Research Proposal For Assessing Patient Safety Culture in Public

Georgia State University
ScholarWorks @ Georgia State University
Public Health Theses School of Public Health
Spring 5-16-2014
Research proposal for Assessing Patient Safety Culture in Public

Hospitals under the Essential Package of Hospital Services
(EPHS) in Afghanistan
Haroon Achakzai
Georgia State University
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Recommended Citation
Achakzai, Haroon, "Research proposal for Assessing Patient Safety Culture in Public Hospitals under the
Essential Package of Hospital Services (EPHS) in Afghanistan." Thesis, Georgia State University, 2014.
doi: https://doi.org/10.57709/5559435
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Running head: ASSESSING PATIENT SAFETY CULTURE IN AFGHAN HOSPITALS
Research proposal for Assessing Patient Safety Culture in Public Hospitals under the
Essential Package of Hospital Services (EPHS) in Afghanistan
by
Haroon Achakzai
MD, University of Kandahar, Afghanistan
A Capstone Submitted to the Graduate Faculty of Georgia State University

in Partial Fulfillment of the Requirements for the Degree
MASTER OF PUBLIC HEALTH
Atlanta, Georgia
2014
ASSESSING PATIENT SAFETY CULTURE IN AFGHAN HOSPITALS ii
AUTHOR’S STATEMENT
In presenting this Capstone as a partial fulfillment of the requirements for an advanced degree
from Georgia State University, I agree that the Library of the University shall make it available
for inspection and circulation in accordance with its regulations governing materials of this type.
I agree that permission to quote from, to copy from, or to publish this capstone may be granted
by the author or, in his absence, by the professor under whose direction it was written, or in his
absence, by the Dean, School of Public Health. Such quoting, copying, or publishing must be
solely for scholarly purposes and will not involve potential financial gain. It is understood that
any copying from or publication of this capstone which involves potential financial gain will not
be allowed without written permission of the author.
Haroon Achakzai
________________
Signature of Author
ASSESSING PATIENT SAFETY CULTURE IN AFGHAN HOSPITALS iii
ACKNOWLEDGEMENTS
First, I thank Allah (Subḥhnahu Wa Ta'Ala) for giving me health and patience to complete this
work. I would like to acknowledge and thank my family who has always supported and
encouraged me through this effort. I would also like to thank the entire staff of the School of
Public Health, especially my capstone committee members, Dr. Douglas Roblin and Dr. Rodney
Lyn for providing me their guidance and support.

ASSESSING PATIENT SAFETY CULTURE IN AFGHAN HOSPITALS iv
TABLE OF CONTENTS
Title ................................................................................................................................. Page

ABSTRACT..................................................................................................................... 1
CHAPTER I: INTRODUCTION
Introduction .......................................................................................................... 2
Patient safety and Patient Safety Culture ................................................................ 4
Public Hospitals in Afghanistan ............................................................................. 6
Hospital Survey on Patient Safety Culture ............................................................. 10
CHAPTER II: LITERATURE REVIEW
Background ........................................................................................................... 11
Patient Safety Research ........................................................................................ 12
Relevance of AHRQ Hospital Survey ................................................................... 13
International Use of the AHRQ Hospital Survey .................................................... 15
Afghanistan’s Context ........................................................................................... 16
CHAPTER III: RESEARCH METHODS
Study Design ........................................................................................................ 20

Sampling .............................................................................................................. 22
Data Collection ..................................................................................................... 23
Data Management ................................................................................................. 25
Proposed Analysis ................................................................................................. 26
Ethical Consideration ............................................................................................ 29
CHAPTER IV
Management Plan .................................................................................................. 31
Time Scale............................................................................................................. 31
Dissemination ....................................................................................................... 32
Conclusion ........................................................................................................... 33
REFERENCES ................................................................................................................ 34
APPENDICES ................................................................................................................ 38
ASSESSING PATIENT SAFETY CULTURE IN AFGHAN HOSPITALS 1
ABSTRACT
Patient safety is an issue of global concern, which is sometimes missed due to the complexity of
the healthcare systems. There is an increasing concern for negligence of patient safety in
developing countries, especially countries with poor healthcare systems and less reliable data. In
2005, the Ministry of Public Health in Afghanistan developed the Essential Package of Hospital
Services (EPHS) in order to promote quality of care in Afghan Hospitals. Patient safety, as one
of the key objective of the EPHS, appears to need additional attention and evaluation. The main
purpose of this research proposal is to develop a validated patient safety culture instrument and
to evaluate the use of the instrument in Afghan Hospitals. The proposal introduces a framework
for sampling hospitals followed by a plan for conducting a cross-sectional study using the survey
instrument. The proposal also includes an assessment of the psychometric properties of the
instrument. The findings achieved from the administration of the survey are intended to compare
12 dimensions of patient safety culture among different groups of providers, categories of
hospitals under EPHS and the overall grade of patient safety culture within Afghanistan and with
results from use of the instrument in other countries. The proposed research will have important
implications for both the hospital management systems and policy making. The findings will
help hospital managers and decision makers understand different dimensions of patient safety.
Results should assist hospitals and health departments redesign strategies and policies that are
focused on attitudes, behaviors and practices to improve the overall culture of safety.
Additionally, hospitals will recognize their weak and strong points and will contribute in
exchange of experiences and share their best practices.

CHAPTER I
INTRODUCTION
Patient safety is the central theme and ultimate objective of health care quality. Health
care organizations around the world have lately been observed to pay more attention to the
importance of establishing a culture of safety. To achieve a culture of safety, it is necessary to
understand the principles, attitudes, and standards related to an organization and what attitudes
and behavior related to patient safety are expected and appropriate.
There are numerous studies on hospital (secondary) care in developed countries
indicating a noteworthy percentage (10%) of medical errors, which means one out of every ten
patients admitted to hospital, suffers an adverse event. There is some evidence about other
settings such as primary care, long term care and mental care, indicating a similar rate of patient
safety issues (“WHO | Global Priorities for Research in Patient Safety,” 2008, p. 5). Although
medical errors happen in countries at all levels of development, there is a fear that developing
countries may be impacted disproportionately.
In 2005, the Afghan Ministry of Public Health started to monitor and evaluate the
performance of provincial hospitals in Afghanistan. The assessment involved workshops, focus
group discussions and critical reviews by hospital managers. The process took 18 months and a
report of findings was released in 2007. (“Report of the Provincial Hospital Performance
Assessment,” 2007, pp. 2–3).The instruments mainly assessed resources, processes and
outcomes of provincial hospital. There were groups of questions which evaluated 8 areas of
hospital activities including; 1-Management and Administration, 2-Financial Systems, 3-Human

Resources, 4-Capacity for Service Provision, 5-Quality and Safety, 6-Functionality, 7-Patients
and Community, and 8-Ethics and Values.
The Quality and Safety in provincial hospitals were measured by three categories of
indicators that included Quality, Health Workers Interaction and Hospital Safety. The results,
displayed by Balanced Scorecard (BSC) method, indicated that, overall, the quality and safety
scores were poor. Among the provincial hospitals, the minimum score for the quality and safety
was 28.7 and the maximum score was 58.2 out of 100. In the southwest region, Kandahar had a
score of 46.9, Helmand 38.8 and Urozgan 28.7, which was comparatively lower than other
regions of the country. The report links this to instability in the area (“Report of the Provincial
Hospital Performance Assessment,” 2007, pp. 78–83). The following table displays the scores
for all indicators of quality and safety across the 3 provincial hospitals in Kandahar, Helmand
and Urozgan:
Figure 1: Results for provincial hospitals in Kandahar, Helmand and Urozgan on all indices of
quality and safety:

Medical errors are not necessarily the result of just one simple factor. A British study, for
example, examined the complex array of medical mistakes within the National Health Service
(NHS) hospitals. Some of the contributory factors they found included errors in diagnoses
frequently made by inexperienced clinicians, poor medical records, poor communication
between professional providers, insufficient input by consultant physicians into day-to-day care,
and lack of thorough evaluation of patients before discharging them out of hospital. All of those
are considered organizational factors, which if measured and monitored by administrations,
could result in change to a hospital safety climate (Neale, Woloshynowych, & Vincent, 2001, p.
322).
Patient safety and Patient Safety Culture
The World Health Organization defines patient safety as,” the absence of preventable
harm to a patient during the process of health care” (“WHO | Patient safety,” n.d.). Generally,
this implies a discipline of coordinated efforts to avoid patient harm, caused during or by the
process of health care itself. During the past two decades, patient safety has been increasingly
accepted as an issue of global importance, but the complexity of healthcare has made it even
challenging to measure and, therefore to design and to implement programs to address deficits in
patient safety. The new emerging term, patent safety culture, could probably better explain this
phenomenon. The Agency for Healthcare Research and Quality (AHRQ) explains the safety
culture of an organization as, “the product of individual and group values, attitudes, perceptions,
competencies, and patterns of behavior that determine the commitment to, and the style and
proficiency of, an organization's health and safety management” (“AHRQ | Introduction,” 2004).
Organizations with all the above mentioned positive characteristics of a safety culture should
then be considered truly committed to the value of patient safety.

Leape (2009) summarizes findings from the Institute of Medicine (IOM) report, “To Err
is Human” which sparked medical and public attention to medical errors. He largely attributes
failure in system organization, processes and procedures to patient harm and suggests more focus
on system errors than human errors such as slips, lapses and mistakes. He suggests six principles
that he believes are necessary for a change in the culture of patient safety. First, that we see
errors as a result of a poorly designed system rather than individual mistakes. Second, that a safe
culture should take the place of punitive environment. His other suggestions include
transparency, patient-centered care, collaboration and teamwork and finally that accountability
should be shared ( pp. 1–2).
In 1995, a 6-month study that involved 11 medical and surgical units in two tertiary care
hospitals found 344 medical errors, 78% of which were attributed to system failure. For example,
physician orders were responsible for 39% of the errors and nurse administrations were
responsible for 38% of them. The study also found that almost half of the errors made by
physicians were intercepted either by nurses (86%) or pharmacists (12%). Generally, 16 factors
of system failure were identified. The most common factor was lack of knowledge about the
drug. After an investigation of the factors, the study found that 264 out of the total 344 errors
were preventable (Leape LL, Bates DW, Cullen DJ, & et al, 1995, pp. 35–40). Medication errors
have been confirmed in several other studies. For instance, a prospective cohort study assessed
the rates of medication errors in 1120 pediatric patients. The study reviewed 10,778 orders, from
two facilities that used hand-written medication orders. The results indicated a (5.7%) error rate
or 55 medication errors for every one hundred admissions. The study concluded that19% of
those errors was preventable. The study reviewed errors by two physicians independently and
found that 93% of the potential medication errors were potentially preventable by physician
computer order entry with clinical decision support and 94% by ward-based clinical pharmacists
(Kaushal R, Bates DW, Landrigan C, & et al, 2001, pp. 2115–2117).
Bates, Cohen, Leape, Overhage, & al (2001) have explained another good example of
system change they feel necessary in the US healthcare system. They mention numerous areas of
the US healthcare where information technology is not used sufficiently or efficiently. For
example, they point out miscommunication between laboratory systems and pharmacy systems
to be faulty. They also call attention to the role of information technology in accurate reporting
and eventual reduction of error. They reported a study in which large majority of administrators
had been unaware of the high frequency of medication errors in their facilities (pp. 301–305).
Other dimensions of systems such as teamwork, staffing, organizational learning and supervision
are equally important to be evaluated for their role in medical error.
A retrospective study of patient safety that was performed in some developing Middle-
eastern and African countries assessed the frequency and nature of medical errors in hospitalized
patients. The study found that the proportion of preventable error was significantly high at 83%,
while previous studies showed 50% preventable error. The authors suggest that previous studies
might have confused causation and preventability and misclassified some errors (Wilson et al.,
2012, p. 5). It is evident that patient safety is even more vulnerable and misunderstood in
developing countries and therefore, it is important to explore the perception and level of
awareness of health professionals about different dimensions patient safety.
Public Hospitals in Afghanistan
Unlike other developing countries, Afghanistan has suffered long years of conflicts and
wars, which has severely damaged not only the political, social, and economic infrastructures in
Afghanistan but also the health system. While there are very few reliable statistics, it is clearly
evident that people’s health status is very poor. Despite a completely collapsed health system, the
Ministry of Public Health (MoPH) in Afghanistan was able to establish a new healthcare system,
which included the hospital management system as well.
Figure 2: Afghanistan (Administrative Divisions)
The MoPH Hospital System has categorized all public hospitals into four levels of
facilities; District Hospitals, Provincial Hospitals, Regional Hospitals, and National Specialty
Hospitals. In each of the first three levels of hospitals, collectively called as the Essential
Package of Hospital Services (EPHS), four core clinical functions exist: medicine, surgery,
pediatrics, and obstetrics/gynecology. Mental health and dental health are mainly provided as
outpatient services at each of these levels, however inpatient mental care may only be available
at the regional hospitals (Ministry of Public Health, 2011, p. 5). The Essential Package of
Hospital Services (EPHS) was developed by the Hospital Management Task Force (HMTF)
generally to promote quality of care and with the following three particular purposes:
1. Identify a standardized package of hospital services at the first three levels of
hospital.
2. Provide a guide for the MoPH, private sector, nongovernmental organizations
(NGOs), and donors on how the hospital sector should be staffed, equipped, and
provided with materials and drugs.
3. Promote a health referral system that integrates the primary care Basic Package of
Health Services (BPHS) with hospitals.
The EPHS also classified all the essential services, staff, facilities, equipment, and
medicines for the district, provincial, and regional hospitals. For example, the standardized
provision of services to be offered by a district hospital include, “30-75 beds, serving population
of 100,000-300,000 in 1-4 districts, basic surgery, medicine, obstetrics and gynecology,
pediatrics, mental health, dentistry, plus support services for nutrition, pharmacy, physiotherapy,
laboratory, radiology and blood bank” (Ministry of Public Health, 2011, p. 5). A provincial
hospital should have 100-200 beds with all the services provided at district hospital, plus
rehabilitation services and infectious disease control. Similarly, a regional hospital should have
200-400 beds with all the services of a provincial hospital, plus surgery for ENT, urology,
neurology, orthopedics, plastic surgery; and medicine to include cardiovascular, endocrinology,
dermatology, lung and chest, oncology, forensic medicine and expanded support services
(Ministry of Public Health, 2005, p. 25)

Figure 3: Afghan Health Facilities (BPHS)
The Afghan Ministry of Public Health measures the quality of prevention and care
mainly by clinical inspection. However, a more comprehensive quality improvement program
will require assessment of patient safety. To align the quality of services with the recommended
international standards, it is essential to look at both at national risk factors and at the same time
learn from experience of other countries (Ministry of Public Health, 2005, p. 58). One important
aspects of quality and safety measurement is the Patient Safety Culture (Nieva & Sorra, 2003, p.
ii 17). In the following section we introduce one of the most widely used and very reliable
instruments of assessing patient safety culture.

Hospital Survey on Patient Safety Culture
In 2004, the Agency for Healthcare Research and Quality (AHRQ) designed a Hospital
Survey on Patient Safety Culture, which is completed by hospital staff. The survey collects data
on their perception of the culture of safety in their organizations. So far, hundreds of US and
international hospitals have successfully implemented the survey (“AHRQ | Hospital Survey on
Patient Safety Culture,” 2014). Later in 2006, the Agency funded the development of a
comparative database on the survey so that hospitals, which had requested such a database,
would be able to compare their results on safety culture to other hospitals. The database only
contains data from hospitals that voluntarily participated in submitting their data. The database
reports are available from 2007 to 2012 (“AHRQ | Hospital Survey on Patient Safety Culture,”
2014). The data entered into the database are only from US hospitals; however the survey form,
its related tools and the database are available for public use both inside United States and for
international users. The users are allowed to translate the survey to any other language or apply
any modification if needed to fit the local context.

CHAPTER II
LITERATURE REVIEW
Background
While patient safety might appear to be a new and emerging issue, historical evidence
shows a concern for patient safety that existed long before modern medicine. Hippocrates, for
example, had known the possible harm that arises from the well intentioned actions of healers. In
the 4th Century B.C., Greek healers wrote the Hippocratic Oath , in which they indicated their
commitment for the good of their patients according to their ability and judgment and to avoid
patient harm (“Greek Medicine - The Hippocratic Oath,” 2002). However, it is true that patient
safety has become a prominent topic recently, especially ever since President Bill Clinton
introduced a nationwide system of reporting for medical errors in response to the Institute of
Medicine report of 44000 to 98000 American deaths each year from medical mistakes. He also
required all 50 states to adopt the error reporting systems (Charatan, 2000, p. 597).
In 2008, Palmieri, DeLucia, Peterson, Ott, & Green studied healthcare errors and
explained patient safety as a “distinct healthcare discipline supported by an immature yet
developing scientific framework”. They used a trans-disciplinary approach to explain the
contribution of health care leaders in addressing error. According to their trans-disciplinary
theory, patient safety knowledge constantly informs improvement efforts in different areas like
business and industry, innovative technologies, health literacy and enhancing error reporting
systems. Thus, health care leaders can play an important role using their organizational skills and
health care safety principles to improve patient safety (para. 1).
In October 2004, the World Alliance for Patient Safety was founded in Washington, DC,
to bring together the heads of agencies, health policy-makers, representatives patients' groups
and the World Health Organization in order to promote the patient safety goal of "First do no
harm", and minimize the risk of unsafe health care (“WHO | World Alliance for Patient Safety,”
2004).
In 2008, the World Alliance for Patient Safety released a report of evidence on patient
safety in which the positive characteristics of a patient safety culture were explained as open
communication about safety problems, effective teamwork, and support by local and
organizational leaders who make safety a priority. Beside the healthcare organizations, other
high-hazard industries were also considered essential to have a positive safety culture and that
they should measure and report safety culture with standardized instruments to develop safety.
The report also suggested that due to the multidimensional nature of safety culture and for a
better understanding of the factors related to patient safety culture, we need further research,
especially in developing countries and countries with economies in transition.(“WHO | Summary
of the Evidence On Patient Safety,” 2008, pp. 7–8).
Patient Safety Research
In 2006, the World Health Organization gathered a group of international experts to
identify priority areas for patient safety research. Its main objective was to present research
commissioners and funding institutions with general guidance on these priorities so that new
research will contribute to patient safety. The group included specialists in patient safety, health-
care and health services research, researchers, policy-makers, patient advocates and research
commissioners from a wide range of countries and socioeconomic contexts. After a thorough
literature review, assessment and consensus building, a list of priority areas were identified in
mid-2007. Because of the local need for knowledge, the group of experts recommended that
countries use the global priorities as a starting point but expand them and set their own priorities
(“WHO | Global Priorities for Research in Patient Safety,” 2008, p. 4).The group basically
classified the priority areas into four different categories; 1- Research priorities for developing
countries, 2- Research priorities for countries with economies in transition, 3- Research priorities
for developed countries and 4- Research priorities common to countries at different levels of
development (“WHO | Global Priorities for Research in Patient Safety,” 2008, pp. 5–6).
Most of the high priorities for the developing countries were patient safety issues that are
associated with high mortality and disability. However, the top priority for research in
developing countries was to help with the design and testing of locally effective and affordable
solutions. This largely refers to the assessment of already identified and existing solutions and
strategies, which are designed in most developed contexts and see if they are cost-effective and
feasible (“WHO | Global Priorities for Research in Patient Safety,” 2008, pp. 5).
In this proposal, we develop a research plan for the assessment of patient safety culture in
Afghan hospitals by using the Hospital Survey on Patient Safety Culture, developed by the
Agency for Healthcare Research and Quality (AHRQ). It is a standard, effective and applicable
instrument for Afghan Hospitals. It will be the first validated instrument to assess patient safety
climate in Afghanistan.
Relevance of AHRQ’s Hospital Survey
In 2004, the Medical Errors Workgroup of the Quality Interagency Coordination Task
Force (QuIC) responded to the need for a measurement tool to assess the culture of patient safety
in health care organizations and funded the development of a hospital survey on patient safety
culture. The survey was developed by a private research organization under contract with the
Agency for Healthcare Research and Quality (AHRQ). It can be applied in different institutional
contexts. For example, it can be implemented in a hospital setting as a whole, or in specific units
within hospitals. Besides, it can track changes and assess the effectiveness of interventions in
patient safety culture if repeated over time. The survey was pretested with hospital staff and later
pilot tested with more than 1,400 hospital employees from different US hospitals. The pilot data
was analyzed and also checked for the reliability and validity of the questionnaire. Finally, the
survey was adjusted by keeping only the most accurate items and scales with strong
psychometric properties (“AHRQ | Introduction,” 2004, sec. 2).
Considering WHO’s priorities for developing countries on patient safety research, the
AHRQ’s Hospital Survey on Patient Safety Culture is both effective and totally applicable in the
local context of a developing country like Afghanistan. Similarly, all other aspects of the survey
including required resources, the organizational culture, the ethos and values of the population
groups, users and beneficiaries of the research and the cost implication are matching and already
tested in several countries. (“WHO | Global Priorities for Research in Patient Safety,” 2008, pp.
4–6). Out of the top twenty research priority areas recommended by WHO for developing
countries, the AHRQ’s Hospital Survey on Patient Safety Culture matches on the following ten
priories either directly or indirectly (“WHO | Global Priorities for Research in Patient Safety,”
2008, sec. Appendix 3):
1. Identifications, design and testing of locally effective and affordable solutions
2. Inadequate competence, training and skills
3. Extent and nature of the problem of patient safety
4. Lack of appropriate knowledge and its transfer
5. Poor safety culture and blame-oriented processes
6. Lack of communication and coordination
7. Inadequate regulations
8. Latent organizational failures
9. Lack of adequate reporting on patient safety
10. Inadequate safety indicators
The AHRQ website provides very helpful resources with the survey to assist hospital
administrators with information and tools needed for a safety culture assessment and how the
data could be used. The survey is general enough to be used in most hospitals, however, users
who might feel the need for changes in the language and terms of the survey are allowed to do
so. Some might even feel necessary to add or remove questions according to their relevance with
the local context. It helps researchers adopt the survey to the local settings to be better
understood Therefore, AHRQ has also provided modifiable formats of the survey and the
feedback report templates (“AHRQ | Introduction,” 2004).
International Use of the AHRQ’s Hospital Survey
So far, the Hospital Survey on Patient Safety Culture has been translated into 24
languages and used in 45 different countries to measure patient safety culture in their hospitals
(AHRQ, 2012). In some cases, researchers have tried to conduct the studies across different
countries to compare their results. For instance, Wagner, Smits, Sorra, & Huang (2013)
conducted a study that involved 45 hospitals in the Netherlands, 622 in the United States and 74
in Taiwan, considering the similarities of their well-developed healthcare systems, educated
professional groups and a focus on improving patient safety. Using their existing data of the
AHRQ’s hospital survey, they compared the results and revealed the similarities and differences
within and between the three countries. The three countries indicated similar positive results on
Teamwork within units. The average positive responses supporting one another in a unit was the
highest (Netherlands: 92%; Taiwan: 88%; USA: 85%), however, communication openness
appeared to be different among them. Compared to USA and Taiwan, respondents in Dutch
hospitals showed higher commitment (82%) to speak up against patient harm and to question the
decisions or actions of higher authorities (56%). The results overall found strong teamwork
within units but weak culture dimension handoffs and transitions for all three countries (p. 213-
216). Such studies will help healthcare systems learn and share best practices of patient safety
within each country and with other countries.
Because, the AHRQ hospital survey has been implemented in many developing
countries, the available data from the surveys let other developing countries compare their survey
results on any dimension that affect patient safety. The best example that Afghanistan’s survey
results could be compared with, is its neighboring country Iran. They both share a long border
with similar ethnic groups living on both sides. They also have many cultural, religious and
linguistic similarities. Furthermore, they have mutual cooperation agreements and are expected
to expand their scientific and educational exchanges (Ruttig, 2013).
The AHRQ hospital survey was conducted in 2013 in three hospitals affiliated with
Islamic Azad University in Tehran, Iran. The results indicated that the hospitals did not meet a
proper level of patient safety and that a punitive culture dominated the workplace. Mutual
respect among unit employees was the highest positive (56 %), while employees’ concern that
their faults were being recorded was the lowest positive (6%). The study had some constructive
suggestions related to the number of employees, the distribution of the employees, work hours,
and communication (Moussavi et al., 2013, p. 668).
In another Iranian study, a modified version of AHRQ hospital survey was implemented
across 21 randomly selected health centers, which basically offered primary healthcare services.
This study’s findings indicated that patient safety culture had been relatively neglected in the
outpatient facilities. However, the overall patient safety score of these health centers was (57),
which was better in comparison to the patient safety score from other Iranian hospitals and
Turkish primary services. The score for “non punitive response to error” was the lowest (8.3%)
for physicians. The study did not find any significant relationship between gender or working
years and total patients safely culture. The results show that adverse events and errors are being
under-reported (50%) (Tabrizchi & Sedaghat, 2012, pp. 508–509). Other comparable good
examples from the region include same hospital surveys from China and India.
Afghanistan’s Context
Basically, there are four main reasons why we recommend the AHRQ survey to assess
patient safety culture in Afghanistan. First of all, Afghanistan lacks data from medical records to
provide information on patient safety. Even if the data were available, it is not likely to be
accurate and reliable. For example, in 2013 a study was conducted to assess the accuracy of
medical records in three maternal health facilities. Two of the facilities were selected from
within Kabul and a third facility was selected from a closer province to Kabul, all of which
should be considered more organized compared to facilities from rural areas. The researchers
compared their own recorded observation of vaginal deliveries to the data recorded in patient
medical records and facility registers. They found that the medical record accuracy in these
facilities, where data play a vital role, was generally poor (Broughton, Ikram, & Sahak, 2013, pp.
1–2).
Secondly, the AHRQ hospital survey is designed to be quite general and is applicable in
both primary care and secondary care settings; therefore, it is very appropriate for assessing
patient safety culture in all three levels of hospitals within the Essential Package of Hospital
Services (EPHS), as it consists of both primary care and secondary care hospitals. Among the
three levels of hospitals of EPHS, the District hospitals are included in both of Basic Package of
Health Services (BPHS) and as well as Essential Package of Hospital Services (EPHS), thus they
make a referral system between the two (“MoPH | EPHS,” 2005, pp. 3–4).
Figure 4: Link between the BPHS and Hospital Sector
Thirdly, Afghanistan has very limited resources and low funds (0.2% of the health
budget) for research and development in health sector (“MoPH | National Health Accounts,”
2011, p. 24). In consideration of this fact and as well as the priorities of patient safety research
recommended by WHO for developing countries, the most economical approach to assess patient
safety culture would be the AHRQ hospital survey, which has been already tested in many other
countries and proven to be efficient. A future large scale or countrywide application of this
survey would be more enlightening and possible with limited resources.

Fourth, the concept of patient safety was introduced by WHO in Afghanistan in 2009 and
in 2012, WHO signed a pledge with the Ministry of Public Health on "Patient Safety/Clean Care
is Safer Care"(“WHO EMRO | Afghanistan | Countries | Patient safety,” n.d., para. 1–2). The
Ministry of Public Health mainly uses clinical indicators, such as the safe surgery checklist, to
assess quality and patient safety, however, there is a need to introduce and develop patient safety
culture among hospital employees in Afghanistan as one element of a strategy to improve patient
safety in the country.

CHAPTER III
RESEARCH METHODS
Study Design
The AHRQ Hospital Survey on Patient Safety Culture, which is already used in various
countries, will be used to ask hospital staff about patient safety issues, medical error and event
reporting. For the proposed study, the survey was translated into a local language (Pashto) using
forward translation technique. To confirm the linguistic validity and contextual relevant to target
population, the translated version will be assessed by cognitive interview method and further pre-
tested before administration.
The survey totally has 51 items out of which 42 items measure the following 12
dimensions of patient safety culture:
1. Supervisor/manager expectations & actions promoting patient safety.
2. Organizational learning-continuous improvement.
3. Teamwork within units.
4. Communication openness.
5. Feedback & communication about error.
6. Non-punitive response to error.
7. Staffing.
8. Hospital management support for patient safety.
9. Teamwork across hospital units.
10. Hospital handoffs & transitions.
11. Overall perceptions of safety.
12. Frequency of events reported.

Seven of the above mentioned safety dimensions assess safety culture at the unit/department
level (1-7), three dimensions measure safety culture at the hospital level (8-10), and two
dimensions are outcome measures (11-12). We include all 12 safety culture dimensions so that
the results can be compared on all dimensions to other hospitals in other countries that have used
the same survey. The survey also has two additional outcome items that ask about the patient
safety "grade" that respondent would assign to their work area/unit and the number of adverse
events the respondent has reported in the previous 12 months (“AHRQ | Introduction,” 2004).
Respondents will be asked to rate each item of a dimension on a five-point Likert scale of
agreement (strongly disagree, disagree, neutral, agree and strongly agree) or frequency (never,
rarely, sometimes, most of the time, always). The instrument includes 6 items that ask
respondents to provide limited background information related to their work/profession. The
survey places most of its emphasis on safety culture at the unit level, because staff will be most
familiar with safety culture at this level.
Respondents are also given the opportunity to provide written comments at the end of the
survey. These open-ended comments can be used to obtain direct quotes for feedback purposes.
To analyze the data from the comments section, the responses will be coded according to the
type of comment that was made. For example, staff may respond with positive comments about
patient safety efforts in their unit. Or, they may comment on some negative aspects of patient
safety that they think need to be addressed. Code numbers will be assigned to similar types of
comments and later the frequency of each comment type will be counted. The comments will be
coded only after the data has been entered electronically.

Sampling
Hospitals will be selected based on convenience sampling from three provinces
(Kandahar, Helmand and Urozgan) in the Southwest region of the country where Pashto is the
main spoken language. One regional hospital will be selected from Kandahar province, 2
provincial hospitals will be selected from Helmand and Urozgan provinces and 4 district
hospitals will be selected from Kandahar and Helmand. Selecting all samples of hospitals from
these three provinces will be important, in that they share similar opportunities and challenges.
For example, the Southwest region is generally more affected by insurgency and conflicts
compared to other regions of Afghanistan, eventually impacting many development programs
including healthcare (UNGA, 2014, p. 4). On the other hand, a random selection of hospital will
also need a Dari translation of the survey, because both Pashto and Dari are official languages of
Afghanistan and are spoken in different regions.
The study will include physicians, nurses, lab technicians and management staff from all
units of the hospital. Participants should be full-time current employees. Hospital staff who are
on extended leave at the time of survey distribution will be excluded from the list. The sample
list will be compiled from the management of each participating hospital. The list will include
the first and last name, hospital area/unit and job title for each participant. This will help us track
the distribution and collection of the survey.
To have sufficient number of participants from each of the three levels of hospital, we
need to look at the average number of staff at each facility. Since higher-level hospitals have
larger number of staff compared to lower levels, we include one regional hospital (200-400
staff), two provincial hospitals (each 100-200 staff) and four district hospitals (each 30-70 staff)
in this study, totally reaching to 7 hospitals. If we take the average number of staff from each of
the 7 facilities, all 7 facilities together will have 800 staff. The following table shows the number
and type of participating hospitals and their estimated number of staffing.
Table 1: Estimated number of participating hospitals and their staffing
Category/Level of Estimated Number Number of Total estimated

Hospital of staff hospital(s) number of staff
Regional Hospital 300 1 300
Provincial Hospital 150 2 300
District Hospital 50 4 200
Total - 7 800
Considering an estimated 100 ineligible from the total 800 staff, we will remain with 700
eligible participants. AHRQ suggests a consideration of 50% response rate. Based on our initial
sample size of 700 participants from all 7 hospitals, we estimate a minimum response goal of
350 completed surveys, which is sufficiently large sample to give us statistically significant
result.
Data collection
The survey instrument could be implemented either in paper format or online. We choose
the paper format for two reasons. First, it is a more feasible method in Afghanistan because many
people in Afghanistan do not have access to internet to complete the survey and second, because
AHRQ recommends paper format for a highest possible response rate.
The surveys will be distributed at a single location inside hospital where hospital
employees check in at the beginning of a working day. The first step in data collection process
will be to develop a tracking log, which will have a list of unique study IDs. Each unique study
ID will also be printed on the survey cover letter. A research assistant will facilitate the
distribution of the surveys, meanwhile asking participants to write their names in the tracking log
sheet. The assigned study ID in the log should match the ID on the survey cover letter received
by the participant. This will help us track non-respondents and redistribute them the survey and
also explore any possible differences between respondents and final non-respondents.
The distribution of survey inside hospital emphasizes hospital administration’s support
for the data collection effort. Although the survey takes only 10-15 minutes to complete,
respondents will be given enough time to think about responses and not be distracted during their
work hours. They will be asked to return the completed surveys in the following 2-3 days to the
research assistant while checking into hospital. The list of sample will be used to track the
returning completed surveys as well as other staff members who might have not received the
survey either because they were on night duty or on leave.
Each hospital will be assigned a point of contact with the project team, who will facilitate
the entire process of data collection and address any questions or concerns employees might have
about the survey. To remove concerns regarding confidentiality of the survey, hospital staff will
be assured that no one at their hospital will have access to their completed surveys. The contact
information for the hospital point-of-contact including phone number and E-mail address will be
provided in the survey cover letter.
A valid generalization needs a high response rate and therefore maximum effort will be
put to clarify any doubts participants may have and make the process easy for them. The survey
will include a supporting cover letter with clear instructions for completing and returning the
survey (Appendix-A). In the cover letter the staff will be asked to complete the survey within 3
days, however a specific deadline date will not be given because, data collection might get
delayed or rescheduled. If for any reason they fail to complete survey by the deadline date or
there are a large number of non-respondents, a second survey will be distributed a week later to
the non-respondents. The data collection will be held open for at least 1 week after the second
survey or a second follow-up reminder, so that we receive as many responses as possible. The
data collection in one hospital should take approximately 2 weeks.
Data Management
Each survey will be examined for completeness, prior to entering the survey responses
into the data set. A complete survey is one in which every item or most items have a response.
The AHRQ’s recommended criteria on identification of incomplete surveys suggest excluding
responses from a survey form if the respondent answered:
 Less than one entire section of the survey.
 Fewer than half of the items throughout the entire survey (in different sections).
 Every item the same (e.g., all "4"s or all "5"s). If every answer is the same, the
respondent did not give the survey their full attention. The survey includes reverse-
worded items that exercise both the high/positive and low/negative ends of the response
scale to provide consistent answers (AHRQ, 2004).
If a respondent has not answered most of the items in at least one section of the survey, we will
be missing relevant data on too many items. This will become problematic when calculating the
safety culture composite scores. We will probe surveys for missing items and will exclude a
scale if more than 2 items have not been answered.
Before entering data into an electronic file we need to determine the coding for illegible,
mismarked, and multiple-marked responses. Using the AHRQ’s recommendation, the unreadable
responses or inappropriate responses will be marked as missing and in case we have multiple-
marked responses, we will choose the highest number among selected responses.
Proposed Analysis
Most of the items in the questionnaire use a Likert 5- point response scale such as scale
of agreement (strongly disagree=1 to strongly agree=5) or scale of frequency (never=1 to
always=5). Each of the five responses would have a numerical value (1-5), in which the highest
two scoring answers (4-5) are perceived as positive response answers, while the lowest three
scoring answers (1-3) are considered other response answer. A “positive response” is, therefore,
the percent on a scale. There are 18 negatively worded items in the survey, which will be reverse
coded to ensure that positive answers indicate a higher score. The data will be entered into an
electronic file and analyzed using statistical software program SPSS (version 22.0, Illinois,
United States).
The background characteristics of the respondents will be reported by frequency and
percentage for the three levels of hospitals separately (Table-2, Appendix A). It is important to
present frequency information about the background characteristics of all the respondents as a
whole, for example, the units to which they belong, how long they have worked in the hospital or
their unit, their staff position, etc. This information will help the audience better understand
whose opinions are being represented in the data. The responses at the open-ended comment
section will be summarized into major categories of recurrent themes. Any identified patterns or
trends will be reported in the form of descriptive text (“UWM | Steps for Analyzing Responses to
Open-Ended Survey Questions,” 2011). The findings from the open-ended comment section will
help us with further clarification of the quantitative results.
A list of non-respondents, which can be compiled from the original reference list, will be
compared to respondents to know if they differ based on the provided information from the
hospital administrations. Since the 3 levels of hospitals have only four units/wards in common,
all remaining sections will be reported under a separate category (Other).
Comparison of safety culture dimensions
The survey items will be grouped into dimensions of safety culture, so it can be useful to
calculate one overall frequency for each dimension and to determine differences and similarities
between hospital levels and groups of profession.. Each scale item will be transformed into a
numeric scale, where “1” is the least desirable state and “5” is the most desirable state. A scale
score will be computed as the mean of the scales’ item scores. Descriptive statistics will be
computed with 95% confidence intervals to compare safety culture dimensions across the three
categories of hospitals and among different groups of professions. We will also compute the
percent of “positive” or “desirable” scores on a scale. This will be computed as the mean of the
ratio of items with a positive score (equal to 4 or 5, including rescored items) to the items scored
otherwise. For example, if a 3 item scale has scores of 4, 5, and 3, then the percent “positive”
score is 66.7% (e.g. (1+1+0)/3*100).
To assess the significance of any difference we might observe among different levels of
hospitals or among different groups of professionals, it is necessary to conduct further statistical
analyses. In this case, we will conduct one-way between-groups Multivariate Analysis of
Variance (MANOVA), which will let us know if the observed difference(s) are statistically
significant. In case we find significant difference, a post-hoc analysis using the Tukey HSD test
will be performed to find out where these significant difference(s) occur (Appendix A, Table-3
& 4). On each scale, we will be comparing scale means across 4 categories of healthcare roles
(physicians, nurses, lab technicians and management staff), and 3 categories/types of hospital
(regional, provincial and district). The null hypotheses are:

H1(o): p= n= l= m
H2 (o): r= p= d
Where represents the mean scale score by role (p=physicians, n=nurses, l= lab technicians,
m=management staff) or by level of hospital (r=regional, p=provincial, d=district). The
alternative hypotheses (i.e. H(a)) is that there are significant differences. Because we do not
have sufficient a priori evidence as to the magnitude or direction of differences, we will rely on
the evidence as to whether or not the null hypotheses are rejected; and, if so, what other evidence
supports possible reasons for the statistically significant differences.
The overall score for each of the 12 dimension of safety culture will also be compared to
the findings of the same survey from other countries. This will give us a general picture of
Afghan hospitals being compared to regional and international standards. Iran is both
geographically and culturally the closest country that has implemented the AHRQ’s hospital
survey in several settings. Therefore, on regional level Iran makes a good equivalent for
Afghanistan to compare its survey findings with. On the other hand, the wide scale
implementation of the survey in American hospitals makes their results more reliable and
standard, so the study will also compare its findings with the finding from American hospitals.
Reliability and Validity of the Translated Survey
The internal consistency of items in each scale will be evaluated using the most
commonly used psychometric tool, Cronbach’s alpha coefficient. An internal consistency value
of (Cronbach’s α ≥ 0.70) is recommended by AHRQ for the newly developed scales. The
internal consistency of the 12 dimensions of patient safety culture individually and the overall
Cronbach alpha of the scale will be reported and compared to that of the original scale in English
as well as the Persian translated version (Appendix A, Table-5).

The calculated scale scores for every item will be used to compute the Pearson
correlation coefficients between the scales scores (Appendix A, Table-6). This will help us
assess the validity of the scales by examining the strength of the relationship between each pair
of scales. In addition, the means and standard deviations for each of the scale will be reported
Ethical Consideration
Health-related research always needs to be highly formalized, regulated and considerate
of ethical issues. The rights and safety of every participant of a research needs to be a top
priority. Fortunately, we live in an era that has recognized all such rights. A good example is, the
Belmont Report. For the first time it was announced in 1979 by the National Commission for the
Protection of Human Subjects of Biomedical and Behavioral Research. It was basically designed
as, ”the ethical framework for ensuing human participant research regulations and still serves as
the basis for human participant protection legislation” (“Five principles for research ethics,”
2003, sec. 5).
Being aware of the issue of protecting privacy of the participants as an ethical
responsibility, all key ethical principles such as respect, beneficence, sincerity and justice are
considered in the design of this study. Ethical approval will be obtained from the management of
the participant hospitals and the Ministry of Public Health in Afghanistan before data collection.
Participation in this survey will be voluntary and therefore a waiver of the consent form will be
requested. The Survey will have a cover letter that will state the purpose of the survey, the
expected time for survey to be completed, description of the topic and content of the survey,
statements about confidentiality, anonymity, and about how the participant may obtain additional
information (Appendix-B).
To protect the confidentiality of the participants, the questionnaire does not include any
question or section seeking personal information that would disclose their identity. Similarly,
categories with less than 5 participants will not be reported separately. The paper surveys will be
stored in a secure place and will be accessed only by researchers until the data is transferred into
an electronic file. Participants will be assigned a random identification code. After the data
collection and data entry is completed, the paper surveys will be destroyed and previous ID
numbers will be replaced by new randomly assigned ID numbers. Each hospital will receive a
final report identifying the results for that particular hospital in comparison to all other hospitals
while keeping other hospitals de-identified.

CHAPTER IV
Management Plan
Patient safety culture is a critically important aspect of healthcare. The high rate of
adverse events needs a closer attention and careful evaluation. The ultimate goal of this research
proposal is to assess the underlying organizational factors of patient safety in Afghan hospitals.
The research project will begin with acquiring ethical approval from both the Afghan IRB
Committee and related Hospital administrations. This is normally a slow process and may take
approximately 2 months. The next step would be to hire research personnel who will assist with
the collection, management and analysis of the data. Project staff will be hired based on their
research skills. A basic training program to each staff member will ensure that they understand
the project and their role in project activities. The whole process of hiring and training research
personnel is estimated to take two months. The project staff will include one principal
investigator and three research assistants. The principal investigator will be responsible for
obtaining ethical approval, hiring and training research personnel, supervising research
personnel, analyzing the data and writing the research report. The research team will also
constitute an advisory committee of 4-5 members from the Ministry of Public Health. The
advisory committee will help to ensure close collaboration between the research staff and
participating hospitals. The findings of the survey will be shared with the advisory committee;
however, hospitals will be de-identified in their report to protect the confidentiality of the
hospitals.
Time Scale
The estimated time for the duration of this research study, from the beginning of the
ethical approval process to the end of report writing, is 9 months. Table-6 displays each phase of
the research process with the anticipated time scale.

Table 2: Sequence and anticipated time scale of each phase of the research project
Principal 1st 2nd 3rd 4th 5th 6th 7th 8th 9th
Investigator month month month month month month month month month
Ethical approval from

IRB Committee and
X X
Hospitals’
management
Hire Personnel X
Train personnel X
Supervise personnel X X X
Analyze data X
Write research report X
Research Assistants
Collect data X X
Enter data X
Analyze data X
Dissemination
The proposed study will produce significant evidence for improving policies and
procedures related to patient safety in public hospitals working under the Essential Package of
Hospital Services. The study findings can be used by the Ministry of Public Health and the Local
Departments of Public Health in Afghanistan. Additionally, the results will help clinical and
technical workers in the healthcare industry to not only understand the dimensions of patient
safety, but also actively participate in shaping policies. The unique and initiative nature of the
proposed research on patient safety in Afghan hospitals should warrant its publication in a
scientific journal. The potential publisher of this article could be the Afghanistan Journal of
Public Health, which uses international standards for publications. The expected audience
includes healthcare providers, hospital management staff and policy makers in health sector. The
findings may also encourage public health researchers to further investigate patient safety in
Afghan Hospitals.
Conclusion
This research proposal developed a plan of a cross-sectional hospital survey on patient
safety culture to be administered in all three categories of public hospitals working under the
Essential Package of Hospital Services (EPHS) in Afghanistan. A highly validated and widely
used survey instrument, originally developed by the Agency for Healthcare Research and Quality
(AHRQ) in US, was translated into the local language, Pashto. The survey will be the first of its
kind to assess patient safety culture in Public Hospitals in Afghanistan.
A range of safety culture dimensions will be used to compare hospital units, professional
roles and the three levels of public hospitals. The survey dimensions identify organizational
factors that can be changed. Since a convenience sampling method will be used, the results
cannot be generalized to all Afghan Hospitals. If results indicate suboptimal results in a
dimension, the local departments of public health and hospital administrations will have
information for taking action to improve hospital safety climate and patient safety. The results
from Afghan Hospitals will also be compared with the results from use of the survey in other
countries. Furthermore, the translated survey will be assessed for its psychometric properties.
This research project could be referred to in the future as a pilot study for a countrywide
randomized survey. A countrywide hospital survey will have potential implication in integration
of a policy framework into the Essential Package of Hospital Services (EPHS) that would
address patient safety culture, especially areas with low scores. The survey might be repeated
over certain period of time to track changes in patient safety culture.

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Appendix A: Tables
Table 3: Background characteristics of the participants
Level of Hospital
Characteristics Categories District Provincial Regional
Hospital Hospital Hospital
Freq (%) Freq (%) Freq (%)
Physician
Nurse
Staff position
Lab technician
Management Staff
<1 year
1-5 years
Experience in hospital
6-10 years
> 11 years
< 20 hours
Working hours /week 20-39 hours

40-59 hours
> 60 hours
Medicine
Surgery
Work area/unit Pediatrics

Obstetrics and
Gynecology
Other
<1 year
Work experience in the 1-5 years

relevant unit 6-10 years
> 11 years
Direct contact with Yes

patients No
Table 4: Comparative results on safety culture dimensions across district, provincial and
regional hospitals:
Mean Scale Scores (95% confidence interval)

Dimensions of Safety
Culture Overall
District Provincial Regional US Iranian
Afghan p-value
Hospitals Hospitals Hospitals Hospitals Hospitals
Hospitals
Supervisor/manager
expectations & actions
promoting patient safety
Organizational learning-
continuous improvement
Teamwork within units
Communication openness
Feedback &
communication about error
Non-punitive response to
error
Staffing.
Hospital management
support for patient safety
Teamwork across hospital

units
Hospital handoffs &

transitions
Overall perceptions of
safety
Frequency of events
reported
Table 5: Comparative results on safety culture dimensions across different professions:
Mean Scale Scores (95% confidence interval)

Dimensions of Safety
Culture
Lab Management
Physicians Nurses P-value
Technicians Staff
Supervisor/manager
expectations & actions
Teamwork within units
Communication openness
Feedback & communication

about error
error
Staffing.
Hospital management
Teamwork across hospital

units
Hospital handoffs &

transitions
safety
Frequency of events
reported
Table 6: Comparison of internal consistency between the translated version and the original
instrument
Cronbach’s Cronbach’s
Cronbach’s
Dimensions of Safety Number alpha alpha
alpha
Culture of items (English (Iranian
(Pashto survey)
Survey) Survey)
Supervisor/manager
expectations & actions 4
3
Teamwork within units 4
Communication openness 3
Feedback &
communication about 3
error
3
error
Staffing. 4
Hospital management
3
Teamwork across
4
hospital units
Hospital handoffs &

4
transitions
4
safety
Frequency of events
3
reported
Total 42
Table 7: Inter-item correlations of the 12 dimensions
Dimensions of Safety Culture 1 2 3 4 5 6 7 8 9 10 11 12 Total

1. Supervisor/manager expectations
- - - - - - - - - - -
& actions promoting patient safety
2. Organizational learning-continuous
- - - - - - - - - -
improvement
3. Teamwork within units - - - - - - - - -
4. Communication openness - - - - - - - -
5. Feedback & communication about
- - - - - - -
error
6. Non-punitive response to error - - - - - -
7. Staffing. - - - - -
8. Hospital management support for
- - - -
patient safety
9. Teamwork across hospital units - - -
10. Hospital handoffs & transitions - -
11. Overall perceptions of safety -
12. Frequency of events reported
Notes:
1) Means and Standard Deviations of each scale will appear in the diagonal.
2) Pearson correlation between paired scales will appear in the off-diagonal cells.
Appendix B: Survey cover letter:
Hospital Survey on Patient Safety Culture
This survey is part of a research effort for a better understanding of patient safety in public
hospitals in Afghanistan. The questionnaire is intended only for physicians, nurses, lab
technicians and management staff who are fulltime current employees with either a district
hospital, provincial hospital or a regional hospital. The survey, which takes 10-15 minutes to
complete, asks about your opinion on different aspects of patient safety in your Hospital. Please
complete your survey and return it within the next 3 days to the same person and location when
you are signing in to hospital.
Instructions:
 Do not write or sign your name on the questionnaire.

 Answer each question by selecting the response that best applies to you or best represents
your opinion.
 If for any reason you do not want to answer a question, leave it blank.
Important!
 No staff member at your hospital including the manager will ever see or have access to
your questionnaire.
 Questionnaires will be destroyed after the data have been entered into a computer file.
 Only authorized staff from the research team will have access to the survey data.
 Data results will be presented in a manner so that neither individuals nor small groups
can be identified.
 Results may be published; however, no individuals or small groups will be identified.
The scientific value of the survey:
 Depends upon the reliable and accurate representation of the individual views of
practitioners.
 Requires a high participation rate to be scientifically meaningful.
Therefore, your participation is very important and greatly appreciated.
Please contact [contact name and job position] if you have any questions.
[Phone number and E-mail address]
Thank you in advance for your participation in this important effort.

Appendix C: English version of Hospital survey on Patient safety culture
Hospital Survey on Patient Safety Culture: Items and Dimensions
In this document, the items in the Hospital Survey on Patient Safety Culture are grouped
according to the safety culture dimensions they are intended to measure. The item’s survey
location is shown to the left of each item. Negatively worded items are indicated. Reliability
statistics based on the pilot test data from 21 hospitals and more than 1,400 staff are provided for
the dimensions.
1. Teamwork Within Units

(Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, Strongly Agree)
A1. People support one another in this unit.

A3. When a lot of work needs to be done quickly, we work together as a team to get the work
done.
A4. In this unit, people treat each other with respect.
A11. When one area in this unit gets really busy, others help out.
Reliability of this dimension--Cronbach’s alpha (4 items) = .83
2. Supervisor/Manager Expectations & Actions Promoting Patient Safety1
B1. My supervisor/manager says a good word when he/she sees a job done according to
established patient safety procedures.
B2. My supervisor/manager seriously considers staff suggestions for improving patient
safety.
B3. Whenever pressure builds up, my supervisor/manager wants us to work faster, even if it
means taking shortcuts. (negatively worded)
B4. My supervisor/manager overlooks patient safety problems that happen over and over.
(negatively worded)
3. Organizational Learning—Continuous Improvement
A6. We are actively doing things to improve patient safety.

A9. Mistakes have led to positive changes here.
A13. After we make changes to improve patient safety, we evaluate their effectiveness.
1
Adapted from Zohar (2000). A group-level model of safety climate: Testing the effect of group climate on microaccidents in
manufacturing jobs. Journal of Applied Psychology, (85) 4, 587-596.
4. Management Support for Patient Safety
F1. Hospital management provides a work climate that promotes patient safety.
F8. The actions of hospital management show that patient safety is a top priority.
F9. Hospital management seems interested in patient safety only after an adverse event
happens. (negatively worded)
5. Overall Perceptions of Patient Safety
A15. Patient safety is never sacrificed to get more work done.

A18. Our procedures and systems are good at preventing errors from happening.
A10. It is just by chance that more serious mistakes don't happen around here. (negatively
worded)
A17. We have patient safety problems in this unit. (negatively worded)
6. Feedback & Communication About Error
(Never, Rarely, Sometimes, Most of the time, Always)
C1. We are given feedback about changes put into place based on event reports.
C3. We are informed about errors that happen in this unit.
C5. In this unit, we discuss ways to prevent errors from happening again.
7. Communication Openness
C2. Staff will freely speak up if they see something that may negatively affect patient care.
C4. Staff feel free to question the decisions or actions of those with more authority.
C6. Staff are afraid to ask questions when something does not seem right. (negatively
worded)

8. Frequency of Events Reported
D1. When a mistake is made, but is caught and corrected before affecting the patient, how
often is this reported?
D2. When a mistake is made, but has no potential to harm the patient, how often is this reported?
D3. When a mistake is made that could harm the patient, but does not, how often is this
reported?
9. Teamwork Across Units
F4. There is good cooperation among hospital units that need to work together.
F10. Hospital units work well together to provide the best care for patients.
F2. Hospital units do not coordinate well with each other. (negatively worded)
F6. It is often unpleasant to work with staff from other hospital units. (negatively worded)
10. Staffing
A2. We have enough staff to handle the workload.

A5. Staff in this unit work longer hours than is best for patient care. (negatively worded)
A7. We use more agency/temporary staff than is best for patient care. (negatively worded)
A14. We work in "crisis mode" trying to do too much, too quickly. (negatively worded)
11. Handoffs & Transitions
F3. Things "fall between the cracks" when transferring patients from one unit to another.
(negatively worded)
F5. Important patient care information is often lost during shift changes. (negatively
worded)
F7. Problems often occur in the exchange of information across hospital units. (negatively
worded)
F11. Shift changes are problematic for patients in this hospital. (negatively worded)
12. Nonpunitive Response to Errors
A8. Staff feel like their mistakes are held against them. (negatively worded)
A12. When an event is reported, it feels like the person is being written up, not the
problem.
(negatively worded)
A16. Staff worry that mistakes they make are kept in their personnel file. (negatively
worded)
Patient Safety Grade
(Excellent, Very Good, Acceptable, Poor, Failing)
E1. Please give your work area/unit in this hospital an overall grade on patient safety.
Number of Events Reported
(No event reports, 1 to 2 event reports, 3 to 5 event report, 6 to 10 event reports, 11 to 20 event
reports, 21 event reports or more)
G1. In the past 12 months, how many event reports have you filled out and submitted?
Note: Negatively worded questions should be reverse coded when calculating percent
“positive” response, means, and composites.
‫‪ASSESSING PATIENT SAFETY CULTURE IN AFGHAN HOSPITALS‬‬ ‫‪48‬‬
‫‪Appendix D: Pashto version of Hospital Survey on Patient Safety Culture‬‬
‫د ناروغانو د خونديتوب د کلتور په هکله د روغتون سروې‪ :‬توکی او بعدونه‬
‫په دې سند کې‪ ،‬د ناروغانو د خونديتوب د کلتور په هکله د روغتون د سروې توکی د خونديتوب د کلتور د هغه‬
‫بعدونه له مخې يوځای شوی کوم چی دوی به يی اندازه کوی‪ .‬د هر توکی ښی لوری ته د هغه موقعيت په سروی‬
‫کی ښودل شوی دی‪ .‬په معکوس ډول بيان سوی توکی هم په نښه شوی دي‪ .‬د ‪۱۲‬روغتونونو او له ‪ ۲۰۱۱‬زياتو‬
‫کارکوونکو څخه د ازمايښتی سروې له مخې د هر بعد د باورى توب (‪ )Reliability‬شمېری هم ښودل شوی دي‪.‬‬
‫‪ .1‬دروغتون په څانګو‪/‬وارډونو کی دننه ګډكار‬

‫(په کلکه ناموافق‪ ،‬ناموافق‪ ،‬نه موافق نه هم ناموافق‪ ،‬موافق‪ ،‬په کلکه موافق)‬
‫‪ - A1‬په دی څانګه کی خلګ د يو بل نه مالتړ کوې‪.‬‬
‫‪ - A3‬کله چې زيات کار ته اړتيا وي‪ ،‬موږ په ګډه د يوه ټيم په شکل کار کوو تر څو کار پای ته ورسوو‪.‬‬
‫‪ - A4‬په دی څانګه کی خلګ يو او بل ته د درناوی په سترګه ګوري‪.‬‬
‫‪ - A11‬کله چې په دې څانګه کی يوه برخه ډيره بوخته شي‪ ،‬نو نور يې مرسته کوي‪.‬‬
‫د دی بعد باورى توب (‪ ۰( Cronbach’s alpha :)Reliability‬توکي) = ‪.،۳۸‬‬
‫‪ .2‬د مدير‪ /‬سرپرست هيلې او کړنی د ناروغانو د خونديتوب د پرمختګ لپاره‬

‫‪ - B1‬کله چې زما مدير‪ /‬سرپرست د ناروغانو د خونديتوب د تأسيس سوو كړنالرو سره موافق يو کار‬
‫ووينی نو د هغه ستاينه کوی‪.‬‬
‫‪ - B2‬زما مدير‪ /‬سرپرست د د ناروغانو د خونديتوب په هکله د کارکوونکو وړانديزونه په جدي توکه په‬
‫نظر كې نيسی‪.‬‬
‫‪ - B3‬كله چي د کار فشار زيات شی‪ ،‬زما مدير‪ /‬سرپرست غواړي چی موږ ژر ژر کار وکړو‪ ،‬آن که دا د‬
‫لنډو الرو څخه د استفادی په مانا هم وي‪( .‬په معکوس ډول بيان سوی)‬
‫‪ - B4‬زما مدير‪ /‬سرپرست د ناروغانو د خونديتوب پر هغه ستونزو چی بيا بيا رامنځته کيږی ستر ګى‬
‫پټوی‪( .‬په معکوس ډول بيان سوی)‬
‫د دی بعد باورى توب (‪ ۰( Cronbach’s alpha :)Reliability‬توکي) = ‪.،۵۷‬‬
‫‪ .3‬اداری زده کړې ‪ -‬پرله پسې اصالح‬

‫‪ - A6‬موږ په فعاله توګه اجراءات کووتر څو د ناروغانو په خونديتوب کی ښه والی راسي‪.‬‬
‫‪ - A9‬تيروتنی دلته د مثبتو بدلونونه د رامنځته کيدو سبب شوی دی‪.‬‬
‫‪ - A13‬وروسته تر دی چی موږ د ناروغانو د خونديتوب لپاره بدلونونه رامنځته کړو‪ ،‬موږ د هغوی‬
‫اغېزه ارزوو‪.‬‬
‫د دی بعد باورى توب (‪ ۸( Cronbach’s alpha :)Reliability‬توکي) = ‪.،۵۷‬‬
‫‪ .4‬د ناروغانو د خونديتوب لپاره د اداری مالتړ‬

‫‪ - F1‬د روغتون اداره د کار يوه داسی فضا برابروی کوم چې د ناروغانو خونديتوب ال ښه کوی‪.‬‬
‫‪ - F8‬د اداری د کړنو څخه داسی بريښی چې د ناروغانو خونديتوب يو د لوړو لومړيتوبونو څخه دي‪.‬‬
‫‪ - F9‬د روغتون اداره يوازې هغه وخت د ناروغانو د خونديتوب سره عالقه ښيی کله چی يوه ناوړه پېښه‬
‫رامنځته شي‪( .‬په معکوس ډول بيان سوی)‬
‫د دی بعد باورى توب (‪ ۸( Cronbach’s alpha :)Reliability‬توکي) = ‪.،۳۸‬‬
‫‪ .5‬په عمومي توګه د ناروغانو د خونديتوب په باب پوهه‬

‫‪ - A15‬د ناروغانو خونديتوب هيڅکله هم د زيات کار د تر سره کولو لپاره نه قربانی کيږی‪.‬‬
‫‪ - A18‬زموږ کړنالری او سيسټمونه د تېروتنو په مخنيوی کی ښه دي‪.‬‬
‫‪ - A10‬دا يواځی زموږ بخت دی چی دلته جدي تېروتنی نه رامنځته کيږی‪( .‬په معکوس ډول بيان سوی)‬
‫‪ - A17‬موږ په دې څانګه کی د ناروغانو د خونديتوب ستونزی لرو‪( .‬په معکوس ډول بيان سوی)‬
‫د دی بعد باورى توب (‪ ۰( Cronbach’s alpha :)Reliability‬توکي) = ‪.،۵۰‬‬
‫‪ .6‬د تېروتنو په اړه معلومات او خبرې اترې‬

‫(هېڅ كله نه‪ ،‬ډېر لږ‪ ،‬کله ناکله‪ ،‬ډيري وخت‪ ،‬تل)‬
‫‪ - C1‬موږ ته د هغه بدلونونو په اړه معلومات راکول کيږی کوم چی د پېښود رپوټونه پر بنسټ رامنځته‬
‫سوی وی‪.‬‬
‫‪ - C3‬موږ ته د هغه تېروتنو په باب خبر راکول کيږي کوم چی په دې څانګه کی رامنځته کيږی‪.‬‬
‫‪ - C5‬په دې څانګه کی‪ ،‬موږ د داسی الرو چارو په هکله خبرې اترې کوو تر څو د تېروتنو د بيا پيښيدو‬
‫مخه ونيسو‪.‬‬
‫د دی بعد باورى توب (‪ ۸( Cronbach’s alpha :)Reliability‬توکي) = ‪.،۵۳‬‬
‫‪ .7‬د خبرو اترو څرګندوالی‪ /‬آزادی‬

‫‪ - C2‬کارکوونکي په پوره آزادی سره خپل نظر څرګندوی که چيری داسی څه ووينی چی د ناروغ مراقبت‬
‫ته زيانمن وي‪.‬‬
‫‪ - C4‬کارکوونکی په پوره آزادی سره د هغو پرېکړو او کړنو په هکله پوښتنه کوالی شی کوم چی د لوړو‬
‫مقاماتو له خوا تطبيقيږی‪.‬‬
‫‪ - C6‬کارکوونکي له دی ډاريږي چې د هغه څه په هکله پوښتنه وکړی کوم چی سم نه ښکاري‪( .‬په‬
‫معکوس ډول بيان سوی)‬
‫د دی بعد باورى توب (‪ ۸( Cronbach’s alpha :)Reliability‬توکي) = ‪.،۵۱‬‬
‫‪ .8‬د رپوټ شوو پېښو شمير‬
‫‪ - D1‬کله چی يوه تېروتنه پېښه شی‪ ،‬خو ناروغ ته تر زيان رسولو مخکی وموندل شی او اصالح شی‪ ،‬نو‬
‫څومره په دې هکله خبر ورکول کيږی؟‬
‫‪ - D2‬کله چی يوه تېروتنه پېښه شی‪ ،‬خو ناروغ ته د زيان رسولو توان ونلری‪ ،‬نو څومره په دې هکله خبر‬
‫ورکول کيږی؟‬
‫‪ - D3‬کله چی داسی يوه تېروتنه پېښه شی چی ناروغ ته زيان رسوالی شی‪ ،‬خو زيان ونه رسوی‪ ،‬نو‬
‫څومره په دې هکله خبر ورکول کيږی؟‬
‫د دی بعد باورى توب (‪ ۸( Cronbach’s alpha :)Reliability‬توکي) = ‪.،۳۰‬‬
‫‪ .9‬دروغتون د بيالبيلو څانګو‪/‬وارډونو تر منځ ګډكار‬

‫‪ - F4‬دروغتون د هغو څانګو تر منځ چی ګډ کار ته اړتيا لري ښه همکارۍ شته‪.‬‬
‫‪ - F10‬د روغتون څانګی يو د بل سره په ښه ډول ګډ کارکوی ترڅو د ناروغانو ښه مراقبت وشي‪.‬‬
‫‪ - F2‬د روغتون څانګی يو د بل سره ښه همغږي نه دي‪( .‬په معکوس ډول بيان سوی)‬
‫‪ - F6‬د روغتون د نورو څانګو له کارکوونکو سره کار کول زياتره خواتورونكى وي‪( .‬په معکوس ډول‬
‫بيان سوی)‬
‫د دی بعد باورى توب (‪ ۰( Cronbach’s alpha :)Reliability‬توکي) = ‪.،۳۱‬‬
‫‪ .11‬د کارکوونکو ګومارنه‬

‫‪ - A2‬موږ په كافى اندازه کارکوونکي لرو چی د کار حجم سمبال کړی‪.‬‬
‫‪ - A5‬په دې څانګه‪/‬وارډ کی کارکوونکي تر هغه وخت زيات کار کوي چی د ناروغ د مراقبت لپاره غوره‬
‫ګڼل کيږی‪( .‬په معکوس ډول بيان سوی)‬
‫‪ - A7‬موږ تر هغه اندازی زيات موْقتي‪/‬قراردادی کارکوونکی لرو چی د ناروغ د مراقبت لپاره غوره ګڼل‬
‫کيږی‪( .‬په معکوس ډول بيان سوی)‬
‫‪ - A14‬موږ د (بحرانی حالت) په څير کارکوو تر څو ډير کار ډېر ژر تر سره کړو‪( .‬په معکوس ډول بيان‬
‫سوی)‬
‫د دی بعد باورى توب (‪ ۰( Cronbach’s alpha :)Reliability‬توکي) = ‪.،۷۸‬‬
‫‪ .11‬تسليمۍاو لېږدونی‬
‫‪ - F3‬د روغتون د يوی څانګی څخه بلی ته د ناروغانو د لېږد په وخت کی بې پروايى کيږی‪( .‬په معکوس‬
‫ډول بيان سوی)‬
‫‪ F5‬زياتره دکاری وخت يا دوری د بدلون په ترڅ کې د ناروغ مهم معلومات ورکيږی‪( .‬په معکوس ډول‬
‫بيان سوی)‬
‫‪ - F7‬د روغتون د څانګو تر منځ د معلوماتود تبادلی پر مهال زياتره ستونزې رامنځته کيږی‪( .‬په‬
‫‪ - F11‬په دې روغتون کې د دکاری وخت يا دوری بدلون د ناروغانو لپاره ستونزمن وی‪( .‬په معکوس‬
‫د دی بعد باورى توب (‪ ۰( Cronbach’s alpha :)Reliability‬توکي) = ‪.،۳۱‬‬
‫‪ .12‬د تېروتنو په وړاندی غيرجزائى‪ /‬غير تنبيهی غبرګون‬

‫‪ - A8‬کارکوونکی داسی احساسوی چی د دوی سهوی د دوی د مالمتولولپاره کارول کيږی‪( .‬په‬
‫‪ - A12‬کله چې د يوی پيښی رپوټ ورکول کيږی‪ ،‬کارکوونکی داسی احساسوی چې د پيښی پر ځای د‬
‫شخص راپور ليکل کيږی‪( .‬په معکوس ډول بيان سوی)‬
‫‪ - A16‬کارکوونکی دا اندېښنه لري چې د دوی تېروتنی د دوی په دوسيو کی ساتل کيږی‪( .‬په معکوس‬
‫د دی بعد باورى توب (‪ ۸( Cronbach’s alpha :)Reliability‬توکي) = ‪.،۵۷‬‬
‫‪ .13‬د ناروغانو د خونديتوب درجه‬

‫(عالی‪ ،‬ډېر ښه‪ ،‬د منلو وړ‪ ،‬ضعيف‪ ،‬نا کام)‬
‫‪ - E1‬مهرباني وکړي په دې روغتون کې ستاسو کاری څانګی‪/‬وارډ ته د ناروغانو د خونديتوب يوه‬
‫عمومي درجه غوره کړی‪.‬‬
‫‪ .14‬د رپوټ شوو پېښو شمېر‬

‫) د پيښی هيڅ رپوټ‪ ۲ ،‬تر‪ ۱‬د پيښی رپوټونه‪ ۸ ،‬تر‪ ۷‬د پيښی رپوټونه‪ ۷ ،‬تر‪ ۲۱‬د پيښی رپوټونه‪ ۲۲ ،‬تر‪ ۱۱‬د‬
‫پيښی رپوټونه‪ ۱۲ ،‬يا ډير د پيښی رپوټونه(‬
‫‪ - G1‬په تيرو‪ ۲۱‬مياشتو کې‪ ،‬څومره د پېښو رپوټونو تاسو پوره کړی او سپارلي دی؟‬
‫نوټ‪ :‬په معکوس ډول بيانی شوی پوښتنی بايد هغه مهال معکوس کوډ (‪ )Reverse code‬شی کله چی د مثبتو‬
‫جوابونو فيصدی‪ ،‬اوسط او مركب محاسبه کيږی‪.‬‬

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Research Proposal For Assessing Patient Safety Culture in Public

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Georgia State University

ScholarWorks @ Georgia State University

Public Health Theses School of Public Health

Research proposal for Assessing Patient Safety Culture in Public

Follow this and additional works at: https://scholarworks.gsu.edu/iph_theses

A Capstone Submitted to the Graduate Faculty of Georgia State University

MASTER OF PUBLIC HEALTH

be allowed without written permission of the author.

Lyn for providing me their guidance and support.

Title ................................................................................................................................. Page

Study Design ........................................................................................................ 20

12 dimensions of patient safety culture among different groups of providers, categories of

exchange of experiences and share their best practices.

importance of establishing a culture of safety. To achieve a culture of safety, it is necessary to

and behavior related to patient safety are expected and appropriate.

There are numerous studies on hospital (secondary) care in developed countries

countries may be impacted disproportionately.

performance of provincial hospitals in Afghanistan. The assessment involved workshops, focus

hospital activities including; 1-Management and Administration, 2-Financial Systems, 3-Human

and Community, and 8-Ethics and Values.

quality and safety:

frequently made by inexperienced clinicians, poor medical records, poor communication

are considered organizational factors, which if measured and monitored by administrations,

Patient safety and Patient Safety Culture

then be considered truly committed to the value of patient safety.

should be shared ( pp. 1–2).

(Kaushal R, Bates DW, Landrigan C, & et al, 2001, pp. 2115–2117).

are equally important to be evaluated for their role in medical error.

awareness of health professionals about different dimensions patient safety.

Public Hospitals in Afghanistan

which included the hospital management system as well.

Figure 2: Afghanistan (Administrative Divisions)

1. Identify a standardized package of hospital services at the first three levels of

2. Provide a guide for the MoPH, private sector, nongovernmental organizations

provided with materials and drugs.

Health Services (BPHS) with hospitals.

of 100,000-300,000 in 1-4 districts, basic surgery, medicine, obstetrics and gynecology,

neurology, orthopedics, plastic surgery; and medicine to include cardiovascular, endocrinology,

(Ministry of Public Health, 2005, p. 25)

Figure 3: Afghan Health Facilities (BPHS)

mainly by clinical inspection. However, a more comprehensive quality improvement program

instruments of assessing patient safety culture.

Hospital Survey on Patient Safety Culture

any modification if needed to fit the local context.

explained patient safety as a “distinct healthcare discipline supported by an immature yet

developing scientific framework”. They used a trans-disciplinary approach to explain the

contribution of health care leaders in addressing error. According to their trans-disciplinary

health care safety principles to improve patient safety (para. 1).

especially in developing countries and countries with economies in transition.(“WHO | Summary

of the Evidence On Patient Safety,” 2008, pp. 7–8).

Patient Safety Research

In 2006, the World Health Organization gathered a group of international experts to

Relevance of AHRQ’s Hospital Survey

psychometric properties (“AHRQ | Introduction,” 2004, sec. 2).

2008, sec. Appendix 3):

1. Identifications, design and testing of locally effective and affordable solutions

2. Inadequate competence, training and skills

3. Extent and nature of the problem of patient safety

4. Lack of appropriate knowledge and its transfer