Hospitals strive to have the right culture, particularly when it comes to patient safety, but measuring improvement can be challenging. It’s not enough to strive for a health culture, one expert says. You also have to know if you’re getting any closer to your goal.

The idea of a hospital’s culture is challenging enough for many people, but the idea of measuring it can be even more difficult, says Catherine Miller, RN, JD, senior risk management and patient safety specialist for the Cooperative of American Physicians in Los Angeles.

“All of the major patient safety leaders really think that culture most significantly impacts patient safety, worker happiness, and patient outcomes,” Miller says. “It’s nebulous, it’s hard to get your arms around it and define it, but you can see it and feel it. And you can measure it.”

A working definition of hospital culture is the attitudes, behaviors, beliefs, and expectations of an organization, Miller says. A more folksy definition is “the way we do things around here,” she adds. In hospitals with a good safety culture, people feel supported, that they have tools to do the job, that they are listened to, and they can escalate patient safety concerns without fears of retaliation, she says. A good safety culture correlates with fewer infections, fewer readmissions, and overall better patient outcomes.

A multi-pronged approach is best when measuring culture, Miller says. The Joint Commission requires that hospitals annually survey and assess their safety culture, and there are several tools available. One that Miller recommends is the Hospital Survey on Patient Safety, created by the Agency for Healthcare Research and Quality, available online at The survey asks questions of hospital staff such as whether they have enough staff to handle the workload, whether people treat each other with respect, and if the respondent can escalate a patient safety concern without fear of reprisal.

“Surveying your folks is a good way to start improving your culture because you get a baseline,” Miller says. “Another thing to consider doing is conducting patient safety rounds and interviewing staff. Maybe when you get the survey results, that is a good time to go out on the floor and try to drill down deeper into any issues that were identified there.”

Interviewing patients and family members also can yield great insight, Miller says. The most useful information can come from long-term and frequent flyer patients because they have the most exposure to the hospital, she notes.

A common mistake when trying to improve hospital culture is to underestimate how long the process will take, Miller says. She likens it to a political campaign: long and arduous, but you should be able to tell if you’re winning or not.

“It’s easy to think that if you get out there and promote your mission statement, staff will align themselves with it. Then that’s it and after a while you have a culture of safety,” Miller says. “That’s not enough. It’s very much dependent on leadership guiding this from the top down, having a presence at new employee orientation, every chance they get to be seen advocating for a culture of safety.”

Periodically, you should reassess the culture by surveying staff at least annually as required by The Joint Commission, but perhaps more often to explore specific areas that you are trying to improve. Also, don’t underestimate the value of face-to-face discussions with managers and frontline staff, Miller says. Data from surveys and other tools is essential, but sometimes your best assessment of progress will come from the few minutes you spend chatting with a nurse who happened to be walking by. You may hear that he or she has noticed real improvements in the way staff feel about the culture of safety, and you may hear that there are still particular issues that need more attention.

“Leadership can get so bogged down with meetings and other distractions that they find it hard to get out on the unit and connect. Just getting out there and introducing themselves is one way they show their commitment to the culture of safety, so you can’t downplay the importance of just walking onto a unit and saying hello,” Miller says.