Date of Award


Document Type


Degree Name

Master of Science (MS)

Legacy Department

Industrial Engineering

Committee Chair/Advisor

Neyens, David M

Committee Member

Childers , Ashley Kay

Committee Member

Diller , Thomas

Committee Member

Mason , Scott J


The primary aim of this thesis is to design an approach and demonstrate a methodology to supplement safety culture assessment efforts. The framework affords an enhanced understanding of hospital safety climate, specifically reporting culture, through the use of control charts to monitor non-harm patient safety events documented in reporting systems. Assessing safety culture and climate remains difficult. One of the most common methods to assess safety culture is a self-report survey administered annually. Surveys assess safety climate, because they are a snapshot of the management's and front-line staff's perceptions of safety within their settings. One component of safety culture is reporting culture, which is assessed by survey questions targeting the total number and frequency of events reported by individuals. Surveys use subjective data to measure outcome variables with regard to patient safety event reporting. Relying on subjective data when organizations also collect data on actual reporting rates may not be optimal. Additionally, the time lag limits management's ability to efficiently assess the need for, and the effect of improvements. Strategic interventions may result in effective change, but annual summary data may mask the effects. Additionally, there are advantages to focusing on non-harm events, and capturing non-harm event reporting rates may aid safety climate assessment. Despite the limitations of reporting systems, incorporating actual data may allow organizations to gain a more accurate depiction of the safety climate and reporting culture. With the increased prevalence of reporting systems in healthcare organizations, the data can be used to track and trend reporting rates of the organization. Incorporating control charts can help identify expected non-harm event reporting rates, and can be used to monitor trends in reporting culture. Data in reporting systems are continuously updated allowing quicker assessment and feedback than annual surveys. The methodology is meant to be prescriptive and uses data that hospitals typically collect. Hospitals can easily follow the summarized approach: check for underlying data assumptions, construct control charts, monitor and analyze those charts, and investigate special cause variation as it arises. The methodology is described and demonstrated using simulated data for a hospital and three of its departments.



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