Workplace safety should be a top priority for every employee. Please take the time to evaluate your safety by filling in the information below.

Organization *

Reported By:

SECTION A: Working in Your Home Health Organization

How much do you agree or disagree with the following statements? *

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
When someone in this office gets really busy, others help out?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
In this office, there is a good working relationship between staff and providers?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
In this office, we often feel rushed when taking care of patients?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
This office trains staff when new processes are put into place?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
In this office, we treat each other with respect?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
We have too many patients for the number of providers in this office	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
This office makes sure staff get the on-the-job training they need?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
This office is more disorganized than it should be?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
We have good procedures for checking that work in this office was done correctly?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
Staff in this office are asked to do tasks they haven’t been trained to do?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
We have enough staff to handle our patient load?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
We have problems with workflow in this office?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
This office emphasizes teamwork in taking care of patients?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
This office has too many patients to be able to handle everything effectively?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
Staff in this office follow standardized processes to get tasks done?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know

SECTION B: Communication and Follow-Up

How often do the following things happen in your office? *

	Never	Rarely	Sometimes	Most of the Time	Always	Does Not Apply or Don’t Know
Providers in this office are open to staff ideas about how to improve office processes?	Never	Rarely	Sometimes	Most of the Time	Always	Does Not Apply or Don’t Know
Staff are encouraged to express alternative viewpoints in this office?	Never	Rarely	Sometimes	Most of the Time	Always	Does Not Apply or Don’t Know
This office reminds patients when they need to schedule an appointment for preventive or routine care?	Never	Rarely	Sometimes	Most of the Time	Always	Does Not Apply or Don’t Know
Staff are afraid to ask questions when something does not seem right?	Never	Rarely	Sometimes	Most of the Time	Always	Does Not Apply or Don’t Know
This office documents how well our chronic-care patients follow their treatment plans?	Never	Rarely	Sometimes	Most of the Time	Always	Does Not Apply or Don’t Know
Our office follows up when we do not receive a report we are expecting from an outside provider?	Never	Rarely	Sometimes	Most of the Time	Always	Does Not Apply or Don’t Know
Staff feel like their mistakes are held against them?	Never	Rarely	Sometimes	Most of the Time	Always	Does Not Apply or Don’t Know
Providers and staff talk openly about office problems?	Never	Rarely	Sometimes	Most of the Time	Always	Does Not Apply or Don’t Know
This office follows up with patients who need monitoring?	Never	Rarely	Sometimes	Most of the Time	Always	Does Not Apply or Don’t Know
It is difficult to voice disagreement in this office?	Never	Rarely	Sometimes	Most of the Time	Always	Does Not Apply or Don’t Know
In this office, we discuss ways to prevent errors from happening again?	Never	Rarely	Sometimes	Most of the Time	Always	Does Not Apply or Don’t Know
Staff are willing to report mistakes they observe in this office?	Never	Rarely	Sometimes	Most of the Time	Always	Does Not Apply or Don’t Know

SECTION C: Owner/Managing Partner/Leadership Support

A. Are you an owner, a managing partner, or in a leadership position with responsibility for making financial decisions for your office? *

Yes - Go to Section F

No - Continue Below

How much do you agree or disagree with the following statements about the owners/ managing partners/leadership of your office? *

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
They aren’t investing enough resources to improve the quality of care in this office?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
They overlook patient care mistakes that happen over and over?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
They place a high priority on improving patient care processes?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
They make decisions too often based on what is best for the office rather than what is best for patients?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know

SECTION D: Your Home Health Organization

How much do you agree or disagree with the following statements? *

	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
When there is a problem in our office, we see if we need to change the way we do things?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
Our office processes are good at preventing mistakes that could affect patients?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
Mistakes happen more than they should in this office?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
It is just by chance that we don’t make more mistakes that affect our patients?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
This office is good at changing office processes to make sure the same problems don’t happen again?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
In this office, getting more work done is more important than quality of care?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know
After this office makes changes to improve the patient care process, we check to see if the changes worked?	Strongly Disagree	Disagree	Neither Agree nor Disagree	Agree	Strongly Agree	Does Not Apply or Don’t Know

SECTION E: Overall Ratings

Overall Ratings on Quality

How much do you agree or disagree with the following statements? *

	Poor	Fair	Good	Very good	Excellent
Patient Centered - Is responsive to individual patient preferences, needs, and values?	Poor	Fair	Good	Very good	Excellent
Effective - Is based on scientific knowledge?	Poor	Fair	Good	Very good	Excellent
Timely - Minimizes waits and potentially harmful delays?	Poor	Fair	Good	Very good	Excellent
Efficient - Ensures cost-effective care (avoids waste, overuse, and misuse of services)?	Poor	Fair	Good	Very good	Excellent
Equitable - Provides the same quality of care to all individuals regardless of gender, race, ethnicity, socio economic status, language, etc.?	Poor	Fair	Good	Very good	Excellent

Overall Rating on Patient Safety

Overall, how would you rate the systems and clinical processes your office has in place to prevent, catch, and correct problems that have the potential to affect patients? *

SECTION F: Background Questions

How long have you worked in this office location?

Typically, how many hours per week do you work in this office location?

What is your position in this office? Check ONE category that best applies to your job.

SECTION H: Your Comments

Please feel free to write any comments you may have about patient safety or quality of care in your office. *

Less than 2 months	3 years to less than 6 years
2 months to less than 1 year	6 years to less than 11 years
1 year to less than 3 years	11 years or more

1 to 4 hours per week	25 to 32 hours per week
5 to 16 hours per week	33 to 40 hours per week
17 to 24 hours per week	41 hours per week or more