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Effective Leadership to Prevent Errors

Surgery center leadership structures and systems must be established to ensure and perpetuate a Culture of Safety. The measure assesses whether surgery centers have taken action across four dimensions:

  1. Awareness, including ensuring regular board conversations about safety issues, including patients and their families in safety and quality committees, reporting events to the community, and communicating with staff
  2. Accountability, including sustaining a patient safety program, appointing safety-specific leadership, incorporating system performance into performance reviews and compensation, and reporting events to accountability programs
  3. Ability, including dedicating patient safety program budgets to permit investments to support patient safety programs
  4. Action, including engaging the CEO and senior leadership in patient safety meetings


Reporting Period 

  • Latest 24 months prior to Survey submission 

Patients Included in the Measure

  • Outpatients (Patients who are admitted and discharged on the same day)

  • Adults and Children