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Department of Defense (DoD)

Patient Safety
Improvement Guide

Prepared for:
TRICARE Management Activity
DoD Patient Safety Program

Prepared by:
Westat, Rockville, MD

Martha Franklin, M.A.

Laura Milcetich, M.P.H.
Theresa Famolaro, M.P.S.
Joann Sorra, Ph.D.

Contract # 233-02-0087
Task Order # HHSP23300700002T

March 2009

Chapter Page

Executive Summary ............................................................ iii

Purpose of This Guide ......................................................... 1

1 Survey Background & MHS Results ..................................... 3

2008 MHS Results ............................................................... 4

2 Seven Steps of Action Planning........................................... 7

Step # 1: Understand Your Survey Results............................... 7
Step # 2: Communicate and Discuss the Survey Results ............ 8
Step # 3: Develop Focused Action Plans .................................. 8
Step # 4: Communicate Action Plans and Deliverables ............... 9
Step # 5: Implement Action Plans........................................... 10
Step # 6: Track Progress and Evaluate Impact.......................... 10
Step # 7: Share What Works.................................................. 11

3 Patient Safety Improvement Practices................................ 12

Event Reporting and Nonpunitive Culture ........................... 12

1. Educating Staff About Medical Events and Event Reporting ..... 13
2. Maintaining an Open Door Policy About Reporting ................. 15
3. Making Event Reporting Convenient and Easy....................... 16
4. Creating a Nonpunitive Reporting Environment ..................... 17
5. Providing Feedback and Communicating Lessons Learned ...... 19

Handoffs and Transitions .................................................... 20

1. Using Handoff Communication Tools ................................... 20
2. Identifying and Improving Handoffs and Transitions .............. 22

Teamwork........................................................................... 23
1. Cross Training and Use of Universal Protocols....................... 23
2. Implementing a New Way of Doing Rounds .......................... 23
3. Implementing TeamSTEPPS™ ............................................ 24

Management Support for Patient Safety ............................. 25

1. Ensuring Leadership Support ............................................. 25
2. Establishing a Patient Safety Program Manager .................... 26



Chapter Page

3 Staff Engagement/Ownership............................................. 28
1. Establishing Formal Patient Safety Committees..................... 28
2. Spreading Ownership Through a Peer-to-Peer Approach......... 29
3. Recruiting Facility Experts as Patient Safety Champions ......... 29
4. Involving Staff From All Levels ........................................... 30
5. Rewarding Participation in Patient Safety Tasks .................... 31

Raising Staff Awareness of Patient Safety .......................... 31

1. Conducting Short “Pulse” Surveys....................................... 31
2. Conducting Leadership Rounds ........................................... 31
3. Orientation and Other Staff Training ................................... 32

Other Improvement Initiatives ........................................... 34

References.......................................................................... 35


A Department of Defense (DoD) 2008 Tri-Service Survey

on Patient Safety ................................................................ 36

B Department of Defense (DoD) Resources ........................... 44



The DoD Patient Safety Program developed this Guide to help patient safety leaders
in military treatment facilities (MTFs) strengthen their patient safety programs and
patient safety culture. The Guide includes a brief description of the DoD Tri-Service
Survey on Patient Safety and overall results for the Military Health System (MHS),
advice on how to use the survey results to identify opportunities for improving
patient safety culture, and examples of various initiatives and tools that MHS
hospitals and clinics have implemented in their efforts to improve patient safety
culture and the safety of patient care.

Chapter 1. The examples presented are based on information obtained through telephone
interviews conducted with staff from nine MTFs in January 2009. Those MTFs were
Survey invited to participate in the interviews because of a combination of criteria,
Background including notable improvement from 2005/2006 to 2008 on the DoD Tri-Service
and MHS Survey on Patient Safety, high overall percent positive scores on the 2008 survey,
Results Service branch, and facility characteristics such as type (hospital or clinic) and size
of facility. These top-performing facilities were considered important to interview
because their improved survey scores from 2005/2006 to 2008 suggested they had
engaged in initiatives that strengthened their patient safety culture.
The DoD Tri-Service Survey on Patient Safety Culture, sponsored by TRICARE
Management Activity, is an anonymous patient safety culture survey with 42 items
that assess staff attitudes and beliefs about patient safety, medical error, and event
reporting. A facility’s first administration of the survey provides a baseline for
measuring patient safety culture, and subsequent administrations allow facilities to
track change over time.
After administration of the 2008 survey, MTFs received feedback reports that
included a comparison to their 2005/2006 results. For the overall MHS, the three
highest-scoring survey areas were Teamwork Within Units, Supervisor/Manager
Expectations and Actions Promoting Patient Safety, and Management Support for
Patient Safety. The three lowest-scoring areas were Nonpunitive Response to Error,
Staffing, and Handoffs and Transitions.

Chapter 2. Administering the survey is only a starting point in improving patient safety culture.
Taking action based on a facility’s survey results will make the real difference in
Seven Steps whether a facility succeeds in making gains in patient safety culture. Seven steps of
of Action action planning that will help facilities to realize patient safety culture change are
Planning discussed. These seven steps advise patient safety leaders to:
1. Understand your results by carefully analyzing them
2. Communicate and discuss your results with senior leaders, middle managers,
and staff



3. Develop focused action plans that target a small number of areas of opportunity
for improving patient safety culture
4. Communicate your plans to staff who will be involved or affected, thus
providing them with appropriate information regarding their participation and
making the plans transparent
5. Implement your action plans—arrange for necessary resources and support and
recruit a patient safety champion or leader for the effort
6. Track progress and evaluate the impact of your initiatives to determine if they
were successful or not and should be continued, modified, or discontinued
7. Share what works with other areas within your facility and with other facilities

Chapter 3. Chapter 3 picks up on the last action step—sharing what works with other facilities.
During the interviews, the nine facilities reported on many initiatives and practices
Patient that contributed to their improved patient safety culture between 2005/2006 and
Safety 2008. Their improvement initiatives are grouped into the following categories:
Improvement Event Reporting and Nonpunitive Culture – Two prevalent goals among the
Practices facilities were to increase the number of event reports and to change perceptions that
the reporting process is punitive. The facilities described a wide array of initiatives
that promoted progress toward those goals. Examples include: short surveys on
event reporting and follow-up discussions with staff; Web-based training on event
reporting with individualized feedback; quarterly case study presentations (generally
based on sentinel events); weekly meetings to review event cases for system and
process improvement; improvements in electronic reporting methods and paper
report forms; development of a database to track reported events; leadership focus
on solutions to system and policy problems that contribute to events; award
presentations for reporting events; and feedback to reporters as well as more general
feedback to staff on lessons learned from reported events.
Handoffs and Transitions – For some facilities, a primary goal was improving
handoffs and transitions. Stories shared here focused on the use of handoff
communication tools (e.g., “I PASS THE BATON” and SBAR) and on a clinic’s
successful efforts to identify handoff situations and improve handoff
communications with the use of SBAR.
Teamwork – The facilities described activities that they believe strengthened
teamwork within and across units. One facility reported how it has built a strong
teamwork culture through cross training, use of interdisciplinary teams and universal
protocols, and strong leadership support for a teamwork culture that holds all staff
accountable. Other reported initiatives include changes in round procedures and
implementation of TeamSTEPPS™.
Management Support for Patient Safety – The facilities reported on ways in
which senior leadership is crucial to a strong patient safety culture. They also
stressed the need for a strong patient safety leader who is visibly and actively
promoting patient safety with leaders and staff throughout the facility. They
recommended that patient safety leaders present on patient safety at executive and
departmental meetings, participate in formal or informal walkarounds, participate in
staff training, and demonstrate that the patient safety office is there to help other



leaders resolve patient safety issues in their areas of responsibility—it is not there
solely to “push its own agenda.”
Staff Engagement and Ownership – Patient safety leaders described creative ways
for engaging staff and promoting staff ownership of patient safety. This is essential
they said not only because they cannot do everything themselves but also because
patient safety belongs to everyone in the facility and should be everyone’s business.
Their initiatives included engaging other staff in promoting patient safety as
spokespersons, advisors, and champions; and as members on special patient safety
workgroups and committees, Root Cause Analysis teams, tracer teams, and Failure
Mode and Effects Analysis groups. One facility rewards exceptional service on
patient-safety related tasks by presenting a Patient Safety Coin to recipients and
giving them a paid day off.
Raising Staff Awareness of Patient Safety – Important goals for the facilities
between 2005/2006 and 2008 were to raise overall awareness and knowledge about
patient safety and to promote buy-in for a culture of patient safety. The facilities
described a number of initiatives targeted on those goals: conducting short “pulse”
surveys monthly on patient safety and infection control to assess staff knowledge on
these topics, followed up with on-site training in individual departments; conducting
leadership rounds; training new staff on patient safety issues and goals during
orientation, annual training, and unit-based training; holding special trainings on
patient safety, including “Just-in-Time” training that fits into demanding
work/training schedules; conducting activities during Patient Safety Awareness
Week, including a patient safety scavenger hunt; and promoting patient safety with
pocket cards with reference information and including patient safety goals on staff
ID cards/badges.
Other Improvement Initiatives – Other initiatives that facilities said contributed to
reliable and safe care for patients included various quality improvement initiatives.
For example, one facility conducted group workouts to improve processes, and
another improved quality of care by requiring all area leaders to develop flow charts
of their area processes. One facility created a new nursing care program in which a
primary care nurse manages the care for the patient/family. Another facility had a
DoD Patient Safety Program team provide microsystems training that taught staff
how to identify work processes and systems that need to be fixed.



The DoD Patient Safety Program developed this Guide to help Military Treatment
Facility (MTF) leaders strengthen their patient safety programs and the culture of
patient safety in their facilities. The Guide covers three main topics:

 A brief description of the DoD Tri-Service Survey on Patient Safety and survey
results for the overall Military Health System (MHS)
 Advice on how to use the survey results to identify areas of opportunity for
improving patient safety culture and develop corresponding action plans
 Examples of various activities, tools, and strategies that MTF hospitals and
clinics have implemented in their efforts to improve patient safety culture and
the safety of patient care
Helpful DoD patient safety resources are also provided in an Appendix. The
initiatives highlighted in the Guide are presented as examples of activities the MTFs
believed were helpful in improving patient safety. However, the activities are not an
exhaustive or complete listing.
The Guide is based on information obtained through telephone interviews with staff
from nine top-performing MTFs based on their facility’s results on the DoD Tri-
Service Survey on Patient Safety. The interviews were conducted in early 2009 and
focused on patient safety improvement practices that the facilities had implemented
between the 2005/2006 and 2008 administrations of the safety culture survey.
Facility scores were rank ordered and “top performing” facilities were chosen based
on five criteria:
1. Overall average percent positive score across the survey’s 12 composites in
2008 [Facilities selected had average scores ranging from 61% to 68% positive]
2. Number of composites that increased by 5 percentage points or more from
2005/2006 to 2008 [Facilities selected increased on at least 4 of the 12 patient
safety composites]
3. Average overall change in percent positive scores from 2005/2006 to 2008
[Facilities selected had average overall changes in percent positive scores
ranging from 3 to 14 percentage points]
4. An overall score, which was a statistical combination of the three scores
described above, rank ordered from highest to lowest for hospitals and for
clinics [The six MTF hospitals selected were ranked # 11 or higher on this
overall score among 44 MTF hospitals; the three MTF clinics selected were
ranked # 8 or higher among 96 clinics]
Six hospitals and three clinics among CONUS Army, Navy, and Air Force MTFs
were selected. Other facility characteristics, such as size of the facility, were also
taken into consideration when selecting the sites to be interviewed.
We were limited to interviews at nine facilities and, as noted, we selected nine
facilities that represent top performers on the DoD Tri-Service Survey on Patient
Safety as well as a balance of size, scope, and survey scores. Since a combination of
criteria was used to select the exemplary MTFs, the nine MTFs interviewed were not
necessarily the absolute highest-performing facilities. If your MTF was not selected



to participate in one of the nine interviews, it does not mean that your MTF was not
a top performer.
We wish to thank the nine facilities that participated in the interviews for taking time
from their busy schedules to share information about their patient safety initiatives
and practices. Eight of the participating facilities provided consent to have their
facility listed below:

Air Force
99th Medical Group, Nellis AFB, NV—Las Vegas, NV
Brooke Army Medical Center—San Antonio, TX
Irwin Army Community Hospital—Ft. Riley, KS
Tripler Army Medical Center, Hawaii—Honolulu, HI
NNMC—Bethesda, MD

Air Force
95th Medical Group, Edwards AFB, CA—Edwards, CA
Raymond W. Bliss Army Health Center—Fort Huachuca, AZ
Naval Health Clinic, Quantico—Quantico, VA




The DoD Tri-Service Survey on Patient Safety is an anonymous patient safety

culture survey that assesses staff attitudes and beliefs about patient safety, medical
error, and event reporting. The survey, sponsored by TRICARE Management
Activity (TMA), was administered in Army, Navy, and Air Force Military Health
System (MHS) hospital and clinic Military Treatment Facilities (MTFs) worldwide
via the web in 2005/2006 and again in 2008.
The rationale for the DoD Tri-Service Survey on Patient Safety was to:

 Improve the quality of health care services and provide a safer patient care
environment in all MHS settings,
 Understand the status of patient safety culture in MHS facilities,
 Raise staff awareness about patient safety issues,
 Facilitate meeting several Joint Commission Performance Improvement and
Leadership standards,
 Use the survey as a tool for forward action planning and program evaluation,
 Examine patient safety culture change over time.
The DoD Tri-Service Survey on Patient Safety measures 12 patient safety culture
areas and other individual items on patient safety culture (Table 1.1). The survey
consists of 42 items, with 3 to 4 items assessing each patient safety area, plus
additional demographic items. The survey allows for open-ended comments at the
end. A copy of the survey is located in Appendix A.
Table 1.1 Patient Safety Culture Areas

1. Teamwork Within Work Areas 8. Communication Openness

2. Supervisor/Manager Expectations & 9. Teamwork Across Work Areas
Actions Promoting Patient Safety 10. Handoffs & Transitions
3. Management Support for Patient 11. Staffing
Safety 12. Nonpunitive Response to Error
4. Organizational Learning—
Continuous Improvement Other Items
5. Overall Perceptions of Patient Safety 1. Patient safety “Grade” in work area
6. Feedback & Communication About 2. Number of events reported in the
Error past 12 months
7. Frequency of Events Reported



2008 MHS After each administration of the DoD Tri-Service Survey on Patient Safety, MTFs
Results received feedback reports showing their facility’s survey results. In 2008, many
MTFs also received trend data comparing their 2005/2006 and 2008 results to
identify areas where scores increased, stayed the same, or decreased over time.
Survey results were also produced for the overall MHS.
Chart 1.1 shows the composite percent positive scores on the patient safety culture
areas for 2008 and 2005/2006 for the overall MHS. In 2008, patient safety culture
for the overall MHS had a slight improvement of 1 to 3 percentage points in all areas
except communication openness, where the results were the same for 2005/2006 and
2008. The three highest-scoring areas, identified as areas of strength were:

 Teamwork Within Units,

 Supervisor/Manager Expectations and Actions Promoting Patient Safety, and
 Management Support for Patient Safety.

The three lowest-scoring areas that were identified for improvement were:

 Nonpunitive Response to Error,

 Staffing, and
 Handoffs and Transitions.
Charts 1.2 and 1.3 display the overall MHS results for patient safety grade and
number of events reported. The results for patient safety grade show that most
respondents (80% in 2005/2006 and 81% in 2008) believe their work area/unit is
“Excellent” or “Very Good” in patient safety. However, most respondents (73% in
2005/2006 and 2008) also indicate that they have not reported a single event in the
past 12 months.
Because the MHS results reflect general trends found in individual MTFs, it is likely
that your MTF may also have the areas listed above as your facility’s areas for
improvement. The Guide will present a number of activities that MTFs have
implemented to improve in these areas, as well as additional activities they have
implemented that address other areas of patient safety culture that are assessed in the
DoD Tri-Service Survey on Patient Safety.



Chart 1.1 Overall MHS Patient Safety Culture Composite Scores for 2005/2006 and

Patient Safety Culture Composites Average % Positive Response

1. Teamwork Within Units

Supervisor/Manager Expectations & Actions 72%

Promoting Patient Safety 73%

Management Support for 71%

Patient Safety 73%

Organizational Learning--Continuous 68%

Improvement 70%

5. Overall Perceptions of Patient Safety

6. Feedback & Communication About Error
7. Frequency of Events Reported 63%

8. Communication Openness 61%

9. Teamwork Across Units 60%

10. Handoffs & Transitions 49%

11. Staffing 46%

12. Nonpunitive Response to Error 45%

0% 20% 40% 60% 80% 100%



Chart 1.2 Overall MHS Work Area/Unit Patient Safety Grade for 2005/2006 and

Percent of Respondents


60 2005/2006
40 34 2008

17 15
3 3 1 1
Excellent Very Good Acceptable Poor Failing
Patient Safety Grade

Chart 1.3 Overall MHS Number of Events Reported in the Past 12 Months for
2005/2006 and 2008

Percent of Respondents

80 73 73

60 2005/2006

40 2008

18 17
6 6
2 2 1 1 1 1
None 1 to 2 3 to 5 6 to 10 11 to 20 21 or
Number of Events Reported




Keep in mind that the delivery of survey results is not the end point in the survey
process; it is actually just the beginning.

While administering the DoD Tri-Service Survey on Patient Safety can be considered an
“intervention” to educate staff and build awareness about issues related to patient
safety—this should not be the only goal of conducting the survey. Administering the
survey is not enough. It is often the case that the perceived failure of surveys as a means
for creating lasting change is actually due to faulty or nonexistent action planning or
survey follow-up. Seven steps of action planning are provided to help your facility go
beyond simply conducting a survey to realizing patient safety culture change.1
Figure 2.1 Seven Steps of Action Planning

Step #1: Step #2:

Understand Communicate &
Your Results Discuss Results

Step #4:
Step #3:
Create Focused
Plans &
Action Plans

Step #6:
Step #5: Step #7:
Track Progress
Implement Share What
& Evaluate
Action Plans Works

Step # 1: It is important to review your facility’s survey results and interpret them before you
Understand develop action plans. Develop an understanding of your facility’s key strengths and
Your Survey areas for improvement. Examine your facility’s overall percent positive scores on
Results the patient safety culture composites and items:

 Which areas were most and least positive?

 How do your facility’s results compare with the results from other facilities or
the MHS?
 Do any patterns emerge?

1 The seven steps of action planning outlined in this chapter are primarily based on the book “Designing and Using
Organizational Surveys: A Seven-Step Process” (Church & Waclawski, 1998).



In addition, compare your facility’s most recent survey results with its previous
results to examine change over time.

 Did your facility have an increase in its scores on any of the survey composites
or items?
 Did your facility have a decrease in its scores?
 When you consider the types of patient safety actions that your facility
implemented between each survey administration, do you notice improvements
in those areas?
After reviewing the survey results carefully, identify two to three areas for
improvement at the facility level. While your facility may want to improve in almost
all areas, it is better to avoid focusing on too many issues at one time.

Step # 2: Common complaints among survey respondents are that they never get any feedback
Communicate about survey results and have no idea whether anything ever happens as a result of a
and Discuss survey. It is therefore important to thank your staff for taking the time to complete
the Survey the survey and let them know that you value their input. Sharing results from the
survey throughout the facility shows your commitment to the survey and
improvement process.
Use survey feedback as an impetus for change. Summaries of the survey results
should be distributed throughout the facility in a top-down manner beginning with
senior management, administrators, medical and senior leaders, and committees,
followed by department managers and then staff. Managers at all levels should be
expected to carefully review the findings. Summarize key findings, but also
encourage discussion about the results throughout the facility. What do others see in
the data and how do they interpret the results?
In some cases, it may not be completely clear why an area of patient safety culture
was particularly low. Keep in mind that surveys are only one way of examining
culture, so strive for a deeper understanding when needed, by conducting follow-up
activities such as focus groups or interviews with staff to find out more about an
issue, why it is problematic, and how it can be improved.

Step # 3: Once areas for patient safety culture improvement have been identified, formal,
Develop written action plans need to be developed to ensure progress toward change.
Focused Facility-wide and department-based action plans can be developed. Major goals can
Action Plans be established as facility-wide action plans. Department-specific goals can be
fostered by encouraging and empowering staff to develop their own action plans at
the department level.
Encourage action plans that are “SMART”:
 Specific
 Measurable
 Achievable
 Relevant
 Time-bound



When deciding whether a particular action plan or initiative would be a good fit in
your facility, you may find that a guide entitled “Will It Work Here? A
Decisionmaker’s Guide to Adopting Innovations” (Brach, Lenfestey, Roussel,
Amoozegar, & Sorenson, 2008) is a useful resource (available at: The
Guide helps users answer the four overarching questions:

 Does this innovation fit?

 Should we do it here?
 Can we do it here?
 How can we do it here?
Identify funding, staffing, or other resources needed to implement action plans and
take steps to obtain these resources, which are often fundamental obstacles hindering
implementation of action plans. It is also important to identify other obstacles you
may encounter when trying to implement change and to anticipate and understand
the rationale behind any potential resistance toward proposed action plans.
In the planning stage it is also important to identify quantitative and qualitative
measures that can be used to evaluate progress and the impact of changes
implemented. Evaluative measures will need to be assessed before, during, and after
implementation of your action plan initiatives.

How Much Will It Cost?

Many of the initiatives described in this Guide are relatively straightforward and
do not require extensive resource investments of time or money. What they
require most is energy, creativity, and dedication. Other initiatives and tools,
however, have higher direct and indirect costs, so some facilities have adapted
available tools to fit their budgets, time constraints, and facility characteristics.

Step # 4: Once action plans have been developed and approved and resources have been
Communicate cleared, the plans, deliverables, and expected outcomes of the plans need to be
Action Plans communicated. Those directly involved or affected will need to know their roles,
and responsibilities, and the time frame for implementation. Action plans and goals
should also be shared widely so that their transparency encourages further
accountability and demonstrates the facility-wide commitments being made in
response to the survey results.
At this step it is important for senior managers and leaders to understand that they
are the primary owners of the change process and that success depends on their full
commitment and support. Senior-level commitment to taking action must be strong;
without buy-in from the top, including medical leadership, improvement efforts are
likely to fail.



Step # 5: Implementing action plans is one of the hardest steps. Taking action requires the
Implement provision of necessary resources and support. A champion or leader for the effort
Action Plans should be identified to take charge of implementation. It requires tracking
quantitative and qualitative measures of progress and success that were identified in
the planning stage. It requires publicly recognizing those individuals and
departments that take action to drive improvement. And it requires adjustments
along the way.
This step is critical to realizing patient safety culture improvement. While
communicating the survey results is important, taking action makes the real
difference. However, as the Institute for Healthcare Improvement (IHI, 2006)
suggests, actions do not have to be major, permanent changes. In fact, it is
worthwhile to strive to implement easier, smaller changes that are likely to have a
positive impact rather than big changes with unknown probabilities of success.
The “Plan-Do-Study-Act” cycle (Langley et al., 1996) is a pilot-study approach to
change that involves first developing a small-scale plan to test a proposed change
(Plan), carrying out the plan (Do), observing and learning from the consequences
(Study), and determining what modifications should be made to the plan (Act).
Implementation of action plans can occur on a small scale, within a single
department, to examine impact and refine plans before rolling out the changes on a
larger scale to other departments.
Figure 3.2 PDSA Cycle

Act Plan

Study Do

Step # 6: Use quantitative and qualitative measures to review progress and evaluate whether a
Track specific change actually leads to improvement. Ensure that there is timely
Progress and communication of progress toward action plans on a regular basis. If you determine
Evaluate that a change has worked, communicate that success to leadership and staff by
telling them what was changed, and that it was done in response to the safety culture
survey results. Be sure to make the connection to the survey so that the next time the
survey is administered, staff will know that it will be worthwhile to participate again
because actions were taken based on the prior survey’s results. Alternatively, your
evaluation may discover that a change is not working as expected or has failed to
reach its goals and will need to be modified or replaced by another approach. Before
dropping the effort completely, try to determine why it failed and whether
adjustments might be worth trying.



Keep in mind that lasting culture change will be slow and may take years. Frequent
assessments of culture are likely to find temporary shifts or improvements that may
come back down to baseline levels in the longer term if changes are not sustained.
When planning to reassess culture, it is also very important to obtain high survey
response rates. Otherwise, it will not be clear whether changes in survey results over
time are due to true changes in attitudes, or due to the fact that you may be
surveying different staff each time.

Step # 7: In step six, you tracked measures to be able to identify which changes result in
Share What improvement. Once your facility has found effective ways to address a particular
Works area, the changes can be implemented on a broader scale to other departments within
the facility and to other facilities. Be sure to share your successes with outside
facilities as well.




The comments and experiences of the nine top-performing DoD facilities that
participated in patient safety interviews are shared here. During the interviews, they
described initiatives and practices that contributed to patient safety culture
improvements in their facilities between 2005/2006 and 2008. New patient safety
leaders can use the information in this chapter to help them develop plans for
building effective patient safety programs. More experienced patient safety leaders
can learn about initiatives to consider implementing that are relevant to their own
patient safety goals or actions plans.
The initiatives and practices described during the interviews are grouped into the
following categories:

 Event Reporting and Nonpunitive Culture

 Handoffs and Transitions
 Teamwork
 Management Support for Patient Safety
 Staff Engagement/Ownership
 Raising Staff Awareness of Patient Safety
 Other Improvement Initiatives

Event Between the 2005/2006 and 2008 administrations of the DoD Tri-Service Survey on
Reporting Patient Safety, many of the interviewed facilities set goals to:
and  Increase the frequency of event reports by all staff
Culture  Change the perception that the reporting process is punitive
To lay a foundation for meeting those goals, the facilities implemented a broad-
based approach, simultaneously conducting some or all of the following initiatives:
1. Educating staff about medical events and event reporting
2. Maintaining an open door policy about reporting
3. Making event reporting convenient and easy
4. Creating a nonpunitive reporting environment
5. Providing feedback and communicating lessons learned
Improved scores on the DoD 2008 Tri-Service Survey on Patient Safety indicate that
these activities helped many of the nine facilities to create more positive staff
perceptions about reporting. Despite some improvement, most of the facilities,
however, are still striving for increases in the number of events reported during the
past 12 months.



1. Educating Staff About Medical Events and Event

Staff do not always understand what should be considered a medical event and why
it is important to report events. Many staff as well as leaders also do not recognize
that the root causes of events are often problems in the systems and processes for
delivering care rather than the result of individuals prone to human error. Thus,
patient safety leaders must plan and implement educational initiatives about medical
events and event reporting. The nine top-performing MHS facilities shared
information about their activities to educate staff on these issues.


One facility began patient safety leadership rounds to make the Patient Safety
Manager more visible and to educate staff on patient safety issues and event reporting.
During the rounds, the Patient Safety Manager administers a 10-question paper event
reporting survey to staff in a small section of the facility to assess their knowledge and
understanding about event reporting. The four main survey topics include:

 Patient safety topics

 The reporting process (including where to find information on reporting)
 Willingness to report events
 Perceptions about negative consequences if someone files a report
The Patient Safety Manager analyzes the survey results and briefs the department
leader on key findings. They both pay an informal visit to the section and ask staff
additional face-to-face questions to get them to relax and talk about patient safety
issues and events in their area. Typical questions include:

 Tell me what you do here.

 How do patients flow through here?
 Do you know about event reporting and how to do it?
 Do you know why you report?
 What about your work makes you unable to sleep at night?
 What are some of the workarounds in this section?
 What are some recent events that you are concerned about?

Staff often do not recognize that an event is a patient safety event.

Follow-up: Six months to a year later, the Patient Safety Manager and the
department leaders re-administer the event reporting survey. They compare results
across department areas and track individual departmental progress over time.
Benefits: The short surveys and low-key discussions help staff to recognize what
things should be considered patient safety events. Also, they learn how to file reports



and they realize that the Patient Safety Manger is available to help them fill out
forms and file their reports.

Why Staff May Not Report Events

Patient safety leaders at one facility asked staff:
“If you see a friend make an error that would affect patient safety but not result
in patient harm, would you report it?”
Many staff said they would not report it because it would be like “snitching” on
your co-workers instead of supporting them.


One facility also devotes a separate meeting to patient safety once a quarter to
discuss various patient safety topics. At an early 2007 meeting, leaders focused on
patient safety events that people do not think can happen in their facility or facilities
like theirs.
Event lists: To help staff identify events, a patient safety leader in the facility
created and distributed forms (“cheat sheets”) that include the types of events staff
should be reporting. Staff are surprised to see events listed on the forms that they
would never have considered reporting.
Benefit: This facility’s short survey initiative, the monthly meetings on patient
safety issues, and the forms with lists of errors to report all contributed to
improvements in staff perceptions about event reporting.

Patient safety leaders at Nellis AFB reviewed their facility’s results for the DoD Tri-
Service Survey on Patient Safety. The results indicated they needed to help staff
better understand the importance of reporting medical events, even those that do not
result in patient harm. They developed slides on patient safety and event reporting
and presented them on their education website. An email was sent to all staff, under
the Commander’s signature, announcing the new mandatory online training, which
included a posttest. The Patient Safety Manager reviewed all the tests (about 850)
and replied individually to all respondents that had incorrect answers, explaining
why each answer was incorrect. Although this effort was time-consuming, the
manager thought it was necessary to provide individual responses in the initial
stages of staff education about event reporting.


Starting in early 2008, the Patient Safety Manager at Tripler Army Medical Center
coordinated with the Director of Graduate Medical Education to initiate quarterly
clinical case reviews. During the case reviews, a case study—generally one based on a
sentinel event—is presented and then staff members use a healthcare matrix to evaluate
the care provided. The matrix is based on the Institute of Medicine’s six goals for
healthcare (i.e., care is safe, effective, patient-centered, timely, efficient, and equitable)



and the Graduate Medical Education Core Competencies (i.e., competency in patient
care, medical knowledge, practice-based learning, interpersonal and communication
skills, professionalism, and systems-based practice).2 Time is then allowed for
discussion of system changes that occurred as a result of the event, whether the changes
were effective, or if there are other recommendations or suggestions for ways to
improve patient safety. Leadership emphasized attendance by house staff, but other
staff were encouraged to attend as well.
Benefits: The presentations facilitated sharing of lessons learned across the
organization. The information motivated staff to think about the process of care. The
presentations were well received.


The Patient Safety Committee at NNMC Bethesda met weekly to review an event
case for system and process improvement. The goal was to identify processes that
need to be improved (and, later, to jointly develop solutions and corrective actions).
Anyone from the discipline where the event occurred was welcome to attend the
meeting and participate in the informal Q&A that took place.
Benefits: During the reviews, members began realizing that the important issue was
not about blaming individuals but about improving the processes that led to the
event. All participants realized they could come together collegially to discuss and
challenge one another’s opinions about whether various processes in the facility
were intact or in need of improvement.

2. Maintaining an Open Door Policy About Reporting

Staff are not always certain whether they need to report a problem or how to report
an event. Thus, they may simply not report the problem to anyone. Several facilities
recommend strongly that patient safety leaders interact face to face with staff so that
staff get to know them and feel comfortable about asking for help in reporting
events. One Patient Safety Manager described her views about her role:
“I don’t sit in my office. The staff knows who I am. I make it a point
that they know who I am and I make it a point to let them know that I
am here for them. They are not here for me; I work for them…my door
is always open for anybody.”
Another facility, Edwards AFB, said that as a result of efforts by patient safety
leaders to promote communications about errors during staff orientation and
committee meetings, staff now understand they can walk into the Patient Safety
Office at any time and ask questions or clarify if something is a problem that should
be reported. Staff are comfortable with the idea that help is available.

2 For a description of the Institute of Medicine’s six goals for healthcare, see, and for a description of the Graduate Medical Education
Core Competencies, see



3. Making Event Reporting Convenient and Easy

If staff perceive event reporting as inconvenient or time-consuming, they may
decide not to report an event. Several facilities improved existing reporting methods
or forms to encourage more reporting. They also improved their processes for
reviewing event reports.

New Patient Safety Event Reporting System

A new electronic system, Patient Safety Reporting (PSR), developed by Datix
Ltd., U.K., will be piloted at nine MHS sites October 2009 through March 2010.
The system is designed to put the focus on patient safety event capture and
safety improvement processes. Staff with access to the DoD Intranet may
report directly on easy-to-use web pages. Staff will have the option of
reporting events anonymously. All event records will be stored in a central
database at the Defense Information Systems Agency (DISA). After a Patient
Safety Manager approves an event report, it becomes viewable and
searchable, and reports can be aggregated at the Service and DoD levels.


The Patient Safety Manager at Tripler Army Medical Center collaborated with the
Risk Manager, the Infection Control Manager, the Patient Safety Pharmacist, and the
Patient Safety Committee to revise and upgrade their facility’s electronic event
reporting method. The old method was cumbersome to use and not user friendly, and
facility leaders thought it hindered reporting. The Patient Safety Committee
members tested the new electronic method and suggested improvements. Little
training has been required because the new method is so simple for staff to use. The
user process is illustrated in the following flow chart:
Figure 3.1 Event Reporting Flow Chart

User User User

Clicks on Completes/ Receives
Icon to Submits Auto-
Log In Report Confirmation

The report goes to the Patient Safety Manager, who forwards it to the appropriate
person (usually the unit supervisor). That person analyzes the report and adds
recommendations and comments.

Advice on Electronic Event Reporting Design

“Make it [electronic design] easy, make it highly accessible…if it’s
something…they have to learn the mechanics of, they’re not going to bother.”




Edwards AFB developed a new reporting form, promoted reporting, and reviewed
its reporting processes. The Patient Safety Manager created a Microsoft Access
database that facilitates tracking patient safety issues during the reporting and review
processes. It also allows patient safety leaders to pull up reports on each patient
safety issue when needed.
Reports are sent to the Patient Safety Manager, who usually sends it for review to
the commander for the area where the event occurred. The commander completes
the review, which includes discussion, conclusion, recommendation, action, and
follow-up. The Patient Safety Manager sends the review to all relevant areas and to
all executive staff and other commanders. The Patient Safety Manager then notifies
both the person who reported the incident and the commander who completed the
review about the outcome and follow-up actions.
Benefits: Increased reporting, more timely follow-up, an increase in perceptions that
the response to error is nonpunitive, and increased patient safety awareness.

Simplifying Event Reporting Forms

Nellis AFB replaced its lengthy reporting form with simple check sheets. The
percentage of staff saying they had reported one or more events in the past 12
months increased by 5 percentage points from the 2005/2006 to the 2008
administration of the DoD Tri-Service Survey on Patient Safety.

4. Creating a Nonpunitive Reporting Environment

Staff perceptions that the reporting process is punitive are not uncommon in health
care facilities. In the overall MHS, only 45 percent of respondents to the 2008 DoD
Tri-Service Survey on Patient Safety felt that their facility was nonpunitive in its
response to error. Facilities spend considerable time trying to create an environment
in which individual staff members feel assured they will not be penalized unfairly
for reporting events.
For example, senior leadership at one facility emphasize to other leaders and staff
that they are all working within a human system, and within human systems
inevitably there are errors. Rarely are the errors due to gross negligence; more often
they are due to fatigue or to too many things happening, or they are process errors.
The senior leader who made that comment during the interview offered the
following advice to other facilities:
“If administrative people who are working with events and errors are
looking for a fault—who’s to blame—I think they will create a negative
environment. If they are looking for how to solve this so it doesn’t
happen again in the future, they create a totally different
environment…I believe that’s a critical element.”



Resources about “Just Culture” and the “Substitution Test” (highlighted on the next
page) can help facility leaders establish a culture that is nonpunitive when it comes
to system failures that lead to human error, but still holds individuals accountable in
a fair way for intentional and risky violations of rules.

Spotlight on “Just Culture”

“Just Culture” focuses not only on treating events as opportunities to improve
system and process problems that contribute to events but also on managing
at-risk staff behaviors that lead to events.
For more information about “Just Culture,” see the “Patient Safety and the
‘Just Culture’: A Primer for Health Care Executives,” prepared by David Marx,
JD, and available at:

Spotlight on the “Substitution Test”

Psychologist James Reason advises use of the “substitution test” to evaluate
individual blame for errors. Substitute a new individual with a similar
background to the person who made an error and ask:
“In light of how events unfolded and were perceived by those
involved in real time, is it likely that this new individual would
have behaved any differently?”
You can also ask peers of the individual who made the error: “Given the
circumstances that prevailed at that time, could you be sure that you would
not have committed the same or similar unsafe act?”
If the answer to these questions is “probably not,” then individual blame is
inappropriate and system causes should be examined.
Reason J. Engineering a safety culture. In Managing the Risks of
Organizational Accidents. Aldershot, England, Ashgate Publishing Limited,
208–211; 1997.


To promote more reports of events that have not resulted in patient harm but still
represent risks, Nellis AFB started a “good catch” award program to recognize staff
reporting. They also talked to all staff about the potential impact of reported events
if they had reached the patient.
Brooke Army Medical Center rewards staff who report events by acknowledging them
in front of their whole department and presents them with small awards, such as mugs
and pens. A facility leader commented on the benefits of the awards ceremony:
“The person was acknowledged, came up to the front, and received lots
of kudos. And in the same breath, we advertised the importance of
reporting near misses. It showed other people that you’re not going to
get your hand slapped— you’re going to actually be rewarded.”



5. Providing Feedback and Communicating Lessons

It is important for staff to know that reports are taken seriously. A number of
facilities provide feedback about the outcome of reported events to the reporters and
to others involved in the event. They believe such feedback is appropriate:
“It is absolutely critical that anytime there is an event that goes
forward that anybody and everybody that’s involved gets
feedback…need to close the loop.”
Also, they believe communication about the outcome of the report motivates staff to
report. Brooke Army Medical Center commented:
“We have really tried very hard to improve communication. Let’s say if
they had a problem with the lab or with x-ray, they would identify the
problem, and we would coordinate with x-ray or lab and get that
response back to them. So I think that encourages more reporting.”
Timeliness of communications about events is also important. Irwin ACH
encourages its supervisors to discuss events that occur in their units at the next shift
change as a way of getting the word out quickly. Facility patient safety leaders
believe supervisors should share what happened and what was done about the event.
That communication forestalls rumors about events, and has helped to improve staff
perceptions regarding feedback about incidents.


Several facilities also present information about events to staff throughout the
Example: At Nellis AFB, the Patient Safety Manager holds regular briefings in
multiple settings about actions taken and lessons learned from reported events. She
tailors each briefing to the particular audience (e.g., Executive Committee of the
Medical Staff, Nurse Executive Council, pharmacy and therapeutics, data quality,
environment of care). When she sends reports with lessons learned by email, she
makes them colorful to attract attention. Nursing leaders often use those reports to
brief staff.
Facilities also emphasized that event reports are used to improve processes:
“From every single one of our event forms that are submitted, there is
an improvement…Wherever they find a failure, they change the process
so that it doesn’t happen again.”
Example: When investigating a report that a provider submitted the wrong type of
specimen Q tip to the laboratory, facility leaders learned that the provider error
might have been caught at the laboratory stage if the laboratory had done its own
quality check when it received the specimen. They now encourage the laboratory to
perform that check as part of its laboratory procedure.



Handoffs “Handoffs occur anytime there is a transfer of responsibility for a patient from
and one caregiver to another. The goal of the handoff is to provide timely, accurate
Transitions information about a patient’s care plan, treatment, current condition, and any
recent or anticipated conditions.”
– The Joint Commission

Several facilities attributed their improved survey scores on Handoffs and

Transitions to various tools and initiatives as well as to more general efforts to
promote teamwork and to improve processes through Failure Mode and Effects
Analysis (FMEA). The following activities are highlighted:
1. Using handoff communication tools
2. Identifying and improving handoffs and transitions

1. Using Handoff Communication Tools

Various communication tools are available to facilities to adopt or adapt for use in
handoffs. In one facility, the staff use “I PASS THE BATON”—a communication
tool developed by the DoD Patient Safety Program to improve handoffs and
transitions—and the staff know it well. However, several facilities switched to
SBAR (Situation-Background-Assessment-Recommendation), or a modification of
it, because SBAR was easier for their staff to learn, understand, and follow.



Spotlight on “I PASS THE BATON”

I Introduction Introduce yourself and your role/job (include patient)

P Patient Name, identifiers, age, sex, location

Presenting chief complaint, vital signs and symptoms
A Assessment
and diagnosis
Current status/circumstances, including code status,
S Situation level of (un)certainty, recent changes, response to
Safety Critical lab values/reports, socio-economic factors,
Concerns allergies, alerts (falls, isolation, etc.)
Co-morbidities, previous episodes, current
B Background
medications, family history
What actions were taken or care required AND
A Actions
provide brief rationale

T Timing Level of urgency and explicit timing, prioritization of

Who is responsible (nurse/doctor/team), including
O Ownership
patient/family responsibilities?
What will happen next? Anticipated changes? What
N Next
is the PLAN? Contingency plans?

For more information about “I PASS THE BATON,” see the Tools and
Resources section of this Guide (Appendix B).

Spotlight on SBAR
SBAR is a framework for teams to communicate important patient information
clearly and concisely. It can be recalled through the following mnemonic
S: Situation – summarize the patient’s present situation
B: Background – provide relevant background information
A: Assessment – state the various options available
R: Recommendation – propose what actions should be taken
For more information about SBAR, see Appendix B.



2. Identifying and Improving Handoffs and Transitions

Handoff situations are not necessarily self-evident to staff. One clinic switched to
SBAR as part of a major new program on handoffs and transitions in its facility.
Many staff did not recognize that they even had handoffs in the clinic setting. The
prevailing philosophy was that “we’re not moving someone from the ED to the ICU
to the ward.” The goal of the new program was to identify all places and situations
in the facility that might be considered a handoff and to develop more effective
transitions with the use of SBAR.
Leadership support and concerns: The program had the full support of senior
executives—the leaders knew it was important.
Identifying handoffs. Patient safety leaders decided to use the facility tracer team to
assist with identifying handoff situations. Tracer team members in the facility are
responsible for, and were experienced in, identifying gaps or risk points in facility
processes that affect patient care or safety. The facility uses the data they gather for
improving systems and processes and to help prepare staff for Joint Commission
Department heads and the clinic’s tracer team identified, department by department,
how patients flow and when a patient might be in one area but need to be taken
somewhere else. For example, patients may be taken:

 From the behavioral health clinic where a nutritionist thinks a patient needs to
see a primary care provider to the attached primary care clinic,
 From the primary clinic to an ambulance if a patient presents with heart attack
symptoms, or
 From a clinical staff member who is assessing a patient that begins coding to a
rapid response team.
The department heads and the tracer team identified such situations as handoffs,
with the need for clear, concise, and quick communications to perform the handoff
Staff reactions: The Patient Safety Manager worked face to face with staff, assuring
them that help was available in making the change to using SBAR in handoffs.
Nevertheless, staff response to the new program varied. For example, nurses liked the
switch to SBAR and embraced the new program. Staff in some administrative areas,
however, were more resistant to the program. They would say things such as “we’re
logistics, we’re information management, we’re medical records, and we don’t have
anything to do with patients,” to convey their belief that handoffs and transitions were
not issues in their nonclinical work areas. The patient safety program staff response
was to include administrative staff in the training program, but they also provided
specific examples of things that could happen or problems that might begin in
nonclinical areas (e.g., problems with medical equipment). Program staff had good
examples because tracer teams had reviewed both clinical and administrative areas
during their identification of possible patient safety risks in the facility.
Benefits: Staff better understand the meaning of handoffs in their facility and use
more effective communications during transitions.



Teamwork Effective handoffs and transitions are clear examples of strong teamwork within and
across units in health care facilities. Facilities described other activities that
contributed to stronger teamwork in their facilities:
1. Cross Training and Use of Universal Protocols
2. Implementing a New Way of Doing Rounds
3. Implementing TeamSTEPPS™

1. Cross Training and Use of Universal Protocols

One clinic has been making a concerted effort to build a strong teamwork culture.
They use interdisciplinary teams, and they cross-train administrative staff to cover
for each other during busy times or when someone calls in sick. They have also
trained medical assistants and licensed practical nurses to check in patients during
busy times.
In this same clinic, leaders also began placing more emphasis on the use of universal
patient safety protocols that both incorporate teamwork and promote staff
discussions about lessons learned. For example, the protocol to prevent wrong-site
surgery demands teamwork: you check the patient in, and all staff pay attention
during a mandated timeout led by the person doing the procedure. The timeout
leader goes through the protocol, and if anyone doesn’t agree at any point, that
person can raise a hand to speak up.
One staff member commented that as a result of their interdisciplinary teams, cross-
training, use of universal protocols, and strong leadership support for a teamwork
culture that holds all staff accountable, staff do not have a choice about working as
part of a team:
“I think it is part of the culture here. You work as a team and if you
don’t want to be a team player, then this is not the right place for you.
And we’ve worked really hard on that.”

2. Implementing a New Way of Doing Rounds

Brooke Army Medical Center attributed its improved teamwork scores on the DoD
survey in part to its new way of doing rounds.
Old procedure: The most junior doctor would recite all of the patient’s information
and ask the nurse if he or she had anything to add.
New procedure: The nurse starts with a summary of events that occurred during the
night shift; next, the physician in training presents the patient to the interdisciplinary
team. As the plan of care for the day is developed, one physician team member
enters orders into the electronic medical record. At the end of the round on the
patient, the nurse repeats the plan of care for the day and indicates who is
responsible for each part (e.g., write consult, arrange test). This “read back” allows
any team member to clarify the patient plan as needed. All individuals in the round
discuss the plan of care for the day, and everyone makes sure that they understand
and agree.



Benefits: This process ensures that there is open communication among team
members with various levels of experience. The bedside nurse clinician can also use
the process to clarify whether the established care plan is not being followed or to
guide a change to the care plan when the patient’s needs have changed and the care
plan is no longer effective.

3. Implementing TeamSTEPPS™
Two of the interviewed facilities implemented TeamSTEPPS™ between the
2005/2006 and 2008 survey administrations. They briefly described how they
implemented, and adapted, TeamSTEPPS in their facilities.

Nellis AFB originally implemented TeamSTEPPS in late 2005. Training was mandated
for all hospital personnel, which created some resistance, especially among nonclinical
staff. Following the 2008 survey, a team from the Service branch spent a week onsite.
The Service team spent 3 days training 25 trainers. During another 2½ days, they
conducted 4-hour sessions training 65 staff in the fundamentals of TeamSTEPPS. Now,
the facility’s own trainers teach smaller classes and personalize the training with a
selection of videos provided by the hospital.
Implementation approach: The facility learned from its 2005 experience by
realizing that TeamSTEPPS is not an “all or none” program, but a valuable
collection of tools with vast applicability in various areas. Leadership gave
priority to high-risk areas and mandated TeamSTEPPS training for the
Emergency Department, Labor and Delivery, and ICU/SDU. Many
departments have implemented the training; the Medical/Surgical Nursing
Units and the Family Practice Clinic are actively involved.
Results: Rather than becoming a burden of mandatory meetings and
voluminous reports, TeamSTEPPS is now a part of the facility culture. Staff
engage regularly in briefs, debriefs, and huddles and use mnemonic devices
for consistent handoffs; conflict resolution techniques enhance
communication. TeamSTEPPS tools are regularly used in response to
reported patient safety events and are found in the formal action plans of
Root Cause Analyses performed in the hospital.

Irwin ACH implemented TeamSTEPPS in one of its work areas or units before the
2008 survey administration and subsequently in another unit.
Implementation approach: Units volunteer for TeamSTEPPS; it is not a
top-down mandate. Although the Commander and the Patient Safety
Manager support TeamSTEPPS, they believe the program is better accepted
when unit staff develop the program themselves and have responsibility for
Subsequent training in facility: The nurses that were trained in the first
TeamSTEPPS unit (“stellar leaders who fully embraced it”) are now the
trainers in the second TeamSTEPPS unit.



What Is TeamSTEPPS™?
Team Strategies and Tools to Enhance Performance and Patient Safety
“A teamwork system designed to improve quality, safety, and efficiency of
healthcare; offering a powerful solution to improving patient safety within your
For more information about TeamSTEPPS™, see Appendix B.

Management To be effective, patient safety programs require support from leaders throughout the
Support for facility, appropriate staffing for managing patient safety responsibilities, and patient
Patient safety leaders that are highly visible and engaged with staff throughout the facility.
Safety During the interviews, facilities talked about their experiences with the following
elements of management support for patient safety:
1. Ensuring Leadership Support
2. Establishing a Patient Safety Program Manager

1. Ensuring Leadership Support

Facilities reported that leadership support is essential to improvements in patient
safety culture:
“Involve leadership—get leadership behind you. If you don’t have
leadership support behind you, you can’t get anything accomplished.”
The patient safety leaders at one facility said persistence is necessary at times to win
leadership support for an initiative. They wanted the facility to close down for a day
to conduct two half-day training sessions on patient safety and needed to convince
senior leadership to support the training. After senior leadership witnessed the
training sessions, the patient safety leaders were able to gain senior leadership
support and endorsement for additional patient safety initiatives. Advice from this
facility’s patient safety leaders to other leaders seeking senior leadership support:
“Don’t give up and don’t go away. Just keep pounding on it.”
Facilities cited various ways that effective leaders demonstrate their support and
promote a stronger patient safety culture:
Visibly advocate for patient safety
“I think we’re pretty lucky in our leaders. They are strong advocates
for patient safety and I think they make that known.”
Endorse patient safety program initiatives
“…leadership at all levels have to endorse it [patient safety] or it
doesn’t happen.”
Mandate and execute patient safety policies
“I think the number of incidents reported was directly related to
leadership’s mandate that we will report events…our commander… is



100 percent behind patient safety…and he is more concerned if an

event happens and is not reported… he wants it reported so that action
can be taken and prevent it from happening again.”
Invite and respect other leaders’ input on patient safety
“It is critical that everyone [with leadership responsibilities] has the
ability to communicate their issues and their concerns and that they be
recognized equally.”

The Importance of Supervisor/Middle Manager Support

A participant attributed much of Edwards AFB’s progress in the past 2 years
to their “incredibly gifted and talented middle managers.” He credited the
previous Commander and squadron commanders with choosing people for
mid-level positions who were the best qualified for the jobs and then
promoting strong communications among them. In his words:
“They work the issues and find solutions and move the facility forward.”

Even in the best of patient safety programs, key challenges can arise because of
frequent turnover in senior leadership. On occasion, new senior leaders may have
limited experience with patient safety programs. When that occurs, patient safety
leaders must renew their efforts to educate, win, and sustain senior leadership
support for a strong patient safety program.
Suggestion: One facility stressed that once in place at a facility, new Commanders
have so many responsibilities to fulfill (including military requirements) that it is
difficult to carve out time for leadership training on patient safety and processes
such as Root Cause Analysis. They recommend, instead, that more time be spent on
standardized training on patient safety when Commanders receive their special
training for taking over command. They commented:
“A little more education on it would make the patient safety manager’s
life easier.”

2. Establishing a Patient Safety Program Manager

Commander and senior leadership support are not the only essential conditions for a
successful patient safety program. Facilities emphasized that designated patient
safety leaders who interact directly with other leaders and staff are crucial also.

 The facilities varied in whether they had a full-time Patient Safety

Manager/Director between the two survey administrations.
 Facilities with a full-time Patient Safety Manager were strong advocates for
having this type of full-time manager. One staff member advised that to ensure
that patient safety is a number one priority and does not take a back seat to other
initiatives, Patient Safety Managers should be responsible only for patient safety
improvement. She commented:
“If you don’t invest in the program, you will not have good
results…The person has to eat, sleep, and breathe patient safety.”




Several facilities also emphasized that patient safety leaders, in the words of one
facility leader, need to adapt the military philosophy of “Go forth to serve.” By that,
they mean the Patient Safety Manager should not stay behind the desk initiating and
responding to phone calls and emails about patient safety concerns. Rather, the
manager needs to:
“get up from behind your desk, go out to the clinical areas, and
interact in a collegial way with your peers in the clinical areas.”
“…get out there, get involved, get leadership involved.”
Effective patient safety leaders manifest such activity in various ways.
Committee membership and briefings: Patient safety leaders serve as members on
executive councils and leadership committees in their facilities. They raise their
visibility at those meetings by giving presentations on patient safety issues and
goals, survey results, and the status of event reports.
Participation in staff training: They participate in new staff orientation sessions
and in other staff training. Presentations on and discussions about patient safety have
become standard parts of the agendas at their facility meetings and training sessions.
Interactions with staff: They participate in formal or informal walkarounds in the
facility. One hospital reported an initial lack of buy-in for patient safety as well as
some suspicion among staff. Patient safety leaders turned that situation around by
spending a significant amount of time walking around the facility, getting to know
people, letting them get to know the leaders, and building trust:
“If you just send out emails, hang up some posters, and walk away, they
won’t really embrace any of those ideals that you are trying to foster.”
Representation at many different committee meetings: At NNMC Bethesda, the
Patient Safety Office recently expanded from two to four staff members. The
expansion has allowed the Patient Safety Manager to implement a new activity that
has made other leaders and staff in the facility aware that the Patient Safety Program
Office is there to help them resolve patient-safety-related issues in their areas of
responsibility—the office is not there solely to “push its own agenda.”
New activity: The manager or one of her three staff members now attends,
whenever possible, major committee meetings in the facility pertinent to
patient safety (e.g., standards and products, orders and equipment,
maintenance, repair, physicians, nurses, blood bank, and infection control).
Patient safety staff role: The patient safety staff identify issues related to
patient safety that are raised during these committee meetings and they offer
assistance in resolving them. For example, during an infection control
committee meeting, members expressed the need for more staff help with
special cleaning in ICU terminal rooms, but said they had no budget to draw
from. The Patient Safety Manager was able to get approval for funding an
additional full-time-equivalent position for that purpose.



Staff Limited resources usually restrict the size of the patient safety program staff. Thus,
Engagement/ in most of the interview sites, patient safety program staff cannot do everything they
Ownership would like to do. Facilities described creative ways for engaging staff and promoting
staff ownership of patient safety. Patient safety leaders said they need to do this
because they cannot do everything themselves. But they also believe it should be
done because:
“Patient safety is everybody’s business…belongs to everyone.”
“You can’t boil patient safety down to one thing…it has to be
pervasive…there’s nothing we do in this facility that does not impact
patient safety in one way or another. Almost nothing.”
Facilities described many initiatives taken by patient safety leaders for successfully
engaging facility leaders and staff as partners in promoting patient safety:
1. Establishing Formal Patient Safety Committees
2. Spreading Ownership Through a Peer-to-Peer Approach
3. Recruiting Facility Experts as Patient Safety Champions
4. Involving Staff From All Levels
5. Rewarding Participation in Patient Safety Tasks

1. Establishing Formal Patient Safety Committees

Most facilities have some type of Patient Safety Committee that meets regularly for
specific purposes, such as to review event cases, to provide suggestions and advice
for improving processes and systems, to discuss patient safety issues and goals, and
to help implement patient safety initiatives. Members are usually executives and
department heads that represent a broad spectrum of facility areas. Department
heads are often delegated responsibility for educating their area staff on topics
discussed during Patient Safety Committee meetings.

“Patient safety has many faces, not just the Patient Safety Office.”
The Patient Safety Manager at NNMC Bethesda wanted to increase the number of
expert patient safety advocates in the facility. To do so, she expanded and
reorganized the existing Patient Safety Committee. She added department leaders
from high-risk areas and other major areas, such as radiology, laboratory, information
technology, and pharmacy. She also divided the many responsibilities of the single
quality assurance physician advisor on the committee among more physicians to
enhance the effectiveness of the advisor role.
After identifying five physicians in major disciplines across the facility, she educated
them about their roles and responsibilities and discussed the facility’s mission and
vision regarding the patient safety program, as well as National Patient Safety Goals.
She also reviewed what a Root Cause Analysis is and the categories and
subcategories for events. Each of the new quality assurance physician advisors
conducted a preliminary review of any deaths in their individual discipline areas.
The manager achieved her goal—committee members, especially the quality
assurance physician advisors, are now empowered as patient safety spokespersons
at directorate and department meetings.




Some facilities also supplement formal patient safety committees with more informal
advisory or working groups to increase patient safety ownership. Although the groups
often meet regularly, they may not be required to prepare meeting minutes or reports.
At NNMC Bethesda, advisory members primarily include nurses, pharmacists, and
lab technicians. Each member is required to attend 2 days of DoD patient safety
training. Staff throughout the facility learn that they can turn to these dedicated
advocates for quick answers when they have patient safety questions.
At Nellis AFB, representatives from every clinical area meet informally each month
as a working group to discuss patient safety goals and issues. The representatives, in
turn, train their staff on the issues. Also, they each develop a plan for implementation
and compliance monitoring of National Patient Safety Goals in their respective areas.

2. Spreading Ownership Through a Peer-to-Peer

One facility had success in promoting the patient safety message by encouraging
members of a discipline to be the principal spokespersons among their peers in that
discipline. For example, the Patient Safety Manager in the facility said if she tells
doctors they must do medication reconciliation, they are likely to reply that she does
not understand how busy they are because she is not a physician.

Doctor-to-Doctor Communications
It is much more effective to promote patient safety among doctors if a doctor rather
than a nurse says:
“You have to do this universal protocol—it will save lives, this is going to
help you, and I endorse it.”

The Patient Safety Manager persuades physicians to take on this peer leadership role
by providing guidance and assistance to them. She sits down with the physician
team leader and talks about the goals and the elements of performance and how they
will measure it. She also assists the physician in assembling a team.
The team leaders she recruits quickly learn that the activity puts them in front of
their executive councils and their discipline, which enhances their job performance
ratings. That helps in recruiting new team leaders.

3. Recruiting Facility Experts as Patient Safety

At Brooke Army Medical Center, patient safety leaders identified champions to be
responsible for anticoagulation, rapid response teams, and medication reconciliation.
They said that finding expert champions within the facility but outside of the patient
safety service has worked well for them:



“It was important, particularly for the rapid response team, to have the
people who are at the grassroots that were involved in these transfers
to be the leads on these issues.”
The anticoagulation and rapid response team initiatives contributed greatly to the
facility’s improvement in patient safety culture between 2005/2006 and 2008. For
anticoagulation, they have a process in place and a system of resources. For rapid
response teams, they now have a mechanism for staff to call and get help.

The Importance of Patient Safety Champions

“Having a designated safety champion in every department and patient care unit
demonstrates the organization’s commitment to safety and may make other staff
members feel more comfortable about sharing information and asking questions.”
– Institute for Healthcare Improvement (IHI), Develop a Culture of Safety:
Appoint a Safety Champion for Every Unit
For more information about patient safety champions, see

4. Involving Staff From All Levels

One clinic has assigned nonsupervisory staff to work on its tracer teams. The tracers
identify risk points in facility processes that affect patient care or safety. Again, an
added benefit for staff leading a tracer team is a positive statement on their
performance records. But all participants on tracer teams benefit:
“…taking nonsupervisory people on tracers and having them do
tracers is very, very important. They feel important and they learn it.”


Some facilities gain more patient safety advocates by tapping into the energy of
junior staff members. For example, NNMC Bethesda is giving junior nurses, rather
than middle managers, responsibility for chart audits of falls and pressure ulcers. In
this way, the junior nurses come to feel more like they are part of patient safety.


Also at NNMC Bethesda, whenever Joint Commission alerts are received, the
Patient Safety Office converts them to an SBAR form—that is, a succinct summary.
It disseminates the form and supports it with a gap analysis that engages many
people in the facility:
“We pull people together on sentinel event alerts to talk to each other
in real time…”



The analysis team determines whether they do or do not have a problem in that event
area. The Patient Safety Office presents the findings to the Quality Council,
indicating both where they are performing well and any areas where they need to fix
something. The council members responsible for those areas then take ownership for
follow-up action.

5. Rewarding Participation in Patient Safety Tasks

In the military, a coin is given by commanding officers to reward exceptional
service. The Patient Safety Manager at NNMC Bethesda creatively adapted this
practice by developing a “coin for patient safety.” The slogan on the coin is “Safety
Is Everyone’s Business.” The Board of Directors approved the coin proposal as well
the manager’s suggestion that recipients be given a paid day off.
How it works: Staff can become recipients by demonstrating exceptional competency
while serving as a Patient Safety Advisor or while participating on various patient-
safety-related tasks, such as the National Patient Safety Goal Committee, a Failure
Mode and Effects Analysis, or a Root Cause Analysis. Recipients receive their
certificates and coins at an awards ceremony attended by staff.

Raising Staff Between 2005/2006 and 2008, a major goal for the facilities interviewed was raising
Awareness of overall awareness and knowledge about patient safety and promoting buy-in for a
Patient culture of patient safety. Facilities described an array of initiatives:
Safety 1. Conducting Short “Pulse” Surveys
2. Conducting Leadership Rounds
3. Orientation and Other Staff Training

Patient safety leaders realize that establishing a strong patient safety culture
takes time:
“When you develop something, it takes a while…and our strategy
here was to get buy-in throughout the entire institution.”

1. Conducting Short “Pulse” Surveys

The patient safety leaders in one hospital developed a short survey with about 10
questions on patient safety and infection control that they administer each month.
The staff like the survey because they can complete it quickly.
Purpose of survey: To “take the pulse” of staff knowledge about those topics.
Patient safety leaders analyzed the initial results for each department to establish a
baseline, and they now track changes over time.
Follow-up: To keep staff awareness at a high level, patient safety leaders follow up
with onsite training in individual departments. When a department scores 100
percent three times in a row on a question, the patient safety leaders replace the
question with a new one on another aspect of patient safety.



2. Conducting Leadership Rounds

A few facilities implemented formal leadership walkarounds to promote interaction
with staff and awareness of patient safety issues and to demonstrate leadership
support for patient safety.
Example: The Patient Safety Manager at one clinic created colorful brochures that
include tips for all area leaders as well as sample questions. Leaders document
whom they talked to, what they talked about, and what they were able to teach on
the round.
Although the other facilities may not have a formal leadership walkaround program,
their leadership informally circulates and talks with staff, encouraging them to report
events and to share their concerns about patient safety.

Spotlight on Leadership Walkrounds™

Leadership Walkrounds™ can be an effective tool for demonstrating to staff
leadership’s support for patient safety.
As leaders visit units, they can ask questions such as:
 “Have there been any incidents lately that you can think of where a patient
was harmed?”
 “Can you think of a way in which the system or your environment fails you on
a consistent basis?”
 “What specific intervention from leadership would make the work you do
safer for patients?”
For more information about Leadership Walkrounds™, see Appendix B.

3. Orientation and Other Staff Training

Facilities reported that they raise awareness during orientation by training new staff
on patient safety issues, including event reporting and National Patient Safety Goals.
Many of the facilities also conduct annual training for staff as well as unit-based
training, with patient safety issues and goals as important agenda topics.

Communication openness: One clinic dedicated a 2-hour class to patient safety,
focusing on openness and reporting. The trainers emphasized that most events arise
from process errors, not people errors.
Monthly classes: Irwin ACH basically shuts down once every month for 3 hours of
training in the afternoon. Staff can select 3 classes from about 12 that are available.
Class topics vary, but they usually include patient safety issues such as reporting
events and patient safety goals. Staff attendance has been strong.
Just-in-Time training: Leaders at Nellis AFB have responded to the constraint of
competing demands on staff time by packaging their patient safety training so that it



fits into demanding work/training schedules. That is, they do quick and frequent
trainings, such as “Just-in-Time” training activities.
“Passports” for training sessions: The Performance Improvement Manager at
Nellis AFB distributed a “Passport to Joint Commission Success and Patient Safety
Goals” to all staff. Staff were asked to gather voluntarily in one area of the cafeteria
during their lunch time to listen to 10-minute briefings on National Patient Safety
Goals. Ten sessions were conducted over a 2-week period. For example, a physician
delivered a presentation on medication reconciliation about six times during the 2
weeks. Staff who participated in a briefing had their passports stamped for that
training activity. A special drawing was held among staff whose passports were
stamped for all topics covered during the 2 weeks.


Many of the facilities conduct activities during Patient Safety Awareness Week that
are designed to educate staff on patient safety issues and goals. For example, at NNMC
Bethesda, a subcommittee of their Patient Safety Working Group developed posters,
games, and special films to educate staff during Patient Safety Awareness Week.
Irwin ACH planned a scavenger hunt for Patient Safety Awareness Week activities.
Staff arranged for a hospital room to be full of errors, such as tubing problems. The
staff member who identified the most problems won a prize. Staff involvement in
“owning” the scavenger hunt helped to make it a success.


Pocket cards with reference information: As part of a major promotion that
included postings on the intranet, posters, and cluster boards, patient safety leaders
at NNMC Bethesda created pocket cards with reference information. The pocket
cards are popular because staff do not have to rely on memory—for example, for
rapid response situations, the cards include a list of warning symptoms that should
trigger a call for a rapid response team.



Patient safety goals on ID badges: One hospital has included patient safety goals on
staff ID cards/badges. The purpose for doing so was twofold: to remind staff of patient
safety and to serve as a tangible reinforcement for staff while they work.

Other Other initiatives contributed to reliable and safe care for patients between the
Improvement 2005/2006 and 2008 administrations of the DoD Tri-Service Surveys on Patient
Initiatives Safety. For example, facilities engaged in the following quality improvement
Group workouts: At NNMC Bethesda, staff take a day and stay in the same room
until a process is fixed. This Lean Six Sigma effort brings in a large group of people
who do not usually have input into processes and systems. In the past 6 months, the
facility has completed two workouts.
Flow charts: Under the commander’s direction, all area leaders in one clinic
became knowledgeable about their area processes and prepared flow charts of them.
They have used their compiled data from this Lean Six Sigma initiative to improve
quality of care in their facility.
New nursing care program: In late 2007, Tripler Army Medical Center
implemented a new nursing program—Relationship Based Care. Each patient is
assigned a primary care nurse who manages the care for the patient/family. Staff
have been highly engaged in the new program because it promotes high personal
Microsystems training: A team from the DoD Patient Safety Program came and
briefed commanders in one of the facilities on microsystems training. Initially the
facility started projects in the Intensive Care Unit and the Emergency Department.
The training was valuable because staff learned how to identify what needs to be
fixed. Staff were trained to assess the care a group provides to patients (Is it state of
the art?) and to identify and evaluate all components of a group’s work process—
what they are doing, how they are doing it, and what they need to improve.

DoD Patient Safety Resources

The DoD Patient Safety Program offers a wide variety of courses available
either in person or online. You can view the upcoming course schedule
offerings and even register for courses online. For many of these patient safety
courses, you can earn accreditation credit for continuing education.
For more information about DoD Patient Safety Program online courses, see
Appendix B.



Brach C., Lenfestey N., Roussel A., Amoozegar J., and Sorensen A. Will It Work
Here? A Decisionmaker’s Guide to Adopting Innovations. Prepared by
RTI International under Contract No. 233-02-0090. Agency for Healthcare
Research and Quality (AHRQ) Publication No. 08-0051. Rockville, MD:
AHRQ; September 2008.

Church, A.H., and Waclawski, J. Designing and Using Organizational Surveys:

A Seven-Step Process. San Francisco: Jossey-Bass, 1998.

Hospital Survey on Patient Safety Culture. Rockville, MD: Agency for

Healthcare Research and Quality
(, 2004.

Institute for Healthcare Improvement (IHI). Improvement Methods: The Plan-

Do-Study-Act (PDSA) Cycle.
oImprove), 2006.

Langley, C., Nolan, K., Nolan, T., Norman, C., and Provost, L. The Improvement
Guide: A Practical Approach to Improving Organizational Performance.
San Francisco: Jossey-Bass, 1996.


Appendix A: Department of Defense (DoD) 2008 Tri-Service
Survey on Patient Safety

Description of This Survey

The DOD 2008 Tri-Service Survey on Patient Safety is sponsored by TRICARE Management Activity
(TMA) and was approved by the TMA Chief Medical Officer and the Services Surgeons General for DOD-
wide dissemination with staff in Army, Navy, and Air Force Military Health System (MHS) facilities.

Military and civilian staff with email access in MHS facilities, including Military Treatment Facilities (MTFs)
and DENTACs (Dental Activities/DTFs), are being asked to complete this survey. It asks for your opinions
about patient safety issues, error, and event reporting in your MHS facility.

 It will take about 10 minutes to complete this web-based survey and your individual
responses will be anonymous. Only group-level results will be reported.

Your response to this survey is very important and will help the DOD assess patient safety improvement
efforts in MHS facilities.


For questions about this survey, please email [Name a point-of-contact and provide email] or call [provide phone].


According to the Privacy Act of 1974 (Public Law 93-579), the Department of Defense is required to
inform you of the purposes and use of this survey. Please read the following carefully:

Authority: 10 U.S.C., Chapter 55, Public Law 102-484, E.O. 9397.

Purpose: This individually anonymous survey asks staff in Military Health System (MHS) facilities
(including MTFs and DTFs) for their opinions about patient safety issues, medical error, and
event reporting in their facilities. The data will help the DOD assess patient safety improvement
efforts in MHS facilities.

Routine Uses: None.

Disclosure: Voluntary. Failure to respond will not result in any penalty to the respondent.
However, maximum participation is encouraged so that data will be as complete and
representative as possible.

This survey has been approved by the Office of Management and Budget (OMB Number 0720-0034,
Expiration Date 09/30/2008). It is estimated that it takes 10 minutes to complete. If you have comments
about the survey, its length, or any other aspects of this collection of information, send them to: TRICARE
Management Activity, Information Management Control Officer, HPA&E, 5111 Leesburg Pike, Suite 810,
Falls Church, VA 22041.



1. The Military Health System (MHS) facility where you work is in what country and state (if
[NOTE: A drop-down list of by country and state is provided on the web survey. This question is
MANDATORY and must be answered before moving on in the web survey.]


State (if applicable): _______________

2. What is the name and DMIS Code of your Military Treatment Facility (MTF) or DENTAC (Dental
Activity/DTF)? [NOTE: A drop-down list of MTF/DENTAC names is provided on the web survey. This
question is MANDATORY and must be answered before moving on in the web survey.]

MTF or DENTAC Name:__________________________________________________________

DMIS Code: _____________________

[NOTE: If a respondent is in an MTF hospital, they will receive this additional question. If their MTF is an
outpatient clinic or dental facility, they WILL NOT receive this additional question. This question will be
MANDATORY for staff in an MTF hospital and must be answered before moving on in the web survey.]

3. In what area of your Military Treatment Facility (MTF) do you work?

 1. Hospital
 2. Ambulatory/outpatient clinic
 3. Dental clinic

When completing this survey, keep in mind the following definitions:

– An “event” is defined as any type of error, mistake, incident, accident, or

deviation, regardless of whether or not it results in patient harm.
– “Patient safety” is defined as the avoidance and prevention of patient injuries
or adverse events resulting from the processes of health care delivery.



SECTION A: Your Work Area/Duty Area

In this survey, think of your work area or duty area as the section, department, clinical unit, or
area of the Military Health System (MHS) facility where you spend most of your work time or
provide most of your clinical services.

Ai. What is your primary work area/duty area in your MHS facility?

2008 Hospital Work Areas 2008 Clinic Work Areas

Many different areas/No specific area Many different areas/No specific area
Admin/Mgmt, Education, Medical
Aerospace Med/BioMed Engineering
Records, QA/QC, Safety, Other Mgmt
Admin/Mgmt, Education, Medical
Aerospace Med/BioMed Engineering
Records, QA/QC, Safety, Other Mgmt
Anesthesiology Allergy & Immunology
Dietary Anesthesiology
Emergency Cardiology
Facilities & Logistics Dermatology
Gastroenterology Facilities & Logistics
Information Technology (IT) Services Family Practice/Family Medicine
ICUs (all types) Gastroenterology
Labor & Delivery/Obstetrics Information Technology (IT) Services
Medicine (Non-surgical) Internal Medicine
Medical-Surgical Unit/Ward Neurology/Neurological Surgery
Oncology Nuclear Medicine
Pathology/Lab Obstetrics/Gynecology
Pediatrics Occupational Medicine
Pharmacy Oncology
Psychiatry/Mental Health Ophthalmology
Radiology Orthopedics/Orthopedic Surgery
Rehabilitation/Physical Medicine Otolaryngology
Surgery Pathology/Lab
Other Hospital work area Pediatrics
2008 Dental Work Areas Preventive Medicine/Public Health
Dental Clinic Psychiatry/Mental health
Laboratory Pulmonology
Oral Surgery Radiology
Other Dental work area Rehabilitation/Physical Medicine
Vascular Medicine
Other Clinic work area



From this point forward, if you do not wish to answer a question, or if a question does not apply to
you, you may leave your answer blank.

SECTION A: Your Work Area, continued

Please indicate your agreement or disagreement with the following statements about your work
Strongly Strongly
Disagree Disagree Neither Agree Agree
    
1. People support one another in this work area .........................     
2. We have enough staff to handle the workload.........................     
3. When a lot of work needs to be done quickly, we work
together as a team to get the work done .................................     
4. In this work area, people treat each other with respect ...........     
5. Staff in this work area work longer hours than is best for
patient care ..............................................................................     
6. We are actively doing things to improve patient safety ...........     
7. We use more agency/temporary staff than is best for
patient care ..............................................................................     
8. Staff feel like their mistakes are held against them .................     
9. Mistakes have led to positive changes here ............................     
10. It is just by chance that more serious mistakes don’t
happen around here.................................................................     
11. When one section in this work area gets really busy, others
help out ....................................................................................     
12. When an event is reported, it feels like the person is being
written up, not the problem ......................................................     
13. After we make changes to improve patient safety, we
evaluate their effectiveness .....................................................     
14. We work in "crisis mode" trying to do too much, too quickly ...     
15. Patient safety is never sacrificed to get more work done ........     
16. Staff worry that mistakes they make are kept in their
personnel file............................................................................     
17. We have patient safety problems in this work area .................     
18. Our procedures and systems are good at preventing errors
from happening ........................................................................     



SECTION B: Your Supervisor/Manager

Please indicate your agreement or disagreement with the following statements about your
immediate supervisor/manager or person to whom you directly report.
Strongly Strongly
Disagree Disagree Neither Agree Agree
    
1. My supervisor/manager says a good word when he/she
sees a job done according to established patient safety
procedures ..............................................................................     
2. My supervisor/manager seriously considers staff
suggestions for improving patient safety ................................     
3. Whenever pressure builds up, my supervisor/manager
wants us to work faster, even if it means taking shortcuts .....     
4. My supervisor/manager overlooks patient safety problems
that happen over and over ......................................................     
SECTION C: Communications

How often do the following things happen in your work area?

Some- Most of
Never Rarely times the time Always
    
1. We are given feedback about changes put into place
based on event reports ...........................................................     
2. Staff will freely speak up if they see something that may
negatively affect patient care ..................................................     
3. We are informed about errors that happen in this work area .     
4. Staff feel free to question the decisions or actions of those
with more authority..................................................................     
5. In this work area, we discuss ways to prevent errors from
happening again .....................................................................     
6. Staff are afraid to ask questions when something does not
seem right ...............................................................................     
SECTION D: Frequency of Events Reported

In your work area, when the following mistakes happen, how often are they reported?
Some- Most of
Never Rarely times the time Always
    
1. When a mistake is made, but is caught and corrected
before affecting the patient, how often is this reported? .........     
2. When a mistake is made, but has no potential to harm the
patient, how often is this reported? .........................................     
3. When a mistake is made that could harm the patient, but
does not, how often is this reported? ......................................     



SECTION E: Patient Safety Grade

Please give your work area an overall grade on patient safety.

    
Excellent Very Good Acceptable Poor Failing

SECTION F: Your Military Health System (MHS) Facility

Please indicate your agreement or disagreement with the following statements about your MHS
Strongly Strongly
Disagree Disagree Neither Agree Agree
    
1. Management in this facility provides a work climate that
promotes patient safety...........................................................     
2. Work areas in this facility do not coordinate well with each
other ........................................................................................     
3. Things “fall between the cracks” when transferring patients
from one work area to another................................................     
4. There is good cooperation among areas that need to work
together ...................................................................................     
5. Important patient care information is often lost during
shift changes ...........................................................................     
6. It is often unpleasant to work with staff from other work
areas in this facility..................................................................     
7. Problems often occur in the exchange of information
across work areas in this facility .............................................     
8. The actions of management in this facility show that patient
safety is a top priority ..............................................................     
9. Management in this facility seems interested in patient
safety only after an adverse event happens ...........................     
10. Work areas in this facility work well together to provide the
best care for patients ..............................................................     
11. Shift changes are problematic for patients in this facility ........     

SECTION G: Number of Events Reported

In the past 12 months, how many event reports have you filled out and submitted?

 a. No event reports  d. 6 to 10 event reports

 b. 1 to 2 event reports  e. 11 to 20 event reports
 c. 3 to 5 event reports  f. 21 event reports or more



SECTION H: Background Information

This background information will help in the analysis of the survey results.

1. How long have you worked in this Military Health System (MHS) facility?
 a. Less than 1 year  d. 11 to 15 years
 b. 1 to 5 years  e. 16 to 20 years
 c. 6 to 10 years  f. 21 years or more

2. How long have you worked in your current work area?

 a. Less than 1 year  d. 11 to 15 years
 b. 1 to 5 years  e. 16 to 20 years
 c. 6 to 10 years  f. 21 years or more

3. Typically, how many hours per week do you work in this MHS facility?
 a. Less than 20 hours per week  d. 60 to 79 hours per week
 b. 20 to 39 hours per week  e. 80 to 99 hours per week
 c. 40 to 59 hours per week  f. 100 hours per week or

4. What is your staff position in this MHS facility? Select ONE answer that best describes your staff position.

2008 Staff Positions

Admin/Mgmt/Executive Staff/ Commander Physician/Attending Physician
Clinical Psychologist, Optometrist,
Aerospace/BioMed Engineering Specialist
Social Worker, etc
Assistant/Clerk/Secretary/Admin Technician LVN/LPN
Dental assistant Patient Care Asst/Nursing Aid
Dental hygienist Resident/Intern/Med Student
Dentist Dietician
Information Technology (IT) Services Staff Nurse Practitioner
Lab Technician Pharmacist
Medical Technician Pharmacy Technician
Physical/Occupational/Speech Therapist Physician Assistant
Respiratory Therapist Other staff position
Registered Nurse (RN)

5. In your staff position, do you typically have direct interaction or contact with patients?
 a. YES, I typically have direct interaction or contact with patients.
 b. NO, I typically do NOT have direct interaction or contact with patients.



6. How long have you worked in your current specialty or profession?

 a. Less than 1 year  d. 11 to 15 years
 b. 1 to 5 years  e. 16 to 20 years
 c. 6 to 10 years  f. 21 years or more

7. Please select your staff type below:

 a. Military—Active duty
 b. Military—Reservist
 c. Civilian—GS employee
 d. Civilian—Contractor
 e. Volunteer
 f. Other, please specify: ______________________________________________________

SECTION I: Your Comments

Please feel free to write any comments about patient safety, error, or event reporting in your MHS
facility. Do not write any comments associated with individual patients or event identifiable
NOTE: Verbatim comments will be reviewed at the Service level.





Appendix B: Department of Defense (DoD) Resources

Department of Defense (DoD) Patient Safety Program

The Department of Defense Patient Safety Program is a comprehensive program with the goal of
establishing a culture of patient safety and quality within the Military Health System (MHS). The
program encourages a systems approach to create safer patient environments; engages MHS
leadership; promotes collaboration across all three Services; and fosters trust, transparency,
teamwork, and communication. The program has collaborative oversight of:
 DoD Center for Education and Research in Patient Safety (CERPS), Uniformed
Services University of the Health Sciences
 DoD Patient Safety Center (PSC), Armed Forces Institute of Pathology
 Healthcare Team Coordination Program (HCTCP), TMA

The DoD Patient Safety Program website offers patient-safety-

related tools and documents. You can order patient safety materials free of charge.

Event Reporting

DoD patient safety data registry (PSR) gathers and standardizes clinically relevant information,
and provides feedback across all three Services about reported instances and categories of actual
events and near misses.

Teamwork and Handoffs

 TeamSTEPPS™ is an evidence-based teamwork system aimed at optimizing patient
outcomes by improving communication and other teamwork skills among healthcare
professionals. The TeamSTEPPS curriculum contains modules in text and
presentation format, a pocket guide that corresponds with the essentials of the course,
video vignettes to illustrate key concepts, workshop materials centered around change
management, coaching and implementation, and a supporting CD and DVD.



 SBAR (Situation, Background, Assessment, Recommendation) and “I PASS THE

BATON” cards are located on the DoD Patient Safety Program website. These
resources can be found by typing in “SBAR” or “I PASS THE BATON” in the search

General Patient Safety Information:

 DoD Patient Safety Materials are available only to medical treatment facilities from
the Army, Navy, or Air Force.
 DoD Patient Safety Newsletter, published quarterly since 2001, provides information
on MHS patient safety initiatives/activities, upcoming events, training schedules, and
links to articles and websites.
 Patient Safety Center Alerts, Summaries, and Advisories are restricted to participants
in the DoD Patient Safety Program. To gain access, please register for an account by
going to:

Ongoing Courses:
 An Introduction to Patient Safety
 Basic Patient Safety Managers Course
 Enhanced Patient Safety Managers Course
 Basic TapRooT®
 Advanced TapRooT®
 TapRooT® Software
 Failure Mode and Effects Analysis (FMEA)

For questions on DoD Patient Safety programs and resources, ask your Service representative or
contact the program directly at:

Department of Defense Patient Safety Program

5111 Leesburg Pike, Suite 810
Falls Church, VA 22041
Phone: 703-681-0064
Fax: 703-681-1242