Joint Commission Changes Survey Process for Assessing Safety Culture

PUBLISHED: Jun 14, 2018
Relevant to: Critical Access Hospitals, Hospitals

The Joint Commission (TJC) has announced that effective this month it is changing its survey process for assessing the culture of safety in hospitals and critical access hospitals. These changes will become effective for all other TJC programs no later than October 2018. TJC defines safety culture as the “product of individual and group beliefs, values, attitudes, perceptions, competencies, and patterns of behavior that determine the organization’s commitment to quality and patient safety.”

The changes to the way in which TJC will survey the safety culture do not include changes to standards or elements of performance (EPs). According to TJC, the improvements to the way they survey organizational culture will include:

  • Making an organization’s most recent Safety Culture Survey one of the required documents included in the Survey Activity Guide. TJC explains that “…surveyors will want to review this prior to the opening conference, or as early in the survey process as possible.”
  • Incorporating a viewing of the video “Leading the Way to Zero.” during the leadership session of the TJC survey.
  • Including the tracing of the safety culture as a part of survey activities.

In their announcement, link provided below, TJC provides a list of example questions they may ask during a survey. Based on these questions, organizations should be prepared to address the following:

  • Processes for surveying the safety culture and evaluating the results of such surveys
  • How safety culture improvement goals are incorporated in performance expectations for leadership
  • Ways in which the organization supports the reporting of intimidating behavior
  • Processes for reporting and analyzing “near miss/close call” incidents
  • Codes of behavior for physicians, staff and leadership
  • Processes for evaluation incidents resulting in patient harm

Included with today’s notice are example policies related to the culture of safety.

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