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Evaluating the Culture of Safety and Quality in your Organization

Since 2009, the TJC Leadership chapter has contained the requirement for organizations to evaluate their culture of safety and quality. The standard is LD.03.01.01 Element of Performance #1 in both the Behavioral Health and Hospital manuals. It requires leaders to “regularly evaluate the culture of safety and quality.”

With this standard, TJC is emphasizing that the culture within an organization directly impacts the safety and quality of care provided. An organization with a culture of safety and quality has the following characteristics:

  • Strong teamwork
  • Open discussions of concerns about safety and quality
  • Encouragement of and reward for internal and external reporting of safety and quality issues

Since this standard came out in 2009, we have seen organizations using a variety of mechanisms to evaluate their culture of safety and quality. Some are making use of their existing employee satisfaction surveys. They are adding questions such as the following:

  • How would you rate teamwork within your program and within the organization?
  • Do we have a culture that supports open discussion of problems?
  • Do employees feel there is retribution for raising issues or identifying problems?
  • Do employees report mistakes that they see happen?
  • Do employees feel they will be blamed if they report mistakes?

Other organizations are choosing to adopt a structured survey instrument such as the Hospital Survey on Patient Safety Culture published by the Agency for Healthcare Research and Quality. This is a 43 item (10 minute) questionnaire for staff that asks them to rate their own unit as well as the hospital on the following issues:

  • Communication
  • Support
  • Learning from mistakes
  • Prioritizing patient safety

Although the AHRQ survey was designed primarily for acute care hospitals, many psychiatric hospitals and behavioral healthcare organizations have modified it and developed a tool suited to their setting and client population.

Keep in mind that once this information has been collected, it must be analyzed by your leadership team. Then, decisions must be made about the best actions to take to improve the culture of safety and quality. Note that EP # 2 states: “Leaders prioritize and implement changes identified by the evaluation.” So, a survey with no follow-up will not meet the intent of this standard.

Some readers have asked how this requirement is being reviewed during TJC surveys. We have not seen a consistent approach among surveyors.  The TJC Document Review List does not include an evaluation of the culture of safety. Some surveyors ask about it during the leadership interview. Others don’t ask about it at all.

It is noteworthy that since 2013 we have begun to see a few hospitals cited for not having completed this type of evaluation. Interestingly, this issue was not cited during the triennial surveys of these hospitals but rather during TJC complaint surveys. These complaint surveys often focus on patient safety issues and leadership oversight of the hospital-wide patient safety program. Thus, it’s not surprising that surveyors are looking to see how leaders have evaluated the culture of safety. Also, given the focus that TJC is placing on patient safety in all of its communications and initiatives, we anticipate that the expectation for a formal evaluation of the culture of safety and quality will likely increase.

So, if your leadership team has not yet tackled the task of designing a mechanism to evaluate the culture of safety and quality within your organization, it’s time to get that on the agenda. For related information on patient safety and creating a high reliability organization, see the article in our May 2014 newsletter “High Reliability: Important Topic for TJC Leadership interview.”