Self-Assessment Tool: National Action Plan to Advance Patient Safety

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Self-Assessment Tool: National Action Plan to Advance Patient Safety

The Self-Assessment Tool, a supplemental resource to the National Action Plan to Advance Patient Safety, assists health care leaders and organizations in deciding where to start with the recommendations and tactics presented in the National Action Plan.

The Self-Assessment Tool is organized by the four interrelated foundational areas, described in the National Action Plan, for developing a total systems approach to advance patient safety: Culture, Leadership, and Governance; Patient and Family Engagement; Workforce Safety; and Learning System. The self-assessment questions represent a selection and synthesis of elements detailed in the complete National Action Plan and may, therefore, provide a partial representation of the current state of an organization’s patient safety efforts.

Who Should Complete the Self-Assessment?

  • The self-assessment is primarily intended for health care delivery organizations to use as a tool for organizational learning and to track the progress of safety improvement efforts over time.
  • The assessment is not meant to serve as a comprehensive review of an organization’s safety program or culture, nor is it intended for comparisons or benchmarking among organizations.
  • See the Instructions section below for more details.

Access the Self-Assessment Tool PDF or Online

The Self-Assessment Tool is available as a downloadable PDF document and in an online format.*


Go to the Online Self-Assessment Tool

*Important note for online Self-Assessment Tool:
It is recommended that you complete the online assessment and enter the results following your team's discussions (see additional Instructions below). After completing the online assessment, you have the option to download a report that displays your responses in various ways to help communicate your organization's current state and progress to various stakeholders. The report of your online assessment responses can only be downloaded at the time they are entered; once you exit the online assessment you will not be able to return to the same assessment to download a report of your responses.

Instructions for the Self-Assessment Tool

The complete instructions for using the Self-Assessment Tool are available within the downloadable PDF document, and also summarized below.

  • Before beginning the self-assessment, it is recommended that you read Safer Together: A National Action Plan to Advance Patient Safety (National Action Plan).
  • Establish an interdisciplinary team within the organization that will work together to implement the recommendations of the National Action Plan.
  • Organizations may complete this assessment tool as a team or choose to have team members review the information independently, and then come together to discuss their responses.
  • Once the assessment is complete and has been reviewed, the team develops an action plan for improvement, including the identification of roles and responsibilities.
  • The team then plans regular meetings or connection points for follow-up, review, and revisions to their action plan, as necessary.

Assess and Score

  • For each row in the tables that follow, select the statement that best represents (or is most reflective of) the current state of your organization’s safety efforts based on your individual or team’s perspective. For any item where there may be uncertainty, consult with colleagues to gain more information and insight to determine the best response.
  • In each row, for each selected statement, write the corresponding score number (noted in the column header) in the Row Score box. For example, if the team selected “Safety goals developed. Some goals are accompanied by an action plan and associated metrics.” in the first row of the Culture, Leadership, and Governance section, write a “1” in the Row Score box.
  • The Total Score is the sum of the Row Scores for each section.

Interpret Score Results

  • Use the Interpreting the Total Score matrix for each section to determine the current state of your organization’s safety efforts and recommended actions to advance patient safety. Based on the recommended actions, the interdisciplinary team develops an improvement plan with clear action steps and metrics.
  • In determining where to start, it may be helpful to review the rows with the lowest scores. Note ideas in the Opportunities for Improvement section below the matrix.
  • For additional information on the recommendations and related resources, refer to the National Action Plan and accompanying Implementation Resource Guide

IHI Patient Safety Congress

The IHI Patient Safety Congress on May 14–16, 2024, is the must-attend conference for those who continue to shape ​​smarter, safer, more equitable care for patients wherever it’s provided — from the hospital and outpatient settings to the home.​​​​​​​​​​​​

Learn More
IHI Patient Safety Congress