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There is a new Patient Safety Systems Chapter in the 2015 Hospital Accreditation Manual. There are no new standards in this chapter. Rather, it describes how existing standards can be used to build an integrated patient safety system. While this new chapter exists only in the Hospital manual, its principles can be used by all organizations seeking to improve patient safety.

So, how should organizations utilize this new chapter? We recommend that your leadership team carefully review it and discuss the key principles at upcoming leadership meetings. Given the emphasis that TJC has placed on this new chapter, it’s likely that these principles will soon be reflected in the survey process; perhaps in the Leadership or Data Use interviews or even in tracer activities.

The following is an outline of the chapter.  The full Patient Safety Systems chapter is available on the TJC website.


Becoming a Learning Organization

This section emphasizes the importance of learning from patient safety events and using them to drive improvement. Key principles are a fair and just safety culture, a strong reporting system and use of data on patient safety events to drive improvement.


Role of Hospital Leaders in Patient Safety

This section defines the essential leadership tasks for an effective patient safety system:

  • Promoting learning
  • Motivating staff to uphold a fair and just safety culture
  • Providing a transparent environment in which quality measures and patient harms are freely shared with staff
  • Modeling professional behavior
  • Removing intimidating behavior
  • Providing resources and training necessary to take on improvement initiatives


Safety Culture

This section describes the attributes of a strong safety culture which are captured in the diagram below of the Trust-Report-Improve Cycle. In this cycle, trust promotes reporting, which leads to improvement, which in turn fosters trust.

Trust-Report-Improve Cycle


Effective Use of Data

This section addresses effective data collection and analysis and, most importantly, using data to drive improvement. The emphasis is on turning data into information, presenting information in a clear manner, and sharing information with appropriate groups throughout the organization (from the front line to the board.)


A Proactive Approach to Preventing Harm

This section includes strategies and tools for conducting proactive risk assessments. It promotes proactive risk reduction to identify and correct process problems in order to reduce the likelihood of adverse events.


Encouraging Patient Activation

This section discusses strategies for helping patients and families become more actively involved in their own care, treatment, and services. It promotes a patient centered approach and notes that activated patients are less likely to experience harm and unnecessary hospital re-admissions.

The details have yet to unfold but it’s clear that the Patient Safety systems Chapter is an important initiative for TJC. It was a high profile agenda item at Hospital Executive Briefings as well as the recent Consultants Forum meeting with TJC leadership. We urge you to make it required reading for your leadership team and facilitate discussion of how your hospital is promoting these important patient safety principles.