Creating a Culture of Safety in the Ambulatory Surgery Environment: Implementation Guide

The collection and reporting of data is an effective means of first engaging staff and physicians in SSI and other surgical complications prevention programs, providing feedback to teams on how they are doing, and sustaining improvement. The first goal of measurement is to determine the efficacy of each intervention. The later goal of measurement is to monitor outcome trends to recognize when thresholds of concern are reached that require intervention. For example, if your facility's SSI rate suddenly spikes, an investigation of causes is required when thresholds have been passed. This investigation will include increased process measurement looking for causes for increased infections. When the causes of increased SSIs are identified, your team will need to work with frontline staff to identify workable solutions to prevent those causes. By continued assessment of process measures and outcome measures, the effectiveness of the solutions employed can be evaluated.

The Centers for Medicare & Medicaid Services outlines 12 measures in the Ambulatory Surgical Center Quality Reporting (ASCQR) Program, a pay-for-reporting, quality data program. Under this program, ASCs report quality of care data for standardized measures to receive the full annual update to their ASC annual payment rate.⁵ Collecting and analyzing these measures allows your facility to use data to find opportunities for improvement in patient care.

Safety Culture Survey

The ASC SOPS can be used to track changes in patient safety culture over time and evaluate the impact of patient safety interventions. The survey should be administered at intervals of no less than 1 year. The survey is anonymous, with no individual staff identifiers. Using the survey results to identify opportunities for improvement allows a team to make specific action plans to address where staff perceptions indicate patient safety culture is not optimal. Administering the survey at least twice allows teams to measure effectiveness of their interventions to improve dimensions of the ASC's safety culture.

Tools

­­­­Ambulatory Surgery Center Survey on Patient Safety Culture – English

This survey is designed specifically for ASC staff and asks for their opinions about the culture of patient safety in their facility.

Ambulatory Surgery Center Survey on Patient Safety Culture – Spanish

Ambulatory Surgery Center Survey on Patient Safety Culture: Composites and Items – English

In this document, the items in the ASC SOPS are grouped together according to the safety culture composites they measure.

Ambulatory Surgery Center Survey on Patient Safety Culture: Composites and Items – Spanish

Ambulatory Surgery Center Survey on Patient Safety Culture: User's Guide

The User's Guide includes information on getting started, selecting a sample, determining data collection methods, establishing data collection protocols, conducting a Web-based survey, preparing and analyzing data, and producing reports.

Improving Patient Safety in Ambulatory Surgery Centers: A Resource List for Users of the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture

This document contains references to Web sites that provide practical resources ASCs can use to implement changes to improve patient safety culture and patient safety.

⁵ASC Quality Reporting. August 2012. Centers for Medicare & Medicaid Services, Baltimore, MD.