Implementing safety culture surveys

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Safety culture is a strong predictor of clinical safety behaviours and patient safety outcomes. It is best measured at the team level, using a mix of methods, and within a structured improvement approach. A culture measurement helps wards, departments, facilities and organisations understand and improve their culture of care.

This guide sets out how to plan, run, analyse and act on a safety culture survey, with resources to support each stage.

Measurement and accreditation

Measuring safety culture demonstrates a commitment to safety and quality and contributes evidence for accreditation. Safety culture measurement supports Action 1.1 (Governance, leadership and culture) of the National Safety and Quality Health Service Standard.

Step 1. Preparation

Careful planning is the foundation of a successful survey. Before you start, build your case, set up a project team, and agree a realistic timeline.

As a guide, plan for:

  • four weeks for project setup and pre-survey communication.
  • six to 10 weeks for survey completion, analysis and reporting.

Timelines may be shorter if your service has run previous culture surveys, or longer for larger facilities or where you aim for a high response rate.

Times to avoid running the survey

Avoid running the survey during:

  • periods when other staff surveys are running, such as the People Matter Employee Survey
  • busy periods such as accreditation, budget cycles and the Christmas holiday period
  • times when staff are rotating or new interns are starting.

Gauging readiness for change

A culture survey works best when the team is open to acting on the results. Before you commit to a date, talk to people across the unit and note who is engaged, who is hesitant, and who is pushing back.

If most are disengaged or actively resistant, work through the reasons before launching the survey. Running a survey into a wall of resistance produces data the team will not act on.

Roles and responsibilities

Leadership support

Safety culture surveys require investment of time, resources and commitment at every stage. Engage your clinical governance unit early – they can connect you with local quality improvement expertise and executive support. You may also find it useful to talk to colleagues in other health services about their experience.

Project sponsor

Your project sponsor provides support and guidance through the survey and the improvement project that follows. They help secure resources and remove barriers. Ideally, your sponsor is in a senior position. Communicate with them regularly.

Governance structure

Your project sponsor will help you work out where governance for the survey sits within your organisation.

Examples:

  • Unit/ward level: integrate reporting into existing ward meetings
  • Facility level: integrate outcomes with existing safety and quality reporting to the executive leadership team and peak clinical safety and quality committees.
  • Local health district level: oversight through peak clinical safety and quality committee

Project team

Your team should be interdisciplinary and include the right mix of experience and perspectives. Consider including:

  • a team leader
  • a quality improvement advisor or expert
  • staff from across the target areas, including junior and senior clinicians, allied health, and administrative staff.

The team leader role is essential. They organise meetings, delegate tasks, and act as the voice of the project.

Engagement activities will look different for each stakeholder group. Some ideas include:

  • using hospital-wide channels such as a newsletter and intranet
  • asking local nursing and medical champions to advocate for the survey
  • displaying response rates on ward information boards
  • setting a standing agenda item at regular meetings
  • using double staffing time or staff meeting to provide short, regular updates
  • creating posters and computer screensavers
  • holding a survey launch
  • distributing information to Visiting Medical Officers and General Practitioners in rural and regional areas.

Step 2. Running the survey

The Safety Attitudes Questionnaire (SAQ) short form is regularly used in NSW. Its psychometric properties are well established through extensive use in multiple health settings nationally and internationally. The SAQ is divided into six domains, with each represented between four and eight questions.

If you use a different culture survey , the rest of this guide still applies to setting up, communicating and debriefing your measurement.

Setting up the SAQ in the Quality Audit Reporting System

The SAQ is available in the Quality Audit Reporting System (QARS). You can include demographic questions, such as profession, employment type and tenure, for more detailed analysis. Demographic questions can be turned on or off in QARS but cannot be edited.

All other SAQ questions are also fixed. This protects the psychometric properties of the survey and keeps your results reliable. Access the survey in QARS by searching for the survey ID 3471.  Request access via your local health district or specialty health network QARS admin user.

Using the paper format

If using the paper version of the SAQ, your safety culture lead is responsible for maintaining the integrity of the survey. Plan for:

  • who will distribute and collect the surveys
  • how staff will be given time to complete them
  • any permissions needed within your organisation
  • how paper surveys will be collected – for example, through sealed collection boxes placed around the organisation
  • how any immediate concerns raised will be resolved and escalated.

Response rates

Response rates determine how accurately your results reflect the safety culture of your team or organisation.

To calculate your response rate, divide the number of completed surveys by the number of surveys sent. Exclude any that were ineligible, undeliverable or returned to sender.

Recommended minimum response rate is 30% of staff

For teams of fewer than eight people, the SAQ is not appropriate. Use a facilitated discussion instead, to maintain confidentiality and reduce identification of respondents. To report separately on professional or demographic groups, you need at least eight respondents per group.

Reminders and follow-up

Keep your team informed throughout the survey period:

  • Make sure staff know the survey is coming, why it matters, and what happens afterwards.
  • Set a clear timeframe for completion.
  • Send reminders through email, meeting agendas, newsletters and other channels.
  • Ask your executive sponsor to mention the survey at meetings and walkarounds.
  • Reinforce that senior leadership is committed to understanding the results and taking action.

    Step 3. Feedback and reporting

    Timely feedback respects the contribution of your team and maintains the integrity of the process. Share results in a group setting where possible, so people can see their input has been heard.

    Once the survey closes, analyse the results. The data highlights areas to focus on during the debrief. Decide upfront what type of analysis and reporting you need, whether you analyse internally or externally.

    In the SAQ, data is presented as subscale scores and individual items. The tools below support data retrieval, analysis and reporting for the SAQ specifically. The facilitation and reporting guidance applies to any safety culture tool.

    Retrieving and analysing SAQ data

    Data from QARS transfers to a specially formatted Excel spreadsheet that calculates domain scores. A report template uses those scores to generate your report.

    Running feedback sessions

    Plan your feedback sessions to encourage participation and honest discussion.

    • Lay out the purpose and goals of the session up front.
    • Set the tone by offering a safe, inclusive space.
    • Agree ground rules, including hearing contributions without judgement.
    • Guide the group to set the discussion topics rather than directing them.
    • Keep discussions constructive and forward-looking.
    • Summarise and clarify key points.
    • Close on a positive note with an agreed action plan.
    • Aim for short, frequent sessions to support attendance, including for night shift staff.
    • Collect feedback after each session.
    • Keep a record of attendance.

    Facilitating the results discussion

    Hold the facilitated discussion no less than two weeks after the survey closes. Develop a local process that suits your team. Larger teams may need multiple sessions, so everyone has the chance to participate.

    Sponsors and leaders are responsible for allocating time and space, and for identifying a local support person with expertise in leadership and culture change to co-facilitate.

    The discussion should include the SAQ subscale scores and the highest and lowest-scoring items.

    Use these four questions to guide the conversation: Does this look like your team? Why or why not? If this is where you are now, what would better look like? How would you get there?

    Write the report

    The report collates and presents the analysed data. As a feedback tool, it is critical for helping participants understand the process and its outcomes.

    Suggested report contents

    • Executive summary
    • Introduction: background, reasons for running the survey, potential benefits
    • Methodology: the survey instrument, the six domains, details of the sample surveyed
    • Demographics: profile of those surveyed
    • Key findings/results:
      • top five priorities for improvement
      • mean scores for the satisfaction items
      • mean scores for the six safety climate domains
      • top five and bottom five performing items
      • item breakdown by domains
      • item breakdown by demographic group.

    Step 4. Action planning

    Taking action is the most important stage of safety culture measurement. Sustainable change happens when staff contribute to the solutions, and a good action plan turns those contributions into a clear sequence of work. The survey is the tool. The improvement activities that follow are what create change.

    An action plan is a working checklist of the tasks needed to reach your goals, based on the survey results and the facilitated team discussion.

    Six steps for developing an action plan

    1. Understand the context.
    2. Identify goals.
    1. Clarify who is involved, who leads, and what the timeline is.
    2. Make the plan.
    3. Implement the plan.
    4. Monitor progress.

    When the team sees that their participation led to real change, they are more likely to engage with future projects. The team or service gains the insight it needs to keep improving.

    Write a clear aim statement

    Your action plan needs an aim statement that captures the goal of the project without prescribing the solution.

    More about aim statements

    Components of an action plan

    A good action plan has five components. Expand each one for detail.

    Break down the work needed to reach the goal. Make sure each task is clearly defined, attainable, and has a person responsible. For larger or more complex tasks, break them into smaller ones that are easier to manage.

    Before generating solutions, make sure you understand the causes of the problem. See Brainstorming for structured approaches.

    Each task needs someone in charge of carrying it out.

    Prioritise the task list - some steps may block others. Set realistic deadlines in consultation with the person responsible, based on their capacity.

    Define when tasks will be completed.

    Milestones are mini-goals leading up to the main goal. They keep the team motivated and give them something to work towards. As a guide, space milestones around two weeks apart - close enough to keep momentum, far enough to allow meaningful progress.

    Before you start, make sure you have the resources you need to complete the tasks. If they are not available, plan first for how to secure them. See Quality improvement tools for a range of tools to support your improvement project.

    Allocate time to review progress with your team.

    Mark completed tasks on the action plan so the team can see progress toward the goal. For tasks that are pending or delayed, work out why, find a solution, and update the plan.

    Download action plan template (PDF 86.0 KB) and adapt for your local needs.

    Visualising your action plan

    Create a plan everyone can understand at a glance. A flowchart or table works well. The format matters less than clarity. Make the plan easy to access and easy to edit.

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