Frequently Asked Questions

Clinical practice guidelines sponsored by the former Agency for Health Care Policy and Research, and released from 1992 through 1996, are available online from the National Library of Medicine through a full-text retrieval system. These guidelines are outdated due to more recent research findings or technological advances. Although these documents are no longer considered guidance for current medical practice, you may access them in the Clinical Practice Guideline Archive.

You may download these clinical practice guideline files for your personal use only. If you want to reproduce guidelines in any form, incorporate them into other computer access systems, or adapt or update content, copyright issues must be addressed.

For specific requirements and contacts, go to the Electronic User Policy and Copyright Information.

Nurses play a vital role in in implementing a culture of patient safety and generate a critical level of thinking that leads to faster and sustained practice transformation—not only in the hospital or ambulatory treatment facility, but also with community-based care and the care performed by family members. Optimizing the skills of nurses is essential in strengthening teamwork and communication to improve patient safety culture and patient safety practices.

For additional information, go to:

• Blog Post: Create Positive Change—Lead From the Middle.
• Blog Post: Emerging Infections: A National Patient Safety Challenge.
• Ricciardi, R. (2015). AHRQ Focuses on Ambulatory Patient Safety. J Nurs Care Qual 30(3), 193-196.
• Ricciardi, R., Moy, E., & Wilson, N. J. (2016). Finding the True North: Lessons From the National Healthcare Quality and Disparities Report. J Nurs Care Qual 31(1), 9-12. https://www.ncbi.nlm.nih.gov/pubmed/26599416.

TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) is a teamwork system for health care professionals to improve communication and teamwork skills that was developed by the Department of Defense's Patient Safety Program and the Agency for Healthcare Research and Quality.

TeamSTEPPS provides ready-to-use materials and a training curriculum in a multimedia format with tools to help a health care organization plan, conduct, and evaluate its own team training program for higher quality, safer patient care.

For more information, go to: https://www.ahrq.gov/teamstepps.

On average, hospitals that have submitted to the Hospital Survey on Patient Safety Culture Comparative Database more than once readminister the survey every 24 months. Although we do not provide any set recommendations regarding when to readminister the survey, we do caution against administering the survey less than 6 months apart. This would apply as well to the medical office, nursing home, community pharmacy, and ambulatory surgery center settings.

In deciding when to readminister the survey, it is important to consider the goal. Are you interested in monitoring your patient safety culture over time? Are you interested in assessing the impact of any specific efforts? If your goal is to assess a specific effort, then it is best to wait until all your training is complete and sufficient time has elapsed for the impact to take place and be relatively permanent (yet before other initiatives are started). If your goal is to monitor your culture over time, keep in mind that some change may or may not be a result of your specific effort and be aware of other initiatives that may have taken place since your original survey administration.

Safety culture surveys are useful for measuring organizational conditions that can lead to adverse events and patient harm in health care organizations. Organizations that want to assess their existing culture of patient safety should consider conducting a safety culture survey. Safety culture surveys can be used to:

• Raise staff awareness about patient safety.
• Elucidate and assess the current status of patient safety culture.
• Identify strengths and areas for patient safety culture improvement.
• Examine trends in patient safety culture change over time.
• Evaluate the cultural impact of patient safety initiatives and interventions.

The Patient Safety Act or PSQIA establishes a framework by which hospitals, doctors, and other health care providers may voluntarily report information to Patient Safety Organizations (PSOs), on a privileged and confidential basis, for the aggregation and analysis of patient safety and health care quality information.

The provisions of this law relating to the listing and operation of PSOs are administered by the Agency for Healthcare Research and Quality (AHRQ). The HHS Office for Civil Rights (OCR) is responsible for implementing the provisions regarding the interpretation, administration, and enforcement of the confidentiality protections and disclosure permissions.

For more information on the Patient Safety Act and how organizations can work with or become PSOs, go to the PSO website.

The QIs of the Agency for Healthcare Research and Quality are a set of quality indicators organized into four "modules," each of which measure quality associated with processes of care that occurred in an outpatient or an inpatient setting. All four modules rely solely on hospital inpatient administrative data:

1. Prevention Quality Indictors (PQIs)—or ambulatory care sensitive conditions—identify hospital admissions that evidence suggests could have been avoided, at least in part, through high-quality outpatient care.
2. Inpatient Quality Indicators (IQIs) reflect quality of care inside hospitals and include:
   • Inpatient mortality for medical conditions.
   • Inpatient mortality for surgical procedures.
   • Utilization of procedures for which there are questions of overuse, underuse, or misuse.
   • Volume of procedures for which there is evidence that a higher volume of procedures maybe associated with lower mortality.
3. Patient Safety Indicators (PSIs) also reflect quality of care inside hospitals, but focus on potentially avoidable complications and iatrogenic events.
4. Pediatric Quality Indicators (PDIs) both reflect quality of care inside hospitals and identify potentially avoidable hospitalizations among children.

The detailed technical reports on the PQIs/IQIs and PSIs are available for download. Go to: https://www.qualityindicators.ahrq.gov/modules/Default.aspx

The Hospital Survey on Patient Safety Culture measures staff perceptions of patient safety culture in their work area/unit, as well as perceptions about patient safety culture in the hospital as a whole. The following 12 dimensions of patient safety culture are included, with each dimension measured by 3 or 4 survey questions:

1. Communication openness.
2. Feedback & communication about error.
3. Frequency of events reported.
4. Hospital handoffs & transitions.
5. Hospital management support for patient safety.
6. Nonpunitive response to error.
7. Organizational learning—continuous improvement.
8. Overall perceptions of safety.
9. Staffing.
10. Supervisor/manager expectations & actions promoting patient safety.
11. Teamwork across hospital units.
12. Teamwork within units.

There are also two other questions that ask about:

1. The patient safety "grade" the respondent would assign their work area/unit.
2. The number of events the respondent has reported in the last 12 months.

The Nursing Home Survey on Patient Safety Culture emphasizes resident safety issues. It includes 42 survey items measuring 12 dimensions. Nine of the 12 survey dimensions are similar to those appearing in the Hospital Survey on Patient Safety Culture (HSOPS), although the items included in the dimensions are different. Three HSOPS dimensions were dropped from the nursing home survey: Frequency of event reporting, Teamwork across units, and Teamwork within units. Three new dimensions were added: Compliance with procedures, Training and skills, and Teamwork.

The dimensions in the nursing home survey are:

1. Communication openness.
2. Compliance with procedures.
3. Feedback and communication about incidents.
4. Handoffs.
5. Management support for resident safety.
6. Nonpunitive response to mistakes.
7. Organizational learning.
8. Overall perceptions of resident safety.
9. Staffing.
10. Supervisor expectations and actions promoting resident safety.
11. Teamwork.
12. Training and skills.

In addition, the nursing home survey includes seven background demographic questions and two overall rating questions:

1. Would they tell friends that this is a safe nursing home for their family?
2. How would they rate this nursing home on resident safety?

The Medical Office Survey on Patient Safety Culture emphasizes patient safety and health care quality issues. The survey includes 51 items measuring 12 dimensions. Six of the survey dimensions (Communication Openness, Communication About Error, Organizational Learning, Overall Perceptions of Patient Safety and Quality, Owner/Managing Partner/Leadership Support for Patient Safety, and Teamwork) are similar to dimensions in the Hospital Survey on Patient Safety Culture, although the items are different in the two surveys. The remaining six survey dimensions are unique to the medical office survey with items that focus specifically on issues related to patient safety or quality of care in medical offices.

The dimensions in the medical office survey are:

1. Communication about error.
2. Communication openness.
3. Information exchange with other settings.
4. Office processes and standardization.
5. Organizational learning.
6. Overall perceptions of patient safety and quality.
7. Owner/managing partner/leadership support for patient safety.
8. Patient care tracking/followup.
9. Patient safety and quality issues.
10. Staff training.
11. Teamwork
12. Work pressure and pace.

In addition, the medical office survey includes three items about respondent background characteristics and two overall rating questions:

1. How they would rate this medical office on five different areas of health care quality (patient centered, effective, timely, efficient, and equitable)?
2. How they would rate this medical office on patient safety?

AHRQ's health IT initiative is part of the Nation's strategy to put information technology to work in health care. By developing secure and private electronic health records for most Americans and making health information available electronically when and where it is needed, health IT can improve the quality of care, even as it makes health care more cost-effective.

The broad mission of AHRQ's health IT initiative is to improve the quality of health care for all Americans. The Agency has focused its health IT activities on the following three goals:

1. Improve health care decisionmaking.
2. Support patient-centered care.
3. Improve the quality and safety of medication management.

If your grant is under expanded authorities (in general, the following AHRQ grant activity codes are included under expanded authorities: F31, F32, K01, K02, K08, K18, K99, P20, R00, R01, R03, R13, R18, R21, R33, R24, R25, R36), the grantee institution has the authority to automatically extend the final budget period end date one time for a period of up to 12 months. Effective on August 1, 2020, AHRQ grant recipients may, and effective October 1, 2020, AHRQ grantee recipients must, use the No-Cost Extension feature in the eRA Commons to execute this extension. Read Notice NOT-HS-20-012. Select to watch a tutorial on the standard process that an AHRQ grantee may follow to submit a one-time No Cost Extension in eRA Commons.

This action must be taken before the final budget period expires, using the No-Cost Extension (NCE) feature in the eRA Commons. Accessible from the eRA Commons “Status” screen, the link for the No-Cost Extension feature appears 90 days before the final budget period end date and closes at 11:59 p.m. on the final budget period end date. In extending the final budget period end date of the grant through the eRA Commons, the grantee agrees to update all required certifications, including human subjects and animal welfare, in accordance with applicable regulations and policies. An interim progress report and an interim FFR, reflecting programmatic progress and financial expenditures, respectively, through the original project end date, will be required to be submitted to the AHRQ GMS named on the most recent NOA no later than 90 days from the original project end date.

Grantees may not extend a project end date previously extended by AHRQ. Once the eRA Commons link is closed, a NCE becomes a prior approval request and must be submitted for consideration to the AHRQ Grants Management Specialist named on the most recent Notice of Award. Any additional final budget period end date extension beyond the one-time extension of up to 12 months requires AHRQ prior approval.

If your grant is NOT under expanded authorities (e.g. K12, P01, P30, P50, T32, U01, U13, U18, U19, and UC1, or any award for which the terms and conditions indicate either that the award is not under expanded authorities or that the award may not use the no-cost extension option under expanded authorities), the grantee institution must submit a written prior approval request, endorsed by an authorized institutional official, to the Grants Management Specialist named on the most recent Notice of Award. The request is to include a statement of why the extension is needed, the requested duration of the extension (not to exceed 12 months), research objectives to be completed during the extension period, and a detailed budget page and budget justification for the use of unobligated funds anticipated to remain at the end of the current budget period. No additional funds will be awarded for an extension. If the extension is approved, AHRQ will issue a revised Notice of Award reflecting the new project end date.

Whether under expanded authorities or not, an extension may only be made when no additional funds are required to be obligated by the awarding agency, there will be no change in the originally approved project scope or objective, and more time is needed to complete the research. The fact that funds remain at the expiration date of the project is not in and of itself sufficient justification for an extension. Conversely, if grant funds have been fully expended, an extension should not be requested/approved.

Please note that a request for a second no-cost extension can only be considered by AHRQ if the grantee can demonstrate that unusual circumstances occurred that prevented the project from being completed during the original extension period. An extension is considered a second extension even if the first extension was less than 12 months long.

Contact the assigned AHRQ Grants Management Specialist for details of what information needs to be included in a prior approval request for a second no-cost extension, which will include at a minimum: an explanation of the unusual circumstances warranting consideration of the request; strong programmatic justification of why it is crucial for the project to be extended further; progress to date; research objectives still to be completed; requested duration of second extension (not to exceed 12 months); the estimated unobligated balance expected to remain at the end of the first NCE, and a detailed budget and budget justification for use of these funds.