Development and pilot testing of survey items to assess the culture of value and efficiency in hospitals and medical offices

BMJ Qual Saf. 2022 Jul;31(7):493-502. doi: 10.1136/bmjqs-2020-012407. Epub 2021 Aug 20.


Background: Given rising costs and changing payment models, healthcare organisations are increasingly focused on value and efficiency. The goal of our study was to develop survey items to assess clinician and staff perspectives about the extent to which the organisational culture in hospitals and medical offices supports value and efficiency.

Methods: Development began with a literature review and interviews with experts and clinicians and staff from hospitals and medical offices. We identified key areas of value and efficiency culture, drafted survey items and conducted cognitive testing. Using purposive sampling to select sites, the 36-item surveys were pilot tested in 47 hospitals and 96 medical offices. Psychometric analysis was conducted on data from 3951 hospital respondents (42% response) and 1458 medical office respondents (63% response).

Results: Factor loadings, multilevel confirmatory factor analysis model fit and reliability estimates were acceptable for the 13 items grouped into 4 composite measures: Empowerment to Improve Efficiency (3 items), Efficiency and Waste Reduction (3 items), Patient Centeredness and Efficiency (3 items) and Management Support for Improving Efficiency and Reducing Waste (4 items). All composite measures were significantly intercorrelated and related to the four Overall Ratings of Healthcare Quality, indicating adequate conceptual convergence among the measures. Eight items assessing Experiences With Activities to Improve Efficiency were also included.

Conclusion: We developed psychometrically sound survey items measuring value and efficiency culture. When added to the Agency for Healthcare Research and Quality Surveys on Patient Safety Culture, the item sets extend those surveys by assessing additional dimensions of organisational culture that affect care delivery. Healthcare organisations can use these item sets to assess how well their organisational culture supports value and efficiency and identify areas for improvement.

Keywords: ambulatory care; healthcare quality improvement; hospital medicine; safety culture; surveys.

Publication types

  • Review
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Hospitals
  • Humans
  • Organizational Culture*
  • Psychometrics
  • Reproducibility of Results
  • Safety Management*
  • Surveys and Questionnaires