Nursing Home Survey on Patient Safety Culture Feedback Results: Evalua
Appendix A: Nursing Home Survey on Patient Safety
Appendix A: Nursing Home Survey on Patient Safety
| In this survey, "resident safety" means preventing resident injuries, incidents, and harm to residents in the nursing home. |
This survey asks for your opinions about resident safety issues in your nursing home.
It will take about 15 minutes to complete.
To mark your answer, just put an X or a check in the box.
If a question does not apply to your job or you do not know the answer, please mark the box in the last column. If you do not wish to answer a question, you may leave your answer blank.
Section A: Working in This Nursing Home
| How much do you agree or disagree with the following statements? | Strongly Disagree | Disagree | Neither Agree nor Disagree | Agree | Strongly Agree | Does Not Apply or Don't Know |
|---|---|---|---|---|---|---|
| 1. Staff in this nursing home treat each other with respect | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 2. Staff support one another in this nursing home | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 3. We have enough staff to handle the workload | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 4. Staff follow standard procedures to care for residents | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 5. Staff feel like they are part of a team | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 6. Staff use shortcuts to get their work done faster | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 7. Staff get the training they need in this nursing home | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 8. Staff have to hurry because they have too much work to do | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 9. When someone gets really busy in this nursing home, other staff help out | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 10. Staff are blamed when a resident is harmed | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 11. Staff have enough training on how to handle difficult residents | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 12. Staff are afraid to report their mistakes | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 13. Staff understand the training they get in this nursing home | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 14. To make work easier, staff often ignore procedures | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 15. Staff are treated fairly when they make mistakes | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 16. Residents' needs are met during shift changes | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 17. It is hard to keep residents safe here because so many staff quit their jobs | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 18. Staff feel safe reporting their mistakes | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
Section B: Communications
| How often do the following things happen in your nursing home? | Never | Rarely | Sometimes | Most of the time | Always | Does Not Apply or Don't Know |
|---|---|---|---|---|---|---|
| 1. Staff are told what they need to know before taking care of a resident for the first time | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
| 2. Staff are told right away when there is a change in a resident's care plan | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 | ___ 9 |
Appendix B
Nursing Home Recommendation
Overall rating on resident safety
Comparison with 40 Pilot Study Nursing Homes
I would tell friends that this is a safe nursing home for their family. (Survey Item E1)
Please give this nursing home an overall rating on resident safety. (Survey item E2)
Appendix C
Positively Worded Items
This is an example of a positively worded item. For this item, the percentage who answered "Strongly Agree/Agree" is shown in green (positive response), "Neither" in yellow, and "Strongly Disagree/Disagree" (negative response) in red.
Negatively Worded Items
This is an example of a negatively worded item. The percentage who answered "Strongly Disagree/Disagree" is shown in green (positive response), "Neither" in yellow, and "Strongly Agree/Agree" (negative response) in red.
Appendix D
Participants' Comments
10% of respondents provided comments
1. Respondent Comments Here
This material was prepared by GMCF, the Medicare Quality Improvement Organization for Georgia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 9SOW-GA-PSF-10-18
*Comments appear as written on the survey. No changes have been made.
5600 Fishers Lane Rockville, MD 20857