Q01
Message
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Nursing Home Patient Safety Culture Assessment
Surveys nursing home staff on teamwork, staffing adequacy, handoffs, communication openness, and overall resident safety, aligned with the AHRQ Nursing Home Survey on Patient Safety Culture framework. An AI follow-up interview reconstructs a recent safety event or near-miss to surface what actually happened versus what gets reported.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
12 questions · ~7 min
Q02
MatrixRequired
Thinking about your day-to-day work, how much do you agree with each statement?
4 rows × 5 columns
- Staff in this nursing home work together as an effective team.
- There are enough staff to handle the workload during evening and night shifts.
- This nursing home relies too much on temporary, agency, or pool staff.
- Staff have to hurry to complete their tasks in this nursing home.
Columns: Strongly Disagree · Disagree · Neither Agree nor Disagree · Agree · Strongly Agree
Q03
MatrixRequired
How much do you agree with the following statements about communication and feedback in this nursing home?
4 rows × 5 columns
- Staff are told about changes made based on incident reports.
- Staff feel free to question the decisions or actions of those with more authority.
- When a mistake is made with a resident, staff report it, even if no harm resulted.
- Staff are afraid to ask questions when something does not seem right.
Columns: Strongly Disagree · Disagree · Neither Agree nor Disagree · Agree · Strongly Agree
Q04
MatrixRequired
How much do you agree with the following statements about handoffs and care transitions?
3 rows × 5 columns
- Important resident care information is shared between shifts.
- Things "fall between the cracks" when residents are transferred between units or shifts.
- Staff know what to do and who to contact if a resident's condition worsens.
Columns: Strongly Disagree · Disagree · Neither Agree nor Disagree · Agree · Strongly Agree
Q05
Opinion ScaleRequired
Overall, how would you rate this nursing home on resident safety?
Scale: 1 – 10
Min:PoorMax:Excellent
Q06
Multiple ChoiceRequired
In the last 12 months, how many incident or event reports have you personally filled out and submitted?
- None
- 1-2
- 3-5
- 6-10
- 11 or more
Q07
AI Interview
Ask the respondent to walk through the most recent safety event or near-miss they witnessed or were involved in at this nursing home: what happened, whether it was reported, and if not, what got in the way of reporting it. If their earlier answers suggest low reporting or fear of speaking up, probe specifically what would make them more comfortable reporting next time. If they say they've never seen a safety event, ask what 'safety' means to them day-to-day instead.
Q08
Multiple Choice
What is your primary staff position?
- Certified Nursing Assistant (CNA)
- Licensed Nurse (RN/LPN/LVN)
- Nurse Manager or Director of Nursing
- Administrator
- Other clinical staff
- Other non-clinical staff
- Prefer not to say
Q09
Multiple Choice
How long have you worked in this nursing home?
- Less than 6 months
- 6 months to less than 1 year
- 1 to 3 years
- 3 to 6 years
- 6 to 10 years
- 11 years or more
- Prefer not to say
Q10
Multiple Choice
On average, how many hours per week do you work in this nursing home?
- Less than 20
- 20-34
- 35-40
- More than 40
- Prefer not to say
Q11
Multiple Choice
Which shift do you work most often?
- Day
- Evening
- Night
- Rotating or varies
- Prefer not to say
Q12
Message
Thank you for your candor. Your responses will be combined with your colleagues' answers into a confidential safety culture report used to guide staffing, training, and communication improvements — no individual responses will be shared.
What’s included
AI follow-ups
Adaptive probes on open-ended answers that pull out detail a static form would miss.
Attention checks
Built-in safeguards against rushed answers and low-quality respondents.
AI-drafted copy
Wording, ordering, and branching written by the AI — tuned to your research goal.
Auto report
Themes, quotes, and a plain-English summary write themselves once responses come in.
How it compares
We reviewed the closest templates from other survey tools. Here’s what they do well — and where this template goes further.
Why this template
- Includes an AI follow-up interview that asks staff to reconstruct a specific recent safety event or near-miss, surfacing what actually happened versus what gets formally reported.
- Covers the core AHRQ Nursing Home Survey on Patient Safety Culture domains — teamwork, staffing adequacy, handoffs/care transitions, and communication openness — via structured matrix questions.
- Captures respondent context (staff position, tenure, weekly hours, shift) and incident-reporting frequency alongside an overall safety rating, so patterns can be segmented by role and shift.
- Automated per-response quality scoring and an auto-generated report turn open-ended event narratives into structured, reviewable findings without manual transcription.
SurveyMonkey
AHRQ Surveys On Patient Safety Culture™(SOPS™) Nursing Home Survey TemplateA fielding-ready template built directly on the same AHRQ SOPS Nursing Home framework, making it the closest direct comparison. It's a static questionnaire meant to be deployed as-is, with SurveyMonkey's standard analytics dashboards for reporting. Good for benchmarking against the AHRQ instrument, but it doesn't probe beyond the fixed item set.
What it does well
- Built on the recognized AHRQ SOPS Nursing Home instrument, giving it face validity and easy benchmarking against the published framework
- Ready to deploy on a widely used, familiar survey platform
- Likely includes standard charting/reporting tools for quantitative item scores
Where it falls short
- Fixed-question format with no adaptive AI follow-up to reconstruct specific safety events or near-misses
- No voice AI interview or guided screen-share task option for richer qualitative data
- No automated per-response quality scoring of open-ended answers
SurveySparrow
Patient Safety Culture Survey TemplateA general healthcare patient safety culture template rather than one specifically aligned to the AHRQ Nursing Home framework, so it's broader but less tailored to nursing home staffing/handoff nuances. It's a conversational-style static form, not a template with adaptive interviewing built in. Useful as a general safety-culture starting point but would need customization for nursing home specifics.
What it does well
- Conversational, chat-style question flow that may feel more approachable to respondents than a plain grid survey
- General healthcare patient safety culture focus applicable across care settings
- Likely offers standard SurveySparrow reporting and dashboard views
Where it falls short
- Not explicitly aligned to the AHRQ Nursing Home Survey on Patient Safety Culture domains (staffing, handoffs, etc.)
- No adaptive AI follow-up interview to reconstruct a specific safety event or near-miss
- No transparent prompt methodology or automated quality scoring of narrative responses
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.