularly in high-turnover environments like teaching hospitals.
  • Structured and Specific: Each element of I-PASS addresses a unique piece of critical information, preventing important details from slipping through the cracks.
  • Interdisciplinary: It’s adaptable for various roles—physicians, nurses, and allied health professionals—allowing everyone to speak a common “language” during handoffs.

SBAR: A Streamlined, Universal Approach

Originally adapted from the U.S. Navy’s communication protocols, SBAR (Situation, Background, Assessment, Recommendation) is another widely recognized framework for patient handoff communication. Its simplicity has made it a go-to method in many hospitals worldwide.

The acronym SBAR stands for:

  1. Situation:
    A succinct statement of the patient’s current condition or the immediate problem (e.g., “Mr. Smith’s oxygen saturation is dropping”).
  2. Background:
    Relevant medical history, recent interventions, or any contextual information that might influence treatment decisions (e.g., “He has a history of COPD and was admitted for pneumonia”).
  3. Assessment:
    The outgoing caregiver’s clinical interpretation—what they believe is happening based on vitals, labs, and observed symptoms (e.g., “I suspect his infection may be worsening due to increasing respiratory distress”).
  4. Recommendation:
    Proposed next steps or desired actions from the receiving team (e.g., “We should obtain an arterial blood gas and consider IV antibiotics immediately”).

Why It Works:

  • Concise and Flexible: SBAR’s four-step format is quick to learn and easy to remember, which is vital in urgent or fast-paced situations.
  • Improves Accuracy: By requiring an explicit “Assessment” and “Recommendation,” SBAR encourages providers to form and share a clinical impression rather than simply relay data.
  • Adaptable Across Departments: From emergency departments to perioperative settings, SBAR can be integrated into almost any workflow to facilitate clear communication.

Choosing Between I-PASS and SBAR

Both I-PASS and SBAR promote standardized patient handoff practices, reduce errors, and improve team collaboration. However, certain hospital environments may favor one approach over the other:

  • I-PASS is often preferred in academic or teaching hospitals where detailed action lists and contingency plans are critical. Its structured “Synthesis by Receiver” step can be especially beneficial in multidisciplinary teaching rounds or complex inpatient settings.
  • SBAR is widely adopted in fast-paced clinical areas—like the ER or ICU—because its four-step design quickly orients the receiver to the most urgent and relevant facts. It is also highly effective for nurse-to-physician communication when immediate clinical decisions are required.

Integrating I-PASS or SBAR Into Your Organization

  1. Policy and Procedure Development
    Write clear policies outlining which model to use (I-PASS or SBAR), in which situations, and who’s responsible.
    – Provide patient handoff examples during training sessions to illustrate correct usage.
  2. EHR Integration
    – Customize existing EHR templates to include fields for I-PASS or SBAR.
    – Ensure that patient handoff checklists are easy to locate and fill out, reducing the likelihood of missing key data.
  3. Ongoing Training and Auditing
    – Offer competency-based workshops and simulations for clinical staff.
    – Conduct regular audits to confirm thorough handoffs and gather feedback for continuous improvement.
  4. Measure Impact on Patient Safety and Outcomes
    – Track patient handoff errors and near-misses in your patient safety event reporting application before and after implementation.
    – Monitor patient satisfaction, staff satisfaction, and any relevant outcome metrics (e.g., falls, medication errors, readmission rates).

Handoffs and Event Reporting: Capturing Near Misses, Incidents, and Driving Process Improvement

Fostering a Just Culture Through Reporting:

Voluntary reporting is a primary method of event detection, which means frontline staff are the main source of information, making it possible to learn about fractured or flawed processes. They provide a unique perspective into everyday workflows that help uncover issues that may otherwise go unnoticed. Furthermore, an organization’s willingness to use these reports to learn from errors and implement changes that prevent future risk and harm are at the heart of a strong safety culture.

Encouraging staff to report near misses and incidents related to handoffs in your event reporting application creates an environment where reporting errors is viewed as an opportunity for learning rather than blame. This approach supports a patient safety culture by:

  • Encouraging Transparent Reporting: When staff are assured that handoff-related issues can be reported without punitive repercussions, they are more likely to share near misses and actual errors.
  • Empowering Frontline Staff: A culture that values open communication and learning helps team members feel more engaged and responsible for patient safety.
  • Building Trust: Transparent handling of handoff events reinforces trust among clinicians, ultimately leading to more accurate and complete communication during transitions of care.

Capturing Handoff Near Misses and Failures:

Patient handoffs are a critical point in transitions of care where communication gaps can lead to errors. When these lapses occur—even as near misses or “good catches”—they provide invaluable data for improving patient safety. By integrating a standardized handoff template into your clinical workflow, hospitals can:

  • Document Critical Details: Capture the who, what, when, where, and why immediately following an event through a structured Summary of Initial Report (SIR) in your event reporting application.
  • Identify Trends: Utilize data from near misses and failures to recognize recurring issues, such as incomplete or untimely communication. If your event reporting application has dashboards that can be easily filtered, this is much easier.
  • Facilitate Immediate Action: Trigger rapid response protocols by flagging high-risk handoff events, ensuring that remedial measures are enacted without delay.

Using Event Data to Drive Handoff Process Improvement:

Event reporting systems should be much more than repositories for data. They are powerful tools for continuous quality improvement. By systematically analyzing reported events related to handoffs, healthcare leaders can:

  • Benchmark Performance: Compare incident rates before and after the implementation of a standardized handoff template (such as I-PASS or SBAR).
  • Refine Protocols: Use actionable insights from event data to optimize handoff processes, ensuring that every communication contains all critical patient details.
  • Close the Loop: Implement feedback mechanisms where frontline staff are informed about changes made in response to their reports, thereby fostering a cycle of continuous improvement and increased engagement.

Integrating these practices ultimately drives better patient outcomes by reducing preventable errors and enhancing overall care coordination.

Patient Handoff Examples: 8 Tips for High Quality Handoffs

The Joint Commission created an infographic to help facilities implement better handoff practices. Download the patient handoff example infographic here.

TJC Patient Handoff Example

The Role of Communication Bias in Patient Handoff Examples

Studies in JAMA Network Open and JAMA Pediatrics show how language bias during handoffs can lead to decreased empathy and even inaccurate recall of vital clinical details. When shifts in perception or hidden biases accumulate, patient care quality suffers.

In December 2024, a study published in JAMA Network Open revealed that when clinicians hear others describe a patient using negatively biased language—such as scorn, skepticism, or stereotyped-based assumptions—they have less empathy toward that individual.

Sometimes clinicians even become less accurate in recalling the person’s critical health details, including lab results, symptoms to pay attention to overnight, or recommended treatments. While such shifts in perception may be subtle and unintentional in many cases, as these hidden biases accumulate, they can influence the care that patients ultimately receive, the study’s authors pointed out.

“Biased language comes from our own implicit biases but can also affect others who do not necessarily hold the same biases,” said lead author Austin Wesevich, MD, MPH, MS, a hematologist and health services researcher at the University of Chicago Medicine. “When talking about a patient behind closed doors, it is important that doctors consider the impact the words they choose may have on other clinicians.”

Executive Perspective: Training staff to use neutral, fact-based language during handoffs and patient safety efforts can lower the risk of discrimination and improve care consistency—both of which align with accreditation standards and community trust.

Executive-Level Strategies for Success

  1. Align With Organizational Goals
    Highlight ROI: Show how improved patient handoff communication reduces falls, lowers liability, and raises patient satisfaction (HCAHPS).
    Set Clear Metrics: Define how many communication-related safety events or falls occur before and after implementing new protocols.
  2. Adopt a Standardized Patient Handoff Tool
    I-PASS or SBAR Patient Handoff Example: Select a model that fits your facility’s culture.
    Integrate With EHR: Ensure that patient handoff templates are built into existing clinical workflows to minimize fragmented documentation.
  3. Ongoing Education and Skill-Building
    Regular Training: Offer simulated patient handoff examples, focusing on real-world scenarios like early-morning falls.
    Peer Feedback: Encourage nurses, physicians, and ancillary staff to constructively critique one another’s handoffs.
  4. Continuous Auditing and Improvement
    Establish KPIs: Track near-misses, sentinel events, and staff-reported handoff issues to measure progress.
    Conduct Random Spot-Checks: Validate the completeness of the patient handoff checklist.
    Adjust Rapidly: Use small tests of change (e.g., PDSA cycles) to refine handoff protocols.
  5. Foster a Bias-Aware Environment
    Implicit Bias Training: Emphasize neutral, patient-focused language.
    Create a Safe Reporting Culture: Staff must feel comfortable reporting handoff gaps—like failing to note fall risks—without fear of punitive action.

Conclusion: Elevating Patient Safety and Reducing Costly Errors

For hospital directors and VPs, optimizing patient handoff communication is a strategic imperative. Standardized handoffs minimize patient handoff errors, enhance staff efficiency, and reduce preventable events—including serious patient falls at shift change. By adopting a structured approach, providing robust training, monitoring performance, and addressing bias, healthcare leaders can create a safer, more equitable environment that raises patient satisfaction and lowers organizational risk.

Next Steps

  • Assess your current handoff protocols for gaps during shift changes.
  • Implement a standardized model (e.g., I-PASS or SBAR), with emphasis on fall-risk communication.
  • Track improvements in fall rates, safety incidents, and patient satisfaction over the next 6–12 months.
  • Refine the process using feedback loops, technology integration, and ongoing education.

By prioritizing structured, consistent patient handoffs, hospitals can protect both patient safety and the bottom line—demonstrating tangible leadership in quality care.

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medical office survey on patient safety culture

Medical Office Survey on Patient Safety Culture: A Roadmap for Leaders

Discover how the Medical Office Survey on Patient Safety Culture can transform your outpatient practice, strengthen your safety framework, and help you stay ahead of emerging standards. Learn how forward-thinking leaders use this tool to benchmark performance, engage staff, and drive meaningful improvements. Don’t miss these practical insights and strategies that can elevate your organization’s quality of care.

9 min read

Table of Contents

As a leader responsible for patient safety, your role extends beyond regulatory compliance. You must foster a proactive, patient-centered environment where continuous quality improvement is standard practice. One powerful and often underutilized resource at your disposal is the Medical Office Survey on Patient Safety Culture, developed by the Agency for Healthcare Research and Quality (AHRQ).

Focusing on patient safety culture (PSC) is not merely a best practice—it’s a critical driver of clinical outcomes. In fact, a March 2023 scoping review, “The association between patient safety culture and adverse events,” found that in more than three-quarters (76%) of the studies reviewed, higher PSC scores were associated with lower rates of adverse events. In other words, strengthening your internal safety climate statistically correlates with preventing harm and improving patient results.

Medical Office Survey on Patient Safety Culture

By leveraging the insights gleaned from the AHRQ Patient Safety Culture Survey for Medical Offices, you can align leadership strategies with frontline realities, increase staff engagement, and design targeted interventions that reduce errors and enhance patient care. From strategic planning and staff training to resource allocation and policy reform, this evidence-based tool provides the data-driven guidance you need to transform aspiration into action.

In this comprehensive guide, we’ll explore how the Medical Office Survey on Patient Safety Culture works, why it matters at the executive level, and how you can seamlessly integrate its findings into your strategic planning and quality improvement efforts.

Medical Office Survey Patient Safety Banner

What Is the Medical Office Survey on Patient Safety Culture?

The Medical Office Survey on Patient Safety Culture is a validated tool created by AHRQ to assess the perceptions and attitudes of clinical and administrative staff regarding patient safety within a medical office setting. Unlike generic employee engagement surveys, this assessment zeroes in on core domains that influence patient safety culture.

Key Focus Areas of the Survey Include:

  • Communication about errors and near-misses
  • Patient follow-up and test result management
  • Teamwork and staff training
  • Information exchange and workflow efficiency
  • Leadership support for patient safety

For a senior leader, these areas provide an invaluable, data-driven snapshot of how your frontline teams perceive patient safety at the ground level.

Access the full survey here: AHRQ Medical Office Survey (PDF).

Clinic Initiative Toolkit Thumbnail

Empower Your Clinic With the Culture of Safety Initiative Toolkit

Outpatient clinics are a vital cornerstone of patient care, yet they often face underreporting and lack cohesive safety-focused practices. At ADN, we’ve identified critical gaps in clinic safety culture and developed the Clinic Culture of Safety Initiative Toolkit to address these challenges head-on.

This comprehensive resource equips your team with actionable tools to enhance communication, transparency, and event reporting, enabling clinics to transform fragmented processes into safer, more reliable systems. With insights from ADN’s initiative, your clinic can build a robust safety culture that empowers both staff and patients.

Take the next step in clinic safety and operational excellence. Download the Clinic Culture of Safety Initiative Toolkit today and create an environment where safety and quality thrive.

Downloadable Resource: Clinic Culture of Safety Initiative Toolkit

Why the Medical Office Survey on Patient Safety Culture Matters to Executive Leaders

1. Aligning Strategy with Operational Reality

While high-level metrics—such as Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores or patient harm indices—offer a bird’s-eye view, they often don’t explain why certain challenges persist. The medical office survey on patient safety culture shines a light on the human factors influencing outcomes, helping executives connect organizational goals with everyday clinical practices.

2. Driving Value-Based Care and Safety Initiatives

In an era where value-based care and reimbursement hinge on quality and safety, understanding the cultural barriers to safe patient care becomes essential. The survey results can inform leadership decisions on resource allocation, technology investments, staff training, and policy modifications, ensuring initiatives directly target the root causes of safety issues.

3. Enhancing Staff Engagement and Retention

Nurses, physicians, and support staff who feel heard, respected, and empowered to report near-misses and errors without fear of reprisal are more likely to remain engaged and committed. By publicly sharing survey findings and improvement plans, you reinforce that leadership values frontline perspectives—fostering a positive work culture that retains talent and reduces turnover costs.

4. Benchmarking Against National Standards

Because the AHRQ survey is widely used, you can benchmark your results against national averages and identify where your medical offices stand relative to peers. This comparative insight helps gauge the effectiveness of ongoing initiatives and clarifies where you need to innovate or implement best practices from other top-performing institutions.

Implementing the Survey: A Practical Roadmap for Leaders

Step 1: Secure Leadership Buy-In and Define Objectives

As a high-level decision-maker, your endorsement is critical. Begin by communicating the survey’s importance to other executives and clinical leaders. Clearly articulate how the results will guide strategic planning, resource distribution, and system-wide improvements. Set concrete goals, such as increasing staff willingness to speak up or reducing communication gaps in test follow-up processes.

Step 2: Ensure Representative Participation

To get an accurate read, you need broad participation from clinicians, nursing staff, managers, and administrative personnel. Leaders should encourage an atmosphere of openness, guaranteeing confidentiality and reassuring staff that honest feedback will be used for improvement—not punishment.

Step 3: Analyze and Interpret the Results With Nuance

Go beyond the top-line scores. Identify patterns: Does a particular department struggle with communication after hours? Are newer clinicians hesitant to report errors due to hierarchical concerns? Understanding these subtleties will help you target the right interventions and resources.

Step 4: Engage Interdisciplinary Teams in Improvement

Once you’ve identified areas for growth, invite representatives from relevant teams—nurses, physicians, quality improvement staff, IT specialists—to co-develop action plans. Multidisciplinary input ensures that proposed solutions are both practical and more likely to gain traction.

Step 5: Invest in Targeted Training, Technology, and Policy Updates

If the survey highlights, for example, that delayed test result follow-ups are compromising patient safety, consider investing in a more robust clinical decision support system or implementing standardized communication protocols. If blame culture is an issue, offer leadership training on just culture principles and enhance transparency in reporting processes.

Step 6: Communicate Progress and Reassess Regularly

Periodically share updates with the entire organization, highlighting improvements and acknowledging remaining challenges. Re-administer the survey annually or biannually to measure progress over time. This cyclical approach creates a feedback loop that continuously refines your patient safety culture strategy.

How Partnering with an Experienced SOPS Survey Provider Maximizes Your Results

While administering the Medical Office Survey on Patient Safety Culture internally can yield valuable insights, partnering with an experienced external provider can significantly enhance the process and outcomes. Enlisting a specialized partner that offers a patient safety culture survey service not only streamlines logistics but also brings a layer of expertise and objectivity that can transform raw data into meaningful, actionable strategies.

1. Expert-Led Survey Administration

Conducting the survey in-house often requires juggling staff communications, ensuring anonymity, and managing follow-up reminders—all tasks that pull your team away from other priorities. A skilled partner handles these details seamlessly, increasing response rates and data quality. With professional oversight, you can trust that the survey is administered in a manner that maximizes participation and preserves staff confidence.

2. Deep-Dive Analysis and Benchmarking

Experienced survey providers bring domain expertise. They help you interpret the results in context, pinpointing what’s truly significant. Rather than spending time sifting through numbers, your leadership team can rely on expert analysis to quickly identify strengths, vulnerabilities, and patterns, allowing you to act much faster on the data. High-quality benchmarking, drawn from a wide pool of respondents, ensures you know where you stand relative to peers and industry best practices.

3. Clear, Actionable Reporting

Raw survey data can be overwhelming. A seasoned partner transforms it into concise reports that highlight key findings, trends, and opportunities for improvement. These user-friendly formats accelerate decision-making and provide a clear roadmap for action—no need for guesswork or additional data wrangling on your end.

4. Tailored Improvement Strategies

Beyond the numbers, the right partner can guide you in developing targeted interventions. Drawing on a wealth of best practices and prior successes, they offer evidence-based recommendations that align with your organization’s unique context. With expert input, you can craft improvement initiatives that are both effective and sustainable, ensuring long-term value from your survey investment.

5. Time Savings and Strategic Focus

By outsourcing the complexity of survey administration and analysis, you reclaim valuable time. This allows you as a senior leader to maintain a strategic focus—interpreting the findings, making informed decisions, and driving meaningful change—rather than getting bogged down in the operational details of the survey process.

In Short: A trusted partner amplifies the impact of the Medical Office Survey on Patient Safety Culture. Their expertise in administration, analysis, reporting, and implementation support can help you move from raw feedback to measurable improvements in patient safety. The result is a more efficient survey process, richer insights, and a stronger, data-informed foundation on which to build a safer, more effective healthcare environment.

Leveraging the Survey Data for Long-Term Organizational Growth

A robust patient safety culture doesn’t just prevent adverse events—it also influences overall operational efficiency, patient satisfaction, and staff well-being. By using the Medical Office Patient Safety Culture Survey as a strategic tool, you:

  • Build a High-Performing, Patient-Centered Environment: Empowered staff and informed leadership jointly foster safer, more efficient care delivery.
  • Improve Regulatory Compliance and Accreditation: Strong patient safety culture supports meeting standards set by bodies like The Joint Commission and the Centers for Medicare & Medicaid Services (CMS).
  • Enhance Reputation and Competitive Positioning: Organizations known for their patient safety culture appeal to patients, payers, and top-tier clinical talent.

Final Thoughts

As a leader committed to advancing patient safety, the Medical Office Survey on Patient Safety culture provides a clear, actionable pathway. When utilized strategically, it moves beyond a simple diagnostic tool to become an engine for sustainable, organization-wide improvement. By deeply understanding frontline perspectives and using data to drive decision-making, you can cultivate a learning-focused, patient-safe environment that stands out in today’s competitive healthcare landscape.

Ready to Get Started?

Don’t wait until new requirements become urgent. Take a proactive step in enhancing your patient safety culture today. Contact American Data Network for a personalized quote or to learn more about how our SOPS Survey service can help streamline your assessment process, benchmark your performance, and guide you toward meaningful, lasting improvements.

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Patient Safety Culture: A Comprehensive Guide to Implementation and Improvement

Uncover how a strong patient safety culture drives healthcare quality improvement and reduces adverse events. This guide explores key elements like leadership engagement, staff empowerment, and communication strategies, while highlighting tools such as the SOPS survey. Discover actionable insights to enhance outcomes, foster a culture of safety across care settings, and align with CMS’s Patient Safety Structural Measures.

12 min read

Table of Contents

Patient safety culture is a cornerstone of healthcare quality improvement, representing the shared values, beliefs, and norms that shape how healthcare organizations approach patient safety. This comprehensive guide explores how healthcare institutions can develop, measure, and strengthen their patient safety culture to enhance outcomes and reduce adverse events.

Patient Safety Culture: The Foundation of Quality Improvement in Healthcare

Providing high-quality care in the hospital is more than having trained, competent professionals treating patients, delivering the services they need and coordinating their care in an effective manner. Enhancing quality – and particularly patient safety – also centers around the wider culture that exists within the hospital walls, from management staff and leadership to physicians, nurses and qualified healthcare professionals.

Patient Safety Culture

More and more, studies and literature reviews are finding that achieving quality improvement in healthcare, and specifically within the acute care setting, relies in a significant way on the patient safety culture, or PSC, that exists within an organization. Labeled by some researchers as “an indicator of quality in healthcare,”² the patient safety culture encompasses various day-to-day activities centered around the experience of hospital staff, from teamwork and work pace to continuing educational opportunities and the openness of communication.

This article will speak to how hospitals can achieve quality improvement in healthcare with a review of some of the latest research on patient safety culture, a direct look at the challenges facing cultural success, and a dive into the tools and questionnaires that hospitals are using to measure their culture and discern how central patient safety is to it – as a way to bolster patient safety overall.

Customize Your Patient Safety Culture Pamphlet

Patient Safety Culture PamphletThis printable Patient Safety Culture Pamphlet is designed to promote safety awareness in your hospital. Perfect for hanging in common areas or handing out to staff, it highlights key components of a strong safety culture, including leadership engagement, open communication, and non-punitive reporting.

  • Editable Formats: Use the included Google Doc to add your hospital logo or access the Photoshop file for full customization.
  • Engage Staff: Reinforce your organization’s commitment to safety and encourage team collaboration to reduce adverse events.

Make patient safety a visible priority—customize and share your pamphlet today!

Downloadable Resource: Patient Safety Culture Pamphlet

The Impact of Patient Safety Culture on Healthcare Outcomes

One recent study, “Enhancing Patient Safety Culture in Hospitals,” published in Cureus in December 2023, took a broad look at research on the topics of patient safety culture and enhancing quality improvement in healthcare. The study reviewed 47 separate articles, including a mixture of systematic reviews and cross-sectional, qualitative and descriptive studies.

What it found was a deep-seated correlation between strong patient safety culture and high-quality outcomes, including a limitation of adverse events. “The quality, performance, and productivity of the healthcare industry can be dramatically improved by changing the patient safety atmosphere operating within the hospital sector,” the study concluded. “Hospitals can significantly reduce medical errors and adverse events by implementing the program and training programmers to prioritize patient safety.”

A separate article, “The association between patient safety culture and adverse events – a scoping review,” published in March 2023, found that more than three-quarters, or 76%, of the studies it assessed found that “increased PSC scores were associated with reduced [adverse events] rates.” While the article included a review of studies around the globe, 62% of those came from facilities in the U.S. and Canada.

The article offers a definition of the patient safety culture, calling it a “multidisciplinary concept,” and further describing it as “the overall attitude and patterns of behaviors related to the patient safety work at multiple levels in an organization. This includes individuals and groups’ shared values, beliefs and norms influencing their actions.”

By focusing on these key areas of a safety-driven culture, including collaboration among staff and support from leadership, hospitals can embrace a strong patient safety culture and advance the cause for quality improvement in healthcare.

Building a Strong Patient Safety Culture: Essential Components

1. Leadership Engagement

Active participation from executive leadership: Leadership must go beyond verbal support to demonstrate genuine commitment through actions. This includes attending safety meetings, participating in root cause analyses, and being visibly involved in safety initiatives.

Clear communication of safety priorities: Leaders should regularly articulate safety goals and expectations through multiple channels, ensuring these priorities are embedded in strategic plans, department objectives, and daily operations.

Resource allocation for safety initiatives: Effective leadership means backing safety commitments with appropriate funding, staffing, and technological resources needed to implement and maintain safety programs.

Regular safety rounds and visible leadership presence: Leaders should conduct scheduled rounding to observe practices, engage with staff at all levels, and demonstrate their commitment to safety through consistent presence on hospital floors.

2. Staff Empowerment

Encouraging incident reporting: Create a blame-free environment where staff feel safe reporting errors and near-misses, understanding that these reports drive system improvements rather than punitive actions. Check out our Free Toolkit to Increase Event Reporting.

Supporting staff development: Provide opportunities for professional growth through continued education, certification programs, and skill development workshops focused on patient safety practices.

Promoting psychological safety: Foster an environment where staff feel comfortable speaking up about safety concerns without fear of retaliation, regardless of their position in the organizational hierarchy.

Recognizing safety champions: Identify and celebrate staff members who consistently demonstrate commitment to patient safety, encouraging others to follow their example and maintaining motivation for safety initiatives.

3. Communication Framework

Structured handoffs: Implement standardized communication tools (like SBAR – Situation, Background, Assessment, Recommendation) to ensure critical patient information is consistently and accurately transferred between caregivers.

Regular safety briefings: Conduct daily huddles or briefings to discuss potential safety issues, share recent concerns, and ensure all team members are aligned on safety priorities.

Clear channels for raising concerns: Establish multiple pathways for staff to voice safety concerns, including anonymous reporting options, direct supervisor communication, and safety committees. A Complaints and Grievances component to a Patient Safety Event Reporting Application is ideal for this.

Transparent sharing of safety data: Regularly communicate safety metrics, incident trends, and improvement initiatives to all staff members, ensuring everyone understands both challenges and progress.

4. Continuous Learning Environment

Regular safety training: Schedule ongoing education sessions that address both foundational safety principles and emerging best practices, ensuring all staff maintain current knowledge of safety protocols.

Sharing of lessons learned: Create structured processes to disseminate insights from safety events across departments and shifts, ensuring valuable learning opportunities benefit the entire organization.

Peer-to-peer learning opportunities: Facilitate mentorship programs and cross-training initiatives that allow staff to learn from each other’s experiences and expertise in patient safety practices.

Integration of best practices: Continuously monitor and incorporate evidence-based safety practices from leading healthcare organizations, adapting them to fit your specific organizational context. Participating in a Patient Safety Organization is a great way to gain shared learnings like this.

Overcoming Challenges to Patient Safety Culture Improvement

The Cureus Journal study highlights seven challenge areas when it comes to creating and continuously cultivating a patient safety culture. In no particular order, they are:

  • Organizational culture. Without organization-wide values and a shared mission, safety initiatives can get stalled in their tracks. Some studies have found that an organization’s commitment to safety enhances staff wellness. “Patient safety culture was positively related to staff work-life balance,” reports a separate 2022 journal article.
  • Communication. This means not only accurate and timely communication among healthcare providers but also strong communication and information transfer between providers, patients and their families.
  • Leadership commitment. The emphasis on a patient safety culture must come from the top, with full buy-in from hospital leadership and team managers, such as nursing leadership.
  • Individual factors. A potential challenge that can be overcome with unified purpose and strength of leadership, individual staff members’ attitudes and beliefs can sometimes curtail the adoption of safety practices.
  • Insufficient resources. Understaffed hospitals and those without the capacity to undergo ongoing staff training or provide adequate technological support are likely to face greater obstacles in achieving quality improvement in healthcare and patient safety.
  • Resistance to change. Linked to individual factors and, more generally, the reluctance to change ingrained habits, resistance to a new operating paradigm can make it difficult to take the leap to a patient safety culture.
  • Time pressures. Juggling patient safety initiatives with busy workloads and other time constraints can prove difficult for staff, especially when the patient safety culture is not ingrained in the day-to-day operating procedures of the facility.

Measuring and Assessing Patient Safety Culture

For hospitals striving to build or enhance their patient safety culture, measurement is crucial. Validated tools help organizations gauge their current culture and pinpoint areas for improvement. Two widely used tools are:

How SAQ and SOPS Work

The SAQ is a concise, 36-question survey that assesses key areas of patient safety, including teamwork, communication, and organizational culture. Questions range from specific operational topics—like how well nurse input is received—to broader cultural perceptions, such as “Working here is like being part of a large family.” The SAQ provides a recommended scoring framework, making it easy for organizations to interpret results and track improvements over time.

The SOPS Hospital Survey 2.0 is a more detailed tool, covering 32 items across 10 composite measures. It takes approximately 10-15 minutes to complete and dives deeply into aspects such as medical error reporting, communication, and leadership’s role in fostering safety. Designed to offer a comprehensive snapshot of patient safety culture, SOPS helps hospitals identify strengths and areas needing improvement. In addition to the core SOPS Survey, facilities can utilize supplemental item sets to dive deeper into specific aspects of their patient safety culture. For example, the Workplace Safety supplemental set allows organizations to align their efforts with standards such as The Joint Commission’s workplace violence prevention (WVP) requirements. This focus can help facilities address critical areas like staff well-being and violence mitigation, supporting a safer environment for both patients and employees. These supplemental data sets can easily be part of ADN’s SOPS Service upon request.

Patient Safety Culture Measurement Beyond the Hospital

While patient safety culture is often assessed within hospitals, its principles extend beyond acute care settings. Healthcare organizations should consider evaluating safety culture across other care environments, such as medical offices, ambulatory care centers, and nursing facilities. Including perceptions from these settings can provide a more comprehensive view of the organization’s overall commitment to safety and help identify systemic opportunities for improvement. ADN offers SOPS Surveys for these additional care settings as part of its comprehensive SOPS service.

Streamline Your SOPS Survey with ADN’s Survey on Patient Safety Culture Service

Administering and analyzing the SOPS survey can be time-consuming, but American Data Network (ADN) offers a tailored SOPS service to simplify the process. Our team handles everything—from survey distribution to data analysis—delivering detailed, actionable reports within 30 days. By partnering with ADN, you’ll save hours of manual work and gain insights to drive meaningful improvements in your patient safety culture.

Learn more about our SOPS Survey Service.

CMS Recognizes the Critical Role of Patient Safety Culture

The importance of patient safety culture has been further validated by the Centers for Medicare & Medicaid Services (CMS) through their new Patient Safety Structural Measures (PSSMs). Beginning in 2025, hospitals will be required to attest to specific cultural and structural elements that support patient safety, including:

  • Leadership commitment to eliminating preventable harm
  • Strategic planning that prioritizes safety
  • A demonstrated culture of safety and continuous learning
  • Clear accountability and transparency
  • Active patient and family engagement

(To dig deeper into PSSMs, see our comprehensive guide: Understanding the New CMS Patient Safety Structural Measures: A Comprehensive Guide for Quality and Patient Safety Leaders.)

These measures align with the research highlighted above, confirming that a strong patient safety culture isn’t just best practice—it’s becoming a regulatory expectation. Hospitals will be scored on their implementation of these cultural elements, with public reporting beginning in fall 2026.

For healthcare organizations looking to strengthen their patient safety culture, these new measures provide a clear framework of essential components, from leadership engagement to family participation. They reinforce that creating a culture of safety requires structural support, strategic planning, and systematic implementation—exactly the elements discussed throughout this article.

Sources

  1. Enhancing Patient Safety Culture in Hospitals. Cureus. December 2023. This study reviewed 47 articles, identifying a strong correlation between improved patient safety culture and better healthcare outcomes.
  2. The Association Between Patient Safety Culture and Adverse Events – A Scoping Review. March 2023. This article analyzed global studies, finding that 76% reported lower adverse event rates associated with higher patient safety culture scores.
  3. Surveys on Patient Safety Culture (SOPS®) Hospital Survey 2.0. Agency for Healthcare Research and Quality (AHRQ). This tool assesses patient safety culture through 10 composite measures, providing actionable insights for healthcare organizations.
  4. Centers for Medicare & Medicaid Services (CMS). Patient Safety Structural Measures (PSSMs). Regulatory framework emphasizing leadership commitment and cultural elements essential to patient safety, effective from 2025.

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