Florida is continuing its efforts to improve patient safety in hospitals and ambulatory surgical centers (ASCs).  The Florida Legislature previously approved a requirement that hospitals and ambulatory surgical centers (ASCs) conduct patient safety surveys and tasked the Agency for Health Care Administration (AHCA) with implementing a rule specifying the submission process for these surveys. AHCA’s proposed rule (Proposed Rule) was announced on November 4, 2021.

Patient Safety Surveys

Every two years, Florida licensed hospitals and ASCs are required to conduct a patient safety culture survey using the applicable Survey on Patient Safety Culture developed by the federal Agency for Healthcare Research and Quality (AHRQ) (the Safety Statute). The surveys must be conducted anonymously to encourage completion of the surveys by all employed and contracted staff. The facilities are permitted to contract with vendors to administer the survey.

The survey data will have to be submitted to AHCA in the format specified by the Proposed Rule once it has been finalized and implemented. The submissions must include the survey’s participation rate, although no minimum amount of participation is specified. AHCA’s Proposed Rule outlines the requirements described below.

Reporting Period

Within twenty-four months of the Proposed Rule becoming effective, and for each subsequent licensure renewal, each hospital and each ASC will be required to submit patient safety culture survey data to AHCA.

Data File Specifications

The facilities must submit the data to AHCA in the format specified by AHRQ.  AHRQ has different data file specifications for hospitals and ASCs.

Survey Questions

AHCA will provide the survey questions that are to be asked, which are different for ASCs and hospitals. While the general concepts are similar, the categories of the questions are different. The majority of the questions in both surveys require the participant to respond to statements by answering: Never; Rarely; Sometimes; Most of the time; Always; Does not apply or do not know.

The Hospital Survey groups the questions into specific sections: (1) the participant’s work area, (2) management at the hospital, (3) communication, (4) the reporting of patient safety events, (5) patient safety rating, (6) the hospital in general, and (7) care provided.

The ASC Survey groups the questions into the following sections: (1) working environment, (2) teamwork and training, (3) organizational learning, (4) documentation of near-misses, (5) management support for patient safety, (6) overall facility rating, and (7) communication in the surgery/procedure room.

Additional Patient Safety Requirements

Hospitals and ASCs do not need to submit patient safety surveys yet, as the Proposed Rule requires the surveys to be conducted within twenty-four months of the Proposed Rule’s effective date. However, it is important to remember that the requirement that surveys be conducted is only a portion of Florida’s strategy for achieving patient safety.

The Safety Statute requires that hospitals and ASCs already have the following in place:

• The adoption of a patient safety plan. The plan will be deemed to comply with this requirement if it adheres to the Centers for Medicare & Medicaid Services’ conditions of participation for quality assessments and performance improvement plans.
• Appointment of a patient safety officer and a committee to promote the health and safety of patients, review the quality of patient safety measures, and assist in implementing the facility’s patient safety plan. The committee must include at least one person who is not employed or practicing in the facility.

In addition to the above requirements, hospitals are required to provide AHCA’s Hospital Quality Measures/Patient Safety Information Form (1) to any patient or patient’s representative upon scheduling the patient’s nonemergency care, or (2) to any other stabilized patient or patient’s representative within 24 hours of the patient being stabilized or at the time of discharge, whichever comes first.  In addition, the form must always be provided to any person who requests this information. The form must include the hospital and statewide average for the most recent year related to the following quality measures:

• The rate of hospital-acquired infections;
• The overall rating of the Hospital Consumer Assessment of Healthcare Providers and Systems survey; and
• The 15-day readmission rate.

Prepare Plan for Patient Safety

Florida is making progress in its goal of advancing patient safety. Hospitals and ASCs are out of compliance if they are not adhering to the previously implemented patient safety requirements, such as the adoption of a patient safety plan. As soon as the Proposed Rule for patient surveys is finalized, hospitals and ASCs will need to turn their attention to implementing a process for timely submission of the biennial surveys.

We are available to hospitals and ASCs to provide guidance in complying with these patient safety standards.