Leadership Survey

Establish a Compelling Vision for Safety

• Yes=  No=  Are the CEO and the leadership team able to clearly communicate the vision to all parties, in both internal and external interactions?
• Yes=  No=  Can all members of the organization articulate the vision for safety and how it relates to their individual work?
• Yes=  No=  Is a patient safety and quality dashboard (which includes safety culture metrics) utilized and regularly reviewed in the context of organizational vision?

Valid Trust, Respect, and Inclusion

• Yes=  No=  Are all clinicians and workforce members provided with training in communicating with patients, including disclosure and apology?
• Yes=  No=  Are measures of respect included in all performance assessment tools?
• Yes=  No=  Is a formal program for respect and trust in place and evaluated regularly?
• Yes=  No=  Is there systematic training on diversity and inclusion for both the clinical and non-clinical workforce?
• Yes=  No=  Do the Board and leadership team regularly create and evaluate improvement plans for addressing disparities in patient care?

Select, Develop, and Engage Your Board

• Yes=  No=  Does the Board conduct regular self-assessments related to knowledge and understanding of culture of safety?
• Yes=  No=  Are programs in place to build competencies in culture improvement for Board members?
• Yes=  No=  Is the amount of time spent on quality and safety during each Board meeting tracked and at least comparable to time spent on finance and other items?
• Yes=  No=  Do performance assessments for the CEOinclude the organizations's safety activities and measures of culture?
• Yes=  No=  Do patient safety and quality leaders participate in at least a portion of all Board meetings?
• Yes=  No=  Is a patient and/or workforce story presented at each Board meeting?

Prioritize Safety in Selection and Development of Leaders

• Yes=  No=  Do all leaders receive training in patient safety science and safety culture?
• Yes=  No=  Is at least one member of the executive leadership team a Certified Professional in Patient Safety or a safety expert?
• Yes=  No=  Are leadership development plans reviewed annually? Do they include measures of key safety culture competencies?
• Yes=  No=  Do leadership development programs include cultivation of a robust skill set in communication, engagement, listening, performance improvement, and emotional intelligence, as well as business acumen?

Lead and Reward a Just Culture

• Yes=  No=  Do Board, leadership, and workforce development programs include training on just culture?
• Yes=  No=  Is there one set of defined behavioral standards for all individuals within the organization, including leadership, physicians, and the workforce?
• Yes=  No=  Is compliance with the established just culture framework part of regularly reviewed performance reviews, including career development plans, for leaders and the workforce?
• Yes=  No=  Does the organization use, evaluate, and define action plans related to measures of just culture on employee surveys?
• Yes=  No=  Is there an existing measure that is regularly evaluated for assessing frontline knowledge of just culture algorithm?

Establish Organizational Behavior Expectations

• Yes=  No=  Does the organization have a clearly defined reporting system and measure utilization of this system (including follow-up and feedback processes)?
• Yes=  No=  Are organizational behavior expectations, such as use of huddles and briefings, with follow-up plans and identified owners of action items, implemented and reviewed regularly?
• Yes=  No=  Are professional accountability standards (e.g. a process to address disruptive behaviors) in place, used, and regularly evaluated?
• Yes=  No=  Are specific tools to encourage teamwork and clear communication in plae, used, and regularly evaluated?
• Yes=  No=  Are communication and resolution/reconciliation programs in place, utilized, and regularly evaluated?