Q01
Message
All templatesHealthcare & Clinical
Medical Office Patient Safety Culture Survey (AHRQ-Aligned)
Benchmarks how staff in your medical office perceive teamwork, communication, error reporting, and leadership support for safety, modeled on AHRQ's patient safety culture domains. An AI follow-up interview digs into the most recent near-miss or error staff witnessed and what stopped or helped them report it.
Sample questions
A preview of what’s in the template. Every question is editable before you launch.
13 questions · ~7 min
Q02
Multiple ChoiceRequired
What is your primary role in this office?
- Physician/Provider
- Nurse
- Medical Assistant
- Front desk/Administrative
- Practice manager/Supervisor
- Other clinical staff
Q03
MatrixRequired
How much do you agree with each statement about your office?
6 rows × 5 columns
- Staff feel free to question the decisions of those with more authority
- When someone points out a mistake, it is not held against them
- We work together as an effective team to care for patients
- Staff are told about changes made based on reported errors
- We have enough staff to handle the workload
- +1 more
Columns: Strongly disagree · Disagree · Neither agree nor disagree · Agree · Strongly agree
Q04
Opinion ScaleRequired
Overall, how would you rate patient safety in this office?
Scale: 0 – 10
Min:PoorMax:Excellent
Q05
Multiple ChoiceRequired
In the last 12 months, how many event or incident reports have you personally filed?
- None
- 1 to 2
- 3 to 5
- 6 to 10
- 11 or more
Q06
Slider MatrixRequired
How comfortable are you doing each of the following?
4 rows, one slider each
- Speaking up if you see something that could harm a patient
- Asking a colleague to double-check a decision you're unsure about
- Reporting a mistake even if no patient was harmed
- Telling a supervisor about a process that isn't working safely
Slider 0–10Min:Very uncomfortableMax:Very comfortable
Q07
Best–Worst Trade-off (MaxDiff)Required
Which of these, if improved, would do the most to make this office safer for patients?
- Clearer handoffs between shifts or providers
- More consistent staffing levels
- Faster follow-up on lab or test results
- Better communication between front desk and clinical staff
- More feedback after safety events are reported
- Clearer protocols for common procedures
- Reduced pressure to rush patient visits
Pick best & worst per setBest:Would improve safety mostWorst:Would improve safety least
Q08
Multiple Choice
In the last 12 months, how often has important patient information been lost during shift changes or handoffs?
- Never
- Rarely
- Sometimes
- Often
- Very often
Q09
AI Interview
Reconstruct the most recent near-miss or safety event this person witnessed or was involved in: what happened, whether it was reported, and what made reporting easy or hard. If they say they'd hesitate to report, probe specifically what they fear would happen and whether they've seen a colleague face consequences for speaking up.
Q10
Long Text
Is there anything about patient safety in this office that you think leadership should know but hasn't heard?
Q11
Multiple Choice
How many years have you worked in this specific office?
- Less than 1 year
- 1 to 5 years
- 6 to 10 years
- 11 to 20 years
- 21 years or more
- Prefer not to say
Q12
Multiple Choice
What is your typical weekly working hours in this office?
- Less than 20 hours
- 20 to 39 hours
- 40 hours or more
- Prefer not to say
Q13
Message
Thank you for your candor. Responses are combined into an anonymous safety culture report shared with leadership to guide concrete improvements — no individual answers are attributed to you.
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 a matrix and slider-matrix covering the core AHRQ teamwork, communication, and error-reporting domains, plus an opinion-scale overall safety rating and a max-diff to prioritize improvement areas
- Goes beyond static rating scales with an AI follow-up interview that reconstructs the most recent near-miss or error the respondent witnessed, probing what helped or blocked reporting it
- Captures role, tenure, and weekly hours alongside incident-report frequency and information-loss-during-handoff questions, giving context to segment results by staff type and exposure
- Closes with an open long-text question inviting candid suggestions for leadership, and ends in an auto-generated report — with transparent prompts so you can see exactly what the AI asked
SurveyMonkey
AHRQ Surveys On Patient Safety Culture™ (SOPS®) Medical Office SurveyA fielding-ready template that directly licenses/mirrors the official AHRQ SOPS Medical Office Survey instrument, which gives it strong face validity for benchmarking against the national dataset. It is a static questionnaire, so all follow-up depends on manual analysis after the fact. Good choice for teams that want an off-the-shelf, unmodified AHRQ instrument rather than a customized flow.
What it does well
- Based on the official, validated AHRQ SOPS Medical Office instrument
- Backed by SurveyMonkey's broad distribution and reporting infrastructure
- Familiar format for practices already benchmarking against AHRQ national data
Where it falls short
- Static question set with no adaptive follow-up to probe individual near-miss stories
- No voice-based interview option or guided screen-share tasks
- No published per-response quality scoring or transparent prompt methodology
SurveySparrow
Patient Safety Culture Survey TemplateA conversational-style survey template aimed at healthcare teams that covers general patient safety culture themes. It reads as a standard question-and-answer template rather than one explicitly built around the full AHRQ domain structure. It's ready to field but relies on fixed questions rather than dynamic probing of specific incidents.
What it does well
- Conversational chat-style UI that can feel more approachable than a plain grid survey
- Positioned specifically for healthcare/patient safety use cases
- Ready to deploy without additional setup
Where it falls short
- No adaptive AI interview to dig into a specific recent near-miss or error
- No voice AI interview or screen-share guided task option
- No automated quality scoring of individual responses or transparent AI prompt disclosure
Frequently asked questions
What questions are in the “Medical Office Patient Safety Culture Survey (AHRQ-Aligned)” template?
The template includes 13 ready-to-use questions, starting with: “Thanks for taking part in our patient safety culture check-in. Your honest input helps us find where communication or re…” · “What is your primary role in this office?” · “How much do you agree with each statement about your office?”. The full set is previewed above, and every question is editable.
How long does this survey take to complete?
Respondents typically finish the 13 questions in about 7 minutes.
Can I customize this template?
Yes — every question, answer option, and the ordering is editable before you launch. You can add or remove questions, or ask the AI editor to rework the survey around your research goal.
Is this template free to use?
Yes. Open it in the editor and start customizing right away — no account required to try it, and the free plan covers launching your survey.
Ready to launch?
Open this template in the editor. Every part is yours to change before the first respondent sees it.
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