Wondering how The Joint Commission’s emphasis on a culture of safety will impact your survey? We’re getting feedback on recent surveys and it’s clear this is a top priority for TJC.

Culture of Safety: Important Focus Area

TJC is actively promoting the establishment of a culture of safety within its accredited organizations. Reason is that establishing a culture of safety is a linchpin of high reliability organizations. High reliability organizations are organizations that operate in complex domains for extended periods without serious accidents or catastrophic failures. The Joint Commission’s President Mark Chassin, MD speaks authoritatively about this in his article High-Reliability Health Care: Getting There from Here.

Culture of Safety: Part of the Survey Process:

Given this focus of promoting a safety culture, surveyors are now probing and educating organizations about basic expectations for a culture of safety. We’ve definitely seen this playing out on recent surveys.

Feedback from the Field

The Quality Director at a psychiatric hospital recently shared with us their survey experience on this. “Right from the beginning, it was clear the topic of our safety culture was something the surveyors were going to explore. They asked our leadership team how they were evaluating the culture of safety. We had done an employee satisfaction survey but that wasn’t what the surveyors were looking for. They wanted us to use an industry accepted tool. We wound up getting a Requirement for Improvement for that issue under the Leadership standards.”

Culture of Safety: Questions for Staff

“The focus on safety culture continued right into the tracers. Surveyors asked staff if they had ever completed a survey about the culture of safety at our hospital. Our employee satisfaction survey included some questions about safety. But our staff really didn’t connect that. So, that didn’t go so well. Thankfully, staff were able to answer questions about how to report a safety concern. They knew all about incident reporting and did a good job with that.”

“The surveyors also asked about root cause analysis and if we had ever done one. The only people who could answer that were myself and our Director of Nursing. We had actually done one last year. So, I guess we got partial credit for that.”

Both the Quality Director and CEO of this hospital indicated that, by the end of their survey, it was clear they had a lot of work to do in this area. They’ve put together a Performance Improvement team to research best practices and tools and made this a priority goal for 2019.

Takeaways for your TJC Survey

If you haven’t yet conducted an evaluation of the culture of safety, it’s time to do so. The Joint Commission’s Leadership standard on this (LD.03.01.01) is very clear. In the Hospital manual, it states Leaders create and maintain a culture of safety and quality throughout the hospital. There are two requirements:

• Leaders regularly evaluate the culture of safety using valid and reliable tools.
• Leaders prioritize and implement changes based on the results of this evaluation.

In the Behavioral Health manual, the standard is similar. However, the requirement to use valid and reliable tools is currently not included. That will change later this year when that requirement is expanded to the Behavioral Healthcare standards as well.

If you’ve already conducted your culture of safety evaluation, make sure you have a robust action plan to address the issues you identified. Surveyors will want to see that you shared the survey results with staff. And that you’re moving forward with solid action items. We take a close look at this high priority requirement during our TJC mock surveys.

Resources

Many of our clients use the Hospital Survey on Patient Safety Culture. It’s published by the Agency for Healthcare Research and Quality (AHRQ.) It’s adaptable to all behavioral healthcare settings. It includes a version which replaces the term “hospital” with “facility.” The majority of questions are generic. They’re applicable across all types of healthcare organizations.

AHRQ also has several resources to help you evaluate and improve your culture of safety. An important goal not just for your survey but for the long term success of your organization!