How Do You Measure Safety Culture?

1. Assessing Climate

A number of survey tools are available to measure the safety culture, or the climate, of an organization. Climate (e.g., teamwork climate, work climate) is a more appropriate term to use than safety culture in questionnaires analyzing group perceptions. A climate is a readily measurable aspect of safety culture, although it generally is not helpful for measuring other qualities such as behavior, values, and competencies. This type of analysis gives you a snapshot in time of how an organization perceives the value of safety.

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Safety climate and safety culture are often used interchangeably by some opinion leaders and in some papers and organizations.

Safety climate can be measured in numerous ways, which will vary with the means and capacity of the organization. Two of the most widely used tools are the Hospital Survey on Patient Safety Culture, published by the Agency for Healthcare Research and Quality (AHRQ), and the Safety Attitude Questionnaire (SAQ).

Smaller organizations may choose to conduct a more informal survey, using staff focus groups or management interviews or observation of hospital practices. A combination of these methods would provide a more holistic view of the safety climate.

The surveys usually include dimensions that are indicative of a positive safety culture such as the following:

• teamwork
• an environment in which it feels safe to speak up
• staffing
• feedback and communication about errors
• non-punitive response to errors
• continuous quality improvement
• communication openness
• learning from errors
• frequency of reporting
• management response to errors
• handoffs and transitions
• general perceptions of patient safety

The survey responses will generate a report that reflects the current perceptions of culture and points out opportunities for improvement. Information from the survey should be analyzed and disseminated to the department and unit level for discussion and creation of an action plan. A comparison with prior years will reveal whether the organization is making progress toward strategic goals so it can adjust tactics as needed. Senior leaders are responsible for reviewing the information and creating an organization action plan that becomes part of the strategic plan.

In most organizations, employees are encouraged to participate, but participation is not mandatory. Therefore, the response rate is a gauge of how safe people feel to speak up. A valid survey response is around 60% for most surveys. If you are getting less than 60%, explore the reasons people are not willing to give their opinion. Other leading indicators that reflect the culture include physician and employee satisfaction surveys and their response rates, employee and physician turnover rates, event reporting rates, and the percent of near-miss reports.

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2. Measuring Culture Over Time

The climate or culture survey is a tool that provides current data about safety perceptions and indicates whether an organization is improving and sustaining the gains. However, to truly measure the culture, a survey will include interviews of staff, clinicians, and leaders and conducting location walks to take the pulse of the organization's safety culture. All of the data should be analyzed to understand where an organization is on the safety culture journey and focus on areas for improvement and monitoring.

The Keil Centre from the United Kingdom has developed the Safety Culture Maturity® Model as a method of calculating the level of an organization's cultural maturity. It is intended to guide the development of a safety culture from inception to maturity. The Centre cautions that only organizations with a risk management approach to identifying, analyzing, and controlling hazards would be likely to enjoy a significant reduction in injury if the culture matures.

Let's look at various levels of safety culture maturity®, each of which introduces a new strength to improve on and aims to remove the weakness of the previous step. You can identify what level your organization is on.

Maturity Level	Description	Actions to Improve
Level 1: Emerging	Safety is defined as adherence to the regulations. Accidents are seen as unavoidable.	Develop management commitment to safety. This includes monetary commitment and a review of current policies and procedures.
Level 2: Managing	Safety is defined as adherence to rules and regulations, policies and procedures, and engineering controls. Accidents are seen as deviations from the rules and are considered preventable.	Realize the importance of frontline staff in identifying safety risks. Promote the development of personal responsibility for safety.
Level 3: Involving	Frontline workers are willing to work with management to improve the safety of the organization. Most workers take responsibility for their own safety.	Engage all staff to develop cooperation and commitment to improving safety.
Level 4: Cooperating	Workers recognize that management decisions can influence safety. Frontline workers accept responsibility for the safety of themselves and others.	Develop consistency in safety through policies and procedures, actions, and beliefs. Fight complacency.
Level 5: Continuous Improvement	A core value of the organization is the prevention of all injuries. The organization has not had an accident recently and strives for continuing improvement.	Strive for continuing improvement by regularly reviewing and refining hazard controls.
Source: Safety Culture Maturity® Model. Copyright The Keil Centre. Prepared by The Keil Centre for the Health and Safety Executive, can be found at here Safety Culture Maturity® is a registered trade mark of The Keil Centre Limited.

Authored by Cindy Ebner, MSN, RN, CPHRM, FASHRM

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