Assessment

Safety Culture Survey Template & Action Planner

A standardizable, team-level safety culture assessment with validated question sets across psychological safety, reporting behaviors, and leadership support, plus an integrated action-planning worksheet that converts survey signals into prioritized, short PDSA experiments with owners and measures.

Interactive Tool

Safety Culture Survey & Action Planner

Purpose

This assessment helps frontline teams measure safety culture across psychological safety, reporting behaviors, and leadership & learning. It collects actionable signals and immediately guides teams to convert findings into prioritized, short-cycle actions they can own and test. Use this as a repeating team-level pulse (monthly or quarterly) rather than a one-time checkbox.

How to use

  • Ask every team member to complete the short survey honestly.
  • Calculate mean scores by domain and review open comments together.
  • Use the action-planning section to capture top barriers and create up to three unit-level PDSA experiments with owners, measures, and short timelines.

Scoring guidance

Each scale item uses 1 (Strongly disagree) to 5 (Strongly agree). Calculate the average per domain. A domain mean ≤3.5 often indicates a material opportunity for focused improvement; prioritize actions where scores are lowest and where staff report concrete barriers. Do not use scores to punish individuals—use them to identify system and leadership gaps.

Enter the unit, department, or team (e.g., 'Medical ICU - Night Shift').
YYYY-MM-DD
1.0 10.0
1.0 10.0
1.0 10.0
1.0 10.0
1.0 10.0
1.0 10.0
1.0 10.0
1.0 10.0
1.0 10.0
Describe concrete obstacles to reporting or psychological safety, with examples if comfortable.
Capture the single most important obstacle that stops safe behavior or reporting (1–2 sentences).
Which barrier does this action address?
Describe the change your team will test (what you will do differently).
Example: number of reports, % of huddles where concern raised, or days between similar incidents.
YYYY-MM-DD
1–3 bullets: what to try, who does it, how to measure, quick timeline.
YYYY-MM-DD
YYYY-MM-DD
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