Standards › Standard 2A › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · QUA-SOP-001 · Version 1.1 · Approved by the ASF Expert Committee
Supports: 2A.7
At a glance
- Use a validated safety culture survey, not a homemade questionnaire.
- Run the survey at least every two years, with the same tool each time, and with a high response rate.
- Share the results with all staff within 60 days, including the weak areas.
- Agree a small number of actions with owners, and check progress every quarter.
- Repeat the survey and compare.
- Stop and get help straight away if: a survey is run with an unvalidated tool, results are not shared, or the actions are not followed up.
1. Purpose
To measure whether staff feel safe to report errors and concerns, and to act on what the survey shows [EC].
2. Scope
| Applies to | All staff, including clinical, non-clinical, locum and bank staff |
| Locations | All services at the facility |
| When | At least every two years; results shared within 60 days; actions checked quarterly |
| Does not apply to | Patient experience, which is measured under CON-SOP-002 |
3. Definitions
| Term | Meaning |
|---|---|
| Validated tool | A questionnaire tested for reliability and validity in published research |
| Safety culture | The shared values, attitudes and practices that determine how safety is managed |
| Response rate | The percentage of invited staff who complete the survey |
4. Background
Absence of complaints does not show a safe culture. Staff who do not feel safe to speak up will not report errors. A validated survey measures this directly, which is what criterion 2A.7 requires [EC].
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Quality lead | Selects the tool, runs the survey, analyses and reports results | Survey analysis competence |
| Chief executive | Sponsors the survey; agrees actions; reports to governing body | Executive leadership |
| Service heads | Share results with their teams; own actions for their area | Management training |
| All staff | Complete the survey honestly and confidentially | Briefing at induction |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Validated survey tool (QUA-FRM-001) | Named tool with licence or permission to use; the committee selects it (EC) | Version and licence recorded |
| Action plan register (QUA-REG-001) | Current | Updated quarterly |
7. Safety
- Surveys are anonymous. Do not try to identify individuals from small group results.
- Do not use the survey to discipline individuals.
8. Before you start
- Choose the tool and confirm its permission to use.
- Tell staff why the survey is run, how results will be used, and that it is anonymous.
9. Procedure
Step 1. Choose a validated tool.
- Select a validated safety culture survey from published research, with its licence or permission checked (EC).
- Record the tool name, version and source on the survey record.
Key point: Only a validated tool gives results that can be compared over time.
Step 2. Run the survey.
- Send the survey to all staff, with a clear explanation and a closing date of at least four weeks.
- Send at least two reminders.
- Aim for a response rate that the committee sets (EC).
Key point: A low response rate makes the result unreliable, so the reminder step is not optional.
Step 3. Analyse the results.
- Calculate the score for each dimension of the tool, by service and for the facility.
- Compare with the previous round and with any published benchmark, where available.
- Identify the three weakest dimensions.
Key point: The weakest areas show where the risk is. Do not only report the average.
Step 4. Share the results.
- Share the facility results with all staff within 60 days of closing.
- Give each service its own results, with a plain summary.
- Explain what will change as a result, and what will not.
Key point: Staff who never hear the results stop taking part.
Step 5. Agree actions.
- Agree no more than three to five actions for the facility, and one or two for each service.
- Enter each action on QUA-REG-001 with owner, due date and measure.
Key point: Too many actions means none are done.
Step 6. Check progress and repeat.
- Check progress every quarter with the governing body.
- Repeat the survey at the next cycle with the same tool, and compare the scores.
Key point: The repeat survey is the evidence that the actions worked.
10. Decision points
- If the response rate is below the target, extend the survey period once, and report the low rate with the results.
11. Special situations
| Situation | Action |
|---|---|
| Small service with few staff | Report results only where at least five staff responded, to protect anonymity (EC). |
12. Escalation
- Results that show serious concern about speaking up go to the chief executive and the governing body at the next meeting.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Survey run within the last 2 years with a validated tool | Yes | Yearly check | Quality lead | Escalate to governing body |
| Results shared within 60 days | 100% | Each round | Quality lead | Escalate to chief executive |
| Actions with owner and due date, progressing | 100% | Quarterly | Quality lead | Escalate to governing body |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Survey tool and licence | Quality file | Duration of the survey cycle plus the period set by the facility’s records policy years |
| Survey results and analysis | Quality file | the period set by the facility’s records policy years |
| Action plan (QUA-REG-001) | Quality file | the period set by the facility’s records policy years |
15. Training
- Quality leads are trained in survey administration and analysis (EC).
- Staff receive a briefing on the survey and on how to report concerns.
16. Related documents
| ID | Title | Use |
|---|---|---|
| QUA-FRM-001 | Safety Culture Survey | Survey form |
| QUA-REG-001 | Safety Culture Action Plan Register | Action tracking |
| GOV-PLN-002 | Quality Improvement Plan | Actions feed the plan |
| SOP-N21 | Whistleblowing and Speak-Up Procedure | Speak-up route |
17. Evidence
| Reference | Note |
|---|---|
| EC | Agency for Healthcare Research and Quality (AHRQ). Hospital Survey on Patient Safety Culture (HSOPSC). Example of a validated tool; licence and version set by the ASF Expert Committee before use. |
| E-009 | ASF Expert Committee consensus. Response rate, survey interval and reporting thresholds are EC decisions. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | Approved by the ASF Expert Committee |
| 1.1 | the date of approval | Internal quality review: corrected cross-references, status wording and document control | Approved by the ASF Expert Committee |
E-learning for this document
- Incident Reporting, Just Culture and Open Disclosure (T-09)
- Safety Management System & Leadership (MGMT-01)
References
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)