subject_line
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
*
- Choose Organization -
Warm Springs Home Health Inc
South Springs Home Health Care Inc
Life Springs Hospice Care Inc
Helenium Home Health Inc
Luxor Care Inc
Galaxy Hospice Inc
Brilliant Health System Inc
Pinnacle Hospice Care Inc
Warm Springs Home Health Care Inc
Reported By:
Year:
*
2022
2023
2024
2025
SECTION A: Working in Your Home Health / Hospice 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 / Hospice 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?
*
Poor
Fair
Good
Very Good
Excellent
SECTION F: Background Questions
How long have you worked in this office location?
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
Typically, how many hours per week do you work in this office location?
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
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.