ACTION PLANNING TOOL
This tool is organized into five sections:
I.
Introduction
II.
Background
1. Previous HSOPS Experience
2. Mission, Vision, Values
3. Response Rate
III.
Action Plan (9 steps):
1. Define the problem or opportunity for improvement
A. Identify overall strengths, weaknesses, and changes in your HSOPS scores over
time
B. Identify variations in safety culture within work areas and job titles
C. Relate themes in open-ended comments to survey results
D. Summarize problems and opportunities for improvement
2. Create the appropriate change team
3. Define your aims and goals and choose interventions to achieve these goals
4. Choose measures to monitor implementation of your intervention(s)
5. Review your overall plan (who is doing what, when?)
6. Consider how you will sustain and spread changes embedded in your intervention(s)
7. Develop a strategy to communicate your survey results and action plan to key stakeholders
8. Write the final action plan
9. Obtain a review and approval of final action plan by key stakeholders
IV.
Inventory of Safe Practices
V.
References
1
I. Introduction
The purpose of this action planning tool developed by the University of Nebraska Medical Center is to help
you interpret results from the Hospital Survey on Patient Safety Culture (HSOPS) and develop an action
plan for improvement. The HSOPS consists of 42 items that are categorized into 12 dimensions and two
additional outcome measures.1 Each of the 12 dimensions can be linked to one of the four key
components of safety culture: reporting culture, just culture, flexible (teamwork) culture, and learning
culture.2 Of the 12 dimensions, 9 measure perceptions of safety culture within a work area and 3 measure
perception of safety culture across the hospital as a whole. Culture can vary significantly from one work
area or department to another, so it is important to identify work areas that are significantly more or less
positive than the hospital’s aggregate score.
Note that results are reported as a “percent positive,” which is the percentage of responses rated 4 or 5
(Agree/Strongly Agree or Most of the Time/Always) for positively-worded items, or 1 or 2
(Disagree/Strongly Disagree or Rarely/Never) for reverse-worded items (marked with an “R”). Using
reverse-worded items enables consistent use of higher, rather than lower, scores as positive. Eight of the
12 dimensions contain at least one reverse-worded item. An example is item “A14R” from the Staffing
dimension: “We work in “crisis mode” trying to do too much, too quickly.” Positive responses are
DISAGREE and STRONGLY DISAGREE.
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II. Background
1.
Have you done the HSOPS before and what was the impact?
A. Has the HSOPS been conducted previously in your hospital? YES
B. If YES, what were the previous dates?
Mo
NO
Year
C. What was the impact of conducting the survey?
2.
Recognize that improving safety culture is consistent with your mission, vision, values, and
strategic goals
A. Describe your hospital’s overall vision, which may include your mission, vision and values:
B. List your hospital’s current strategic goals:
3.
Understand your response rate
A response rate of 50% or greater ensures that survey results are likely to be representative of those
surveyed. If your rate is less than 50%, consider how responders and non-responders might differ. A
response rate of 60% or greater is ideal.
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III. Action Plan (9 Steps):
Step 1: Define the problem or opportunity for improvement
A. Identify overall strengths, weaknesses, and changes in your HSOPS scores over time
Top Three Dimensions (Strengths)
%+
Bottom Three Dimensions (Weakness)
%+
Dimensions Improved > 5% from
previous results
%
Dimensions Decreased > 5% from
previous results
%
1) What patient safety interventions were successfully implemented that might explain improvements?
2) Were there missed opportunities that might explain decreases in scores?
3) Is there evidence of response shift bias in your reassessment results?
Response shift bias is the tendency for a respondent to overestimate their knowledge, skills, and
behavior in a pretest (i.e. initial assessment) because their understanding of relevant concepts is limited
prior to interventions.5 A common example of response shift bias in HSOPS reassessment occurs in
teamwork-related dimensions when a reassessment is done after a team training intervention.
Response shift bias is common in self-report surveys, and it is a sign of progress: respondents’ have
more knowledge about a topic and recognize the need to change. HSOPS scores will increase on
subsequent reassessments when the new knowledge is transferred into behaviors that are routinely
used in the work environment.
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B. Identify how the four components of safety culture vary by work area and job title.
I. Reporting Culture
Reporting and learning from near misses and adverse events is the foundation of high reliability and a
culture of safety.6-8 Effective reporting systems use standardized taxonomies to classify error severity,
type, causes, and contributing factors. These taxonomies, (e.g. the National Coordinating Council for
Medication Error Reporting and Prevention A – I Error Severity Taxonomy) ensure that external
benchmarking and comparisons of data over time within an organization are valid. Effective reporting
systems, whether internal to an organization or external such as the MEDMARX medication error
reporting database, have similar characteristics:8
 Nonpunitive—reporters do not fear punishment as a result of reporting
 Confidential/Anonymous—the identity of a reporter, patient, or institution is never revealed to a
third party; within an organization reports may be submitted anonymously
 Independent—the reporting system is independent of those with the power to discipline
 Expert Analysis—reports are evaluated by those with the expertise to identify underlying system
causes
 Timely—reports are analyzed in a timely fashion and recommendations are rapidly shared
 Systems-oriented—recommendations focus on changes in systems and processes, not on
individual behavior
 Responsive—those receiving reports are capable of disseminating recommendations for
improvement
Questions:
1) What proportion of all respondents responded positively (ALWAYS / MOST OF THE TIME)
to the item “When a mistake is made, but is caught and corrected before affecting the
patient, how often is this reported?”
a. Identify the highest and lowest positive score(s) for this item across work areas.
b. Identify the highest and lowest positive score(s) for this item across job titles.
2) Review the reporting practices in the Inventory of Safety Practices. List practices that may
support improvement in reporting culture in your hospital as a whole and / or in specific work
areas.
II. Just Culture9, 10
A just culture is one in which there is a balance between the role of individual behavioral choices and
system design when an adverse event occurs.11 Implementing the Just Culture model requires:
 An understanding of the role of human factors in adverse events. Human factors is the study of
the interaction between humans and the physical, cognitive, technological and organizational
elements of the systems in which they work.12, 13
 Shared accountability between management and individuals: managers are accountable for the
design of safe systems and fairly responding to staff behaviors; individuals are accountable for
their behavioral choices and for reporting errors and system vulnerabilities;14
 Shared valuing of proactive learning about systems from reported events and near misses;2
 The use of algorithms to understand individual behavior in adverse events and determine
whether that behavior is human error that requires consoling, at-risk behavior that requires
coaching, or reckless behavior that requires punishment;2
 Management’s response to human behaviors that contribute to an adverse event is determined
by the behavior (human error, at-risk, or reckless) and not by the severity of the outcome.15 This
response emphasizes identification of potential risk within the system.
 There is an explicit policy/procedure in place to manage disruptive behavior, which is any
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inappropriate behavior, confrontation, or conflict, ranging from verbal abuse to physical or
sexual harassment. Disruptive behavior is any behavior that is intended to intimidate or evoke
strong psychological and emotional feelings.3
The end result of implementing the Just Culture Model is an agreed upon set of principles16 that clearly
differentiates acceptable and unacceptable behavior. In a just culture, “there is an atmosphere of trust
in which people are encouraged, even rewarded, for providing essential safety-related information—but
in which they are also clear about where the line must be drawn between acceptable and unacceptable
behavior.” 2
Questions:
1) What proportion of all respondents responded positively (DISAGREED) to the reverse-worded
item “Staff worry that mistakes they make are kept in their personnel file”?
a. Identify the highest and lowest positive score(s) for this item across work areas.
b. Identify the highest and lowest positive score(s) for this item across job titles.
2) Did a majority of staff respond positively (DISAGREED) to the statement “When an event is
reported it feels like the person is being written up, not the problem?”
3) Review the Just Culture practices in the Inventory of Safety Practices. List practices that may
support improvement in just culture in your hospital as a whole and / or in specific work areas.
III. Flexible (Teamwork) Culture 2, 17
Teamwork is recognized as an essential component of safety culture2 and high reliability.18 The
knowledge, skills, attitudes, language, and coordinating mechanisms inherent in teamwork19 create the
flexibility team members need to manage complexity20 and learn from experience.21-23 Team Strategies
and Tools to Enhance Performance and Patient Safety (TeamSTEPPSTM) is a team training program
developed by the US Department of Defense and the Agency for Healthcare Research and Quality
(AHRQ) to teach the knowledge and skills that comprise effective teamwork. There are 18 specific tools
within the four basic team skills: leadership, situation monitoring, mutual support, and communication.17
There is an evidence base that successful team training and effective teamwork improves patient
outcomes 24-31 and safety culture.32 However, team training alone does not produce desired
outcomes.33, 34 A recent study found that team training accounted for less than 20% of the variation in
team performance.35 The primary determinant of team performance is what an organization does after
training to implement and sustain team behaviors.36, 37 Given the ability of effective team behaviors to
facilitate collective learning,22 adoption of team behaviors within a hospital positively affects all
components of safety culture and contributes to transformational culture change.38
Each dimension within the HSOPS contains three or four items. These items assess the beliefs and
behaviors that comprise each dimension. However, the observed behavior of human beings is often not
consistent with the espoused values of the organization.39 A key goal in interpreting results from the
HSOPS is to determine where gaps exist between espoused beliefs and behaviors. TeamSTEPPS
provides tools and skills to close that gap and improve teamwork skills that contribute to
transformational culture change.
Questions:
1) Within the dimension, Teamwork within Units, for the hospital as a whole, how big is the gap
between the belief, “People support one another in this department” and the behavior, “When
one area in this department gets really busy, others help out”? This behavior reflects the
teamwork skills of situation monitoring and mutual support and the specific tools seeking and
offering task assistance.
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a. In which work areas and job titles is this gap between the belief (that we support one
another) and the behavior (that we help each other out when it gets busy) highest?
b. In which work areas and job titles is this gap between the belief (that we support one
another) and the behavior (that we help each other out when it gets busy) lowest?
2) Reflecting the relationship between teamwork skills and perceptions of staffing, do those work
areas that are least positive about helping each other out when it gets busy also have the lowest
scores for the Staffing item, “We have enough staff to handle the workload”? Tools such as
briefs, huddles, debriefs, and seeking and offering task assistance can be used to manage
changing work loads and change perceptions of staffing.
3) Within the dimension, Communication Openness, for the hospital as a whole, how big is the gap
between the belief, “Staff will freely speak up if they see something that may negatively affect
patient care” and the behavior, “Staff feel free to question the decisions and actions of those
with more authority”? This behavior reflects the teamwork skill mutual support and the specific
tools advocacy and assertion, Two Challenge Rule, and CUS.
a. In which work areas and job titles is this gap between the belief (that we will advocate for
patients) and the behavior (that we will speak up to those with more authority) highest?
b. In which work areas and job titles is this gap between the belief (that we will advocate for
patients) and the behavior (that we will speak up to those with more authority) lowest?
4) Structured communication tools can improve the reliability of handing off information across and
within work areas. What proportion of all respondents responded positively (DISAGREED) to
the reverse-worded item, “Problems often occur in the exchange of information across hospital
departments”?
a. Identify the highest and lowest positive score(s) for this item across work areas.
b. Identify the highest and lowest positive score(s) for this item across job titles.
5) What proportion of all respondents responded positively (DISAGREED) to the reverse-worded
item, “Shift changes are problematic for patients in this hospital”?
a. Identify the highest and lowest positive score(s) for this item across work areas.
b. Identify the highest and lowest positive score(s) for this item across job titles.
6) Review the teamwork practices in the Inventory of Safety Practices. List practices that may
support improvement in teamwork culture in your hospital as a whole and / or in specific work
areas.
IV. Learning Culture
In a culture of safety, front-line workers must be informed about events and receive feedback about
actions taken as a result of those reported events. Thus, reporting and feedback create a positive loop:
front-line workers are more likely to report events and near misses if they perceive that those reports
are acted upon.2 Leaders engineer safety culture by role modeling the behaviors they desire, providing
feedback about actions taken, requiring evaluation of changes made to systems, and proactively
improving systems.2, 39 Finally, high reliability organizations7 design systems to prevent errors and use
retrospective and prospective tools to make sense and learn from the mistakes that inevitably happen
when human beings operate within complex systems.40 Retrospective learning tools include individual41
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and aggregate root cause analysis.42 Prospective learning tools include Safety Briefings within units
and departments,43 Leadership WalkRounds,44 process mapping45, 46 and failure modes and effects
analysis.47
Questions:
1) What proportion of all respondents responded positively (AGREED) to the item “We are
informed about errors that happen in this department”?
a. Identify the highest and lowest positive score(s) for this item across work areas.
b. Identify the highest and lowest positive score(s) for this item across job titles.
2) What proportion of all respondents responded positively (AGREED) to the item “We are given
feedback about changes put into place based on event reports”?
a. Identify the highest and lowest positive score(s) for this item across work areas.
b. Identify the highest and lowest positive score(s) for this item across job titles.
3) What proportion of all respondents responded positively (AGREED) to the item “My supervisor/
manager says a good word when he/she sees a job done according to established patient
safety procedures”?
a. Identify the highest and lowest positive score(s) for this item across work areas.
b. Identify the highest and lowest positive score(s) for this item across job titles.
4) What proportion of all respondents responded positively (DISAGREED) to the item “Hospital
management seems interested in patient safety only after an adverse event happens,”?
a. Identify the highest and lowest positive score(s) for this item across work areas.
b. Identify the highest and lowest positive score(s) for this item across job titles.
5) What proportion of all respondents responded positively (AGREED) to the item “Mistakes have
led to positive changes here”?
a. Identify the highest and lowest positive score(s) for this item across work areas.
b. Identify the highest and lowest positive score(s) for this item across job titles.
6) Review the learning practices in the Inventory of Safety Practices. List practices that may
support improvement in your hospital as a whole and / or in specific work areas.
C. Relate themes in open-ended comments to survey results.
Do open-ended comments indicate that respondents perceive that there is a balance between patient
safety protective skills and production pressure? Protective skills require a foundation of a fair and just
culture, teamwork skills and organizational learning driven by engagement at the departmental level.
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D. Prioritize up to three opportunities for improvement for your hospital as a whole or for specific
work areas. Take into account the Inventory of Safe Practices and the comments of survey
respondents.
Hospital Opportunities:
1.
2.
3.
Work Area Opportunities:
1.
2.
3.
Step 2: Create the appropriate change team based on influence and relevance to opportunities for
improvement
NAME
ROLE
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Step 3: Define your aims, goals, and interventions based on your priorities for improvement.
Examples are provided below. Delete or add to these examples to meet your priorities. Action plans should be
SMART: Specific, Measurable, Achievable, Relevant, and Time bound.4
1. Staff will value reporting of near misses as a way to learn about system risks without harming patients.
a. Goal: Greater than 50% of all respondents will indicate that near misses are reported “Always / Most of
the Time” at the next HSOPS reassessment
b. We will do this by implementing the following interventions:
i.
Conducting quarterly aggregate root cause analyses of “near miss” and non-harmful event
reports
ii.
Discussing near misses during departmental Safety Briefs (including shift change), huddles, and
debriefs
iii.
Discussing near misses during regular Leadership WalkRounds
c. Identify where this change will occur…hospital-wide or a specific work area?
d. Identify when this change will occur
2. A consistent approach to operationalizing a just and fair culture across the hospital regardless of profession
or hierarchy.
a. Goal: Improve aggregate perceptions of Nonpunitive Response to Error by 5% or more at the next
HSOPS reassessment
b. We will do this by implementing the following interventions:
i.
Providing training about human factors and active vs. latent causes of errors
ii.
Training managers to use Algorithms to balance individual and systems accountability
iii.
Training managers to collaborate with human resources and discipline individuals based on atrisk and reckless behavior and not on outcomes
3. Use team skills to manage changing work loads.
a. Goal: 75% of all respondents will agree that they help each other out when it gets busy
b. We will do this by teaching staff to use briefs, huddles, debriefs, situation monitoring, and
seeking/offering task assistance to manage changing work loads.
c. Identify where this change will occur…hospital-wide or a specific work area?
d. Identify when this change will occur
4. Use team skills to make it psychologically safe for staff to advocate for patients to those with more
authority.
a. Goal: 60% of all respondents will agree that they feel free to question the decisions and actions of
those with more authority.
b. We will do this by teaching staff to use the Two Challenge Rule and CUS from the TeamSTEPPS
mutual support skills.
c. Identify where this change will occur…hospital-wide or a specific work area?
d. Identify when this change will occur
5. Use team skills to standardize handoffs within and across hospital departments.
a. Goal: Improve Hospital Handoffs & Transitions by 5% or more
b. We will do this by implementing the following interventions:
i.
Teaching staff to use SBAR when communicating critical information that needs immediate
attention
ii.
Teaching staff to use I PASS the BATON when handing off responsibility and accountability for
patients across hospital departments
c. Identify where this change will occur…hospital-wide or a specific work area?
d. Identify when this change will occur
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6. Close the loop with front-line workers about reported events and actions taken as a result those events.
a. Goals: Improve Organizational Learning and Feedback and Communication about Error by greater than
5%
b. We will do this by implementing the following interventions:
i.
Providing feedback to font-line staff about the results of individual and aggregate RCAs
ii.
Ensuring relevant front-line staff are involved in conducing individual and aggregate RCA at the
unit and department level
iii.
Implementing Safety Briefings within units
iv.
Implementing patient safety-focused Leadership WalkRounds
v.
Creating a "high reliability academy" for managers; a regular meeting to learn patient safety
principles, human factors, and high reliability concepts using AHRQ Patient Safety Primers
available at http://psnet.ahrq.gov/primerHome.aspx .
c. Identify where this change will occur…hospital-wide or a specific work area?
d. Identify when this change will occur
Step 4: Choose measures to monitor implementation of your intervention(s)
1. Observe and audit
2. Count numbers of new behaviors (e.g. # Briefs, # Reports, #RCAs, # WalkRounds, # Safety Briefings)
3. Collect outcome measures such as rates: fall rate; rate of appropriate pre-op antibiotic usage
4. Staff satisfaction and Turnover
5. Staff overtime
6. Patient satisfaction
7. Repeat Hospital Survey on Patient Safety Culture
Step 5: Review your overall plan (who is doing what, when?)
What
1. Obtain support from senior leaders, Medical Staff, and Board by telling
your story of strengths, areas in need of improvement, and progress
using your Benchmark Graphs
2. Obtain support from department managers by sharing aggregate and
department specific graphs and results using item (7) Action Planning
Work Sheet from your Excel Tool
3. Engage departments in action planning to address their specific
opportunities for improvement; each department can match areas in
need of improvement within the key components of culture with specific
practices from the Inventory of Safe Practices
4. Communicate aims, goals, interventions and time frames of your action
plan at hospital and department levels to key stakeholders
Who
When
5. Conduct and evaluate necessary training
6. Other:
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Step 6: How will you sustain and spread changes embedded in the intervention(s)?
What
1. Role modeling by formal leaders (senior management and department
managers/supervisors)
Who
When
2. Role modeling by informal leaders (coaches and opinion leaders)
3. Auditing, Monitoring, and Feedback
4. Integrate new behaviors required by safe practice interventions into
policies and procedures
5. Integrate new behaviors required by safe practice interventions into job
descriptions
6. Integrate new behaviors required by safe practice interventions into new
employee orientation
7. Integrate new behaviors required by safe practice interventions into
annual competency training and testing
8. Integrate new behaviors required by safe practice interventions into
annual performance appraisals
9. Other:
Step 7: Develop a strategy to communicate your survey results and action plan to key stakeholders
1. Stakeholder analysis (who needs to provide support, who needs to be brought over to your side)?
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2. Use the template below to develop “Elevator Speeches” that communicate what you need to a specific
stakeholder to implement your action plan.
“We have chosen to focus on _______________________________________________________________.
It is important that we improve _______________________________________________________ because
_____________________________________________________ puts our patients at risk and impacts our
performance. We need you to support our efforts by ______________________________________________
_______________________________________________________________________________________.”
Step 8: Write your final action plan covering steps 1 – 7.
Step 9: Review and approval of plan by key stakeholders
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IV. Inventory of Safe Practices
Date_____________
Rate the extent to which practices that support the four components of safety culture are in place. Indicate if
the inventory is for:
Hospital as a whole
Work Area____________________
Scoring: 0 = Not in place
1 = ineffective
2 = moderately effective
3 = very effective
NA = not applicable
Reporting Practices
Score
Formal reporting of adverse events with standardized taxonomies (e.g. National Coordinating Council for
Medication Error Reporting and Prevention A – I Error Severity Taxonomy)
Near misses are frequently reported, valued, and learned from
Non-harmful errors that reach the patient are frequently reported, valued, and learned from 4
Safety Briefings (also considered a Learning Practice)
Leadership WalkRounds (also considered a Learning Practice)
Other (Describe):
Just Culture Practices
Training provided on role of human factors in error and active vs. latent sources of error
The principles of Just Culture are understood and used by management
Discipline is based on risk-taking and not on outcomes
Managers use Algorithms to balance individual and system accountability
Policy/procedures in place to manage disruptive behaviors
Other (Describe):
Flexible Culture Practices: Teamwork and Communication Skills
Briefs are used to assign roles, establish expectations, and establish contingency plans
Huddles are used to assess the need to change a plan
Debriefs are used to learn by reviewing team performance and conducting after action reviews
Monitoring actions of other team members (e.g. Cross Monitoring to “watch each other’s back”)
Front-line providers use a structured approach to monitor patient care situations (e.g. STEP: Status of the
patient, Team members, Environment, Progress toward goals)
Task assistance is sought by individuals when their work load increases
Task assistance is offered to others when their work load increases
Structured communication is used to resolve information conflicts and enable all employees to advocate for
the patient (e.g. CUS: “I’m Concerned/I need Clarity, I’m Uncomfortable, Stop…this is a patient safety
concern”)
Structured communication is used to resolve personal conflicts
Structured communication is used to communicate information that requires immediate attention (e.g.
SBAR: Situation Background Assessment Recommendation)
Structured communication is used to communicate critical information during emergent situations (e.g. CallOut: Information directed at a responsible individual and conveyed to all to anticipate next steps)
Structured communication is used to ensure that information conveyed by a sender is understood by the
receiver (e.g. Check Back)
Structured handoff communication is used to transfer information, responsibility and accountability when
patients transition from department to department or from one hospital to another (e.g. I PASS the BATON)
Other (Describe):
Learning Practices
Process Mapping
Individual Root Cause Analysis
Aggregate Root Cause Analysis of Non-Harmful Events
Failure Mode and Effects Analysis
Safety Briefings (also considered an informal Reporting Practice)
Leadership WalkRounds (also considered an informal Reporting Practice)
Other (Describe):
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