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Making ‘Patient Safety Culture’ Results Public

Imagine the staff within your organization being surveyed every two years to reveal just how successful your organization is when manufacturing or delivering safe services to your clients. Further, the results are then shared with the public.  As of July 1, the state of Florida is requiring hospitals and ambulatory surgery centers to do just that.

Over the years, I have written extensively on how having a healthy ‘culture’ is extremely important for any organization as it drives the right behaviors to successfully function internally and externally. In healthcare, having the right kind of ‘culture’ can make the difference between life and death for patients.  It’s that important.

Simply put, culture – both good and bad – is the DNA of any organization. If given truth serum, an organization’s staff can reveal just how functional (or not) it is. An organization’s culture ensures that its purpose and the purpose of its members are aligned. The compatibility of goals will drive the members to perform well, be self-directed and loyal to the organization.

In healthcare, a ‘culture of safety’ is paramount for patients trusting they will receive appropriate care.  When you think about it, who better to ask about quality of service within a hospital than the frontline workers themselves – staff, nurses, technicians, etc.? Research suggests that medical organizations with higher staff perceptions of working in a safe culture translated into better overall safety and quality outcomes.

Hospital Survey on Patient Safety Culture

A 2018 blog that I wrote touches on the importance of having patient safety culture information available on a public basis. In fact, this blog suggested a simple idea for Iowa policymakers and stakeholders to pursue:

Have ALL Iowa hospitals and outpatient surgery centers undertake the hospital staff survey generated from the Hospital Survey on Patient Safety Culture. The survey would happen every other year (biennial) with the results becoming public.

Having this state-wide policy, I argued, could put Iowa on the map as being one of the more proactive states on safety measures and patient outcomes. In 2018, no other state required this type of information to be reported publicly.

Florida Becomes First State

In early March, right before COVID-19 hit our state and country in full force, I learned that Florida lawmakers were about to pass legislation to require hospitals and ambulatory surgery centers to report – on a biennial basis – results from the standardized patient safety culture surveys that are developed by the federal Agency for Healthcare Research and Quality (AHRQ).

Fast forward to now. The proposed legislation was passed and approved by the Florida Governor and took effect July 1, 2020.  Iowa, unfortunately, will not be the first state to enact this patient-centric legislation.

Florida’s Agency for Health Care Administration, which licenses and regulates health facilities in that state, would receive the anonymous survey results from each facility and then display the results publicly by showing an aggregate of the composite measures by unit and at the facility overall. The composite measure includes teamwork and hospital management support for patient safety. This Agency provided me with the final version in s. 395.1012(4),F.S.

Florida lawmakers believe that displaying this critical information publicly will pressure hospitals and ambulatory surgery centers to change problematic safety cultures.

In addition to including the standardized core survey questions found in the Patient Safety Culture questionnaire, Florida’s law also requires that the survey includes whether or not each respondent would seek care for the “respondent and the respondent’s family at the surveying facility, both in general and, for hospitals, within the respondent’s specific unit or work area.” In other words, would staff members seek care from their own units or hospital system?  This can be quite compelling on whether the organization is fostering a safe culture of care.

Florida Hospital Association

Interestingly, the Florida Hospital Association (FHA) supported this legislation, only asking that composite results be used so that results would be easier for consumers to understand. The FHA also lobbied for a biennial requirement, to allow hospitals enough time to make changes based on the survey results. The Florida Society of Ambulatory Surgical Centers was not opposed to this legislation, but also did not lobby to have it enacted.

I give the Florida providers a great deal of credit for attempting to ensure that the care provided to Floridians will be the best possible care that is tied to a culture of safety. This new law provides the right intent needed to ensure that appropriate change is made in the healthcare delivery system.


I hope to see Iowa policymakers and providers do the same for Iowans. Iowa can still become the leader in safe, effective care, but it does require grit, honesty, and a great amount of passion to make transparent quality of care become wildly successful.

Marketing optics that care is always safe is not adequate. Florida has given Iowa a blueprint to implement practical steps to move best-in-nation care forward. Why can’t our state also embrace this approach?

Iowans certainly depend on it.

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Searching for the Medical ‘Black Box’

A black leather briefcase with words The Big Reveal inside as aWould hospital employees choose to receive medical care from their own hospital? Wouldn’t you want to know how hospital employees truthfully rated their own hospital’s safety culture?

Yep, me too!

The Agency for Healthcare Research and Quality (AHRQ) released their Hospital Survey on Patient Safety Culture results. This survey is very important for many reasons. One key reason is that these results correlate to infection rates and patient outcomes.

When you think about it, who better to ask about quality of service within a hospital than the frontline worker themselves – staff, nurses, technicians, etc.? In fact, when noted physician, Marty Makary and his staff performed a joint study with risk management firm Pascal Metrics, they found “hospitals that scored well on the staff survey had lower rates of surgical complications and other important patient outcomes.” (Marty Makary, MD, “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care.”, Page 28)

Unfortunately, the results from the AHRQ survey are not meant for public consumption. They are meant only to be viewed by participating hospital administrators and the government. You see, this type of survey is not mandatory. In fact, U.S. hospitals participate in these surveys with the condition the results remain out of the public eye. Because hospital competition can be fierce within certain markets, reputations can be marred by having a low safety score – which adversely affects hospital revenue. Unlike the missing black box from Malaysian Flight 370, it appears this ‘black box’ of critical survey results is meant to remain hidden.

After learning of the 2014 AHRQ survey release, I quickly found that only 653 hospitals around the country participated in this non-mandatory survey (representing about 13 percent of approximately 5,000 hospitals in the U.S.). A miniscule 55 hospitals responded from 11 states within the region where Iowa was placed. The report from AHRQ does not list the participating hospitals, for reasons mentioned earlier. After a few email inquiries, I was able to learn that only 28 Iowa hospitals participated in this survey in 2012 and a paltry 9 hospitals in 2014 (Iowa has 118 community hospitals).

In all fairness, other research firms such as Pascal Metrics, also perform these studies. But once again, we have little knowledge on which Iowa hospitals participate and how often – let alone the results that come from these reports.

Dr. Makary’s view on lack of transparency for safety culture surveys is spot on:
“While I sympathize with hospitals who feel threatened by transparency of safety-culture results, I sympathize more with misled patients….In short, data transparency, properly weighted, would empower patients to make informed decisions about where they should spend their health care dollar.”

Compared to other developed countries, U.S. citizens pay world-class prices to our hospitals, but, in return, we receive little or no transparency on what matters most to us – our safety – and, in some cases, our lives.

This topic should be of great interest to employers when initiating (and leading) discussions with the healthcare provider community. Payers are entitled to know what they are paying for and, what the contents of the black box reveal.

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