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Nursing Home Survey on Patient Safety Culture

Chapter 1. Introduction

Survey Development and Content

To develop the Nursing Home Survey on Patient Safety Culture, researchers conducted a review of the literature pertaining to resident safety in nursing homes, health care quality, medical errors, error reporting, safety climate and culture, and organizational climate and culture. In addition, they reviewed existing nursing home surveys. The researchers then consulted more than two dozen experts in long-term care and nursing home safety to identify a potential list of dimensions to include in the survey.

Researchers then developed draft survey items to measure the key dimensions. The survey draft was iteratively pretested with nursing home staff to ensure that the items were easy to understand and answer and were relevant to resident safety in nursing homes. The Flesch-Kincaid score for the pilot test instrument was below a seventh-grade reading level. 

The pilot test version of the nursing home survey was administered in late 2007 to more than 5,000 staff working in 40 nursing homes across the United States. Participating nursing homes varied by bed size, geographic region, urbanicity, and ownership.

At the end of data collection, more than 3,700 surveys were received. Analysts examined item statistics and the reliability of the safety culture dimensions. Exploratory and confirmatory factor analyses were conducted to examine the factor structure of the survey. Based on these analyses, the survey was revised so that the final items and dimensions in the Nursing Home Survey on Patient Safety Culture have sound psychometric properties. The final survey includes 42 items that measure 12 areas, or composites, of patient safety culture. Each of the 12 patient safety culture composites is listed and defined in Table 1-1.

The survey also includes two questions that ask respondents whether they would tell friends that this is a safe nursing home for their family (also called "willingness to recommend") and to provide an overall rating on resident safety for their nursing home. In addition, respondents are asked to provide limited background demographic information about themselves.

The survey's toolkit materials are available at the AHRQ Web site ( and include the survey, survey items and dimensions, user's guide, feedback report template, information about the Microsoft® Excel® Data Entry and Analysis Tool, and the Nursing Home Patient Safety Improvement Resource List. The toolkit provides nursing homes with the basic knowledge and tools needed to conduct a patient safety culture assessment and ideas regarding how to use the data.

2011 Nursing Home Comparative Database and Report

Since its release, the nursing home survey has been implemented in hundreds of nursing homes across the United States. Nursing homes administering the survey have expressed interest in comparing their results with results from other nursing homes as an additional source of information to help them identify areas of strength and areas for improvement. In response to these requests, AHRQ funded the Nursing Home Survey on Patient Safety Culture Comparative Database to enable nursing homes to compare their most recent survey results with those from other nursing homes and to eventually examine trends in safety culture over time. Nursing homes interested in submitting to the database should go to the AHRQ Web site for more information (

Data Limitations

The survey results presented in this report represent the largest compilation of survey data currently available on nursing home resident safety culture and therefore provide a useful reference for comparison. However, several limitations to these data should be kept in mind.

First, the nursing homes that submitted data to the database are not a statistically selected sample of all U.S. nursing homes, since only nursing homes that voluntarily administered the survey and were willing to submit their data for inclusion in the database are represented. However, the characteristics of the database nursing homes are similar to the distribution of nursing homes in the Nursing Home Compare database of the Centers for Medicare & Medicaid Services, as described further in Chapter 3.

Second, nursing homes that administered the survey were not required to undergo any training and administered the survey in different ways. Some nursing homes used a paper-only survey, others used Web-only surveys, and others used a combination of these two methods to collect the data. It is possible that these different modes could lead to differences in survey responses; further research is needed to determine whether and how different modes affect the results.

In addition, some nursing homes conducted a census, surveying all staff, while others administered the survey to a sample of staff. In cases in which a sample was drawn, no data were obtained to determine the methodology used to draw the sample. Survey administration statistics obtained about the database nursing homes, such as survey administration modes and response rates, are provided in Chapter 2.

Finally, the data submitted by nursing homes have been cleaned for out-of-range values (e.g., invalid response values due to data entry errors) and blank records (where responses to all survey items were missing). In addition, some logic checks were made. Otherwise, data are presented as submitted. No additional attempts were made to verify or audit the accuracy of the data submitted.

Page last reviewed October 2014
Page originally created August 2011
Internet Citation: Chapter 1. Introduction. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.


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