With so much of our resources, time and energy devoted to keeping staff and patients safe from COVID-19, maybe it’s been a little easier lately to let other areas of safety fall to the background.
One of the ways to bring any areas that need improvement back into focus is with a Culture of Safety Survey. Surveying facility staff puts many eyes (and brains) reviewing where there are opportunities for improvement to make your facility safe. It can also offer tremendous insight into staff attitudes about safety.
Before the Survey
A Culture of Safety survey should be part of your annual QAPI plan. Use the information obtained to enhance or even define one or more of your QAPI studies. Many years ago, I attended a seminar about identifying areas of concern for safety and HIPAA breeches. The presenter asked two (2) questions that made everyone sit up and pay attention. They were:
- Do you feel like your facility does a good job protecting patients and their private health information?
- Think about the most private or embarrassing procedure that you could have done. Would you have it done at your facility?
If the answers to both of those questions was not a resounding “yes,” then you have some digging to do to identify areas of concern. Those might be good questions to ask in a staff meeting to get buy-in to completing the Culture of Safety surveys.
A great resource (and FREE!) for an Ambulatory Surgery Center-specific Culture of Safety Survey is AHRQ (Agency for Healthcare Research and Quality). They have a survey devoted to Ambulatory Surgery Centers which you can access at: https://www.ahrq.gov/sops/surveys/asc/index.html. AHRQ is a great resource for many quality initiatives. It’s worth a few minutes to click around their website or add it to your favorites on the toolbar when you are looking for QAPI information.
There are other resources for Culture of Safety surveys including online resources that tabulate the results for you. Some of these do have charges associated but it may be worth the fee to decrease your time tabulating the data. https://www.honestly.com/survey-templates/safety-culture-survey is one I found with a quick Google. As to which route you take, my only recommendation is that you start the journey!
Once you have your surveys back from staff and data tabulated; it’s time to review what areas were noted as needing attention and how to incorporate that into your QAPI plan. Some questions may require you to delve deeper into how staff understood the question and the best way to address the area of concern. For example: We get the on-the-job training we need in this facility. Which training does staff feel is needed? Is it offering on site CPR or Basic Life Support to front office staff? It could be a refresher course on your Electronic Health Record because it’s been years since it was implemented and you have many new staff members. A rapid PLAN>>DO>>CHECK>>ACT (PDCA) cycle for just this topic might look something like this: QAPI Plan uses the Survey as part of the plan>> Survey administered>>identified areas of concern>>identify current training available and which trainings are needed. This would feed right into the next cycle of: Plan Training X>>Training X offered on the following dates>>send out shortened culture of safety survey on training to assess effectiveness>>use results to determine next areas of training needed.
As with any QAPI plan make sure to document ties into your regulatory body’s standards related to the study. This will help you be ready for the survey and becomes a reminder to staff how everyday practices tie back to regulatory standards.
For any questions or comments about this topic or other Quality and Risk Management topics, you can reach out to me directly: email@example.com
ASC Quality Reporting Needs ASC-Specific Tools
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