Are you expecting a TJC survey in 2018? If so, be ready for surveyors to explore how your organization has evaluated its Culture of Safety and what you’ve done with the results of that evaluation. We’ve already seen this occurring in 2018 surveys based on feedback from our clients. The requirements for conducting this evaluation are embedded in Leadership standard LD.03.01.01 in both the Hospital and BH manuals: “Leaders create and maintain a culture of safety and quality throughout the hospital.” There are two requirements within this standard:

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

Essentially, you must select and administer a survey, aggregate and analyze the results, and implement an action plan based on those results. Although this standard has been in place for several years, TJC acknowledges that, up to now, it’s been cited very infrequently by surveyors. Our experience has been that surveyors have typically not even asked about this topic. Well, it seems that’s about to change. At our Consultants Forum meeting at TJC headquarters in January, TJC leadership presented their plan for enhancing the current leadership session by expanding it to include a broader focus on how leadership is assessing the Culture of Safety. The plan is to include Safety Culture questions in the opening conference, individual tracers, the data systems tracer, the leadership session, and the exit conference.

What Types of Safety Culture Questions May be Asked?

For Leadership

• What is the response rate for your safety culture assessment?
• Do you benchmark your results?
• What were your top priorities from your last safety culture assessment?
• What progress have you made on those?

For Staff

• Have you ever completed a Safety Culture survey?
• Have you seen the results? Overall results and results for your unit? Did your supervisor review the results?
• Do you know how to report a safety concern?
• Do you know if a process exists to analyze errors?
• Have you ever participated in a root cause analysis? How often is this used? Do you have a recent example? What was the outcome?
• When an error takes place, do you have confidence leadership will take an appropriate look at how the system or process is accountable vs. an individual?

Evaluate Your Culture of Safety

If your organization has not yet conducted an evaluation of the Culture of Safety, it’s time for leadership to move forward on this initiative. The first step, of course, is selecting a tool. Many of our clients use the Hospital Survey on Patient Safety Culture, published by the Agency for Healthcare Research and Quality (AHRQ.) The survey is easily adaptable to all behavioral healthcare settings and includes a version that replaces the term “hospital” with “facility.” The majority of the survey questions are generic and thus applicable to all types of healthcare organizations. There is also a User’s Guide and a Resource List on the AHRQ website – very helpful tools. In addition, there is an excellent Action Planning Tool, which is a great resource for the most challenging aspect of this endeavor: prioritizing and tackling the issues identified by the survey. Several clients have used this tool and report it really helped them organize and implement a comprehensive action plan for improving their safety culture. And that’s exactly the goal!