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Staff Work Together to Prevent Errors

Hospitals must ensure patient safety culture is measured, the feedback is provided to all levels of the organization, and interventions are undertaken that reduce patient harm. The measure assesses whether hospitals have taken action across four dimensions, including:

  1. Awareness, including conducting a culture of safety survey, reporting benchmarked results, and debriefing with staff
  2. Accountability, including sharing the results with senior leadership and holding them accountable for survey response rates and the use of the survey in improvement efforts
  3. Ability, including conducting staff education programs and provisioning for future surveys
  4. Action, including identifying performance improvement interventions, wide dissemination of the results, and developing policies and procedures to measure culture.


Reporting Period 

  • Latest 36 months prior to Survey submission 

Patients Included in the Measure

  • Inpatients (Patients who are admitted to the hospital for at least one overnight stay in an inpatient unit)

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

  • Adults and Children