Form # 3 Form # 3 Site-level POC Instructions for Survey

Attachment C – Site-level POC Instructions for Ambulatory Surgery

Survey of Patient Safety Culture

Survey Implementation Procedures for the Point of Contact (POC)

Westat will mail you a package that includes a survey packet for each person on your Excel staff list. Please notify Jessica Behm if someone on your list no longer works in your office. You will find a few extra surveys in your package. Please use these extras only for new staff who began working in your office after the Excel staff list was finalized. Please notify Jessica Behm about any new staff not on your Excel list. For any new staff, Westat will need to know staff position and ID# on the survey packet label that was given to the new staff. Please also update your Excel list.

WHAT YOU NEED TO DO NOW

Target Dates	Activities
Upon receipt	Post promotional flyers in the office.
NEXT STEPS
Target Dates	Activities
Beginning of Week 1: Start of Survey Data Collection	Distribute survey packets to all eligible staff members as noted on your staff list. For each survey packet, you will need to match the ID number on the survey packet label to the ID number on your Excel staff list so that you know which person to give the survey to. Write the person’s name on the survey packet label before you distribute the surveys. It is crucial that you accurately match the ID numbers and distribute the surveys to the correct persons. Hand out the survey packets to staff members to complete (consider distributing the packets at a staff meeting or at the beginning of each shift). Tell staff to use the postage-paid business reply envelope provided in the survey packets to return their completed surveys directly to Westat. Encourage staff participation. Indicate on your Excel staff list (e.g., through highlighting) when each person has received a survey packet. Notify Jessica Behm when you have distributed all the surveys. If a staff member misplaces his/her survey, notify Jessica Behm with the ID number of that staff member and she will send a replacement survey. Do not use the extra surveys we sent. For statistical reasons, only one ID can be assigned to each staff.
Week 2	Westat will be tracking ID numbers on returned surveys and will send you second surveys for staff who have not returned their surveys. As needed, follow up with staff who have not returned a completed survey. Receive package with second survey packets to give to staff members who have not yet returned their surveys. These second survey packets will have ID numbers on the survey packet label. Follow the same ID matching procedures to identify which person(s) to give a survey to. Write the person’s name on the survey packet label. Again, it is important to do the matching task carefully. Hand out the survey packets and indicate on your Excel staff list (e.g., through highlighting) any person who received a second survey packet. Notify Jessica Behm when you have distributed the second surveys.

Your support in promoting staff participation is crucial to getting results that accurately represent your office. Thank you in advance for encouraging 100% response at your office! Contact Jessica Behm, Study Manager, at ASCpatientsafety@westat.com or 1-800-937-8281 ext. 8013 (toll-free) if you have questions.