Self-Assessment Tool: A National Action Plan to Advance Patient Safety
The Self-Assessment Tool is an essential resource designed to help health care organizations evaluate their safety readiness, identify opportunities for improvement, and track progress over time. The 2024 updated version of the tool aligns with the recommendations in Safer Together: A National Action Plan to Advance Patient Safety (National Action Plan) and incorporates the latest insights and best practices from global safety initiatives.
By using the Self-Assessment Tool, health care organizations can better understand their current strengths and challenges, engage interdisciplinary teams, and develop actionable plans to advance patient and workforce safety.
Thank you for your commitment to patient and workforce safety. We are here to support you every step of the way!
Self-Assessment Tool 2024 Update
The Self-Assessment Tool has been enhanced to align with key national and global frameworks, including:
- The Centers for Medicare & Medicaid Services (CMS) National Quality Strategy
- The CMS Patient Safety Structural Measure (PSSM) and Health Equity Structural Measure (HESM)
- The US Department of Health and Human Services National Action Alliance for Patient and Workforce Safety
- The World Health Organization (WHO) Global Patient Safety Action Plan
Key Updates
- Scoring: Revised to reflect stages of maturity: Beginning (Score 1), Making Progress (Score 2), Significant Impact (Score 3), and Exemplary (Score 4); new options for “Unsure” and Score 0 provide greater accuracy
- Foundational Areas
- Culture, Leadership, and Governance: Updated to reflect alignment with the CMS PSSM and HESM
- Patient and Family Caregiver Engagement: Formerly Patient and Family Engagement, this area expands on the vital role of the patient and family caregiver (e.g., parent, authorized caregiver) in patient safety
- Workforce Safety and Well-Being: Formerly Workforce Safety, this area more explicitly addresses prevention of workplace violence and workforce well-being and joy in work
- Learning System: Broadened to highlight similar, essential practices for both patient safety and workforce safety and well-being
- New Self-Assessment Tool User Guide: Offers more detailed insights, interpretations, and guidance for completing the Self-Assessment Tool, as well as guidance for creating post-assessment action plans to improve safety
Who Should Use the Self-Assessment Tool?
The Self-Assessment Tool is designed for use by:
- Health care organizations across all care settings
- Individual leaders seeking a focused evaluation
- Interdisciplinary teams aiming for a comprehensive assessment
Access the Self-Assessment Tool PDF or Online
The Self-Assessment Tool is available as both a downloadable PDF document and in an online format.
Organizations are encouraged to:
- Complete the online Self-Assessment Tool (see instructions below)
- Download the PDF tool for reference, including instructions and interpreting score results
Get Started with the Online Self-Assessment Tool
Before beginning the self-assessment, it is recommended that you read Safer Together: A National Action Plan to Advance Patient Safety.
The online Self-Assessment Tool is available in two formats and can be completed either as an Individual Assessment or as a Team Assessment, offering flexibility based on your organization’s needs. Please review the steps below for each option and important timelines.
Step 1: Choose Self-Assessment Format
- Individual Assessment: Designed for one person to evaluate their organization’s safety readiness or to gain familiarity with the tool.
Access online Individual Assessment
- Team Assessment: Encourages a collaborative approach with input from diverse leaders, including:
- C-suite executives
- Safety/quality/risk leaders
- Committee chairs (e.g., governing body, quality/safety committee, Patient and Family Advisory Council)
- Others with informed perspectives
Step 2: Complete the Assessment
- Individual Assessment: Begin immediately; completion typically takes 30–60 minutes.
- Team Assessment:
- Before beginning, ensure that a Team Administrator identifies the assessment team members and gathers their contact details (name, title, email).
- Once the assessment is initiated, team members will receive personalized, non-shareable links to complete their portion of the assessment.
- The Team Administrator will notify team members about the purpose, timeline, and importance of providing thoughtful feedback.
- Note: The Team Assessment must be completed within 14 calendar days of initiation (automated reminders are sent periodically). The Team Administrator should plan the assessment timeline to avoid competing priorities such as organizational needs, holidays, or organizational deadlines.
Step 3: Access Completed Assessment Report
- Individual Assessment: A detailed report is generated immediately upon completion.
- Team Assessment: A comprehensive report is emailed to the Team Administrator after the 14-day period ends.
Using Self-Assessment Tool Results
The completed Self-Assessment Tool results report provides a clear snapshot of your organization’s safety readiness, highlighting both strengths and areas for improvement. Use this information to:
- Engage Leadership: Share findings with leaders and teams to prioritize safety efforts.
- Develop Action Plans: Identify actionable steps with defined roles, timelines, and measures of success (see additional guidance in the Self-Assessment Tool User Guide and the Implementation Resource Guide).
- Track Progress: Use subsequent assessments to monitor improvement over time.
Additional Guidance
Self-Assessment Tool User Guide
The Self-Assessment Tool User Guide offers more detailed insights, interpretations, and guidance for completing the self-assessment. The User Guide provides specific guidance and examples for the elements in the four foundational areas to:
- Support your organization’s completion of the self-assessment
- Highlight considerations for your organization’s action plans to improve safety
Implementation Resource Guide
For additional information on the recommended actions to advance patient safety and related resources, refer to the Implementation Resource Guide.