In March 2017, the Joint Commission issued Sentinel Event Alert 57: The essential role of leadership in developing a culture of safety, which calls upon healthcare leaders to prioritize patient safety and demonstrate a commitment to the organization’s safety culture through everyday actions.
According to the alert, “The Joint Commission’s Sentinel Event Database reveals that leadership’s failure to create an effective safety culture is a contributing factor to many types of adverse events – from wrong site surgery to delays in treatment. In addition, through the results of its safety initiatives, The Joint Commission Center for Transforming Healthcare has found inadequate safety culture to be a significant contributing factor to adverse outcomes.”
Prioritizing a Safety Culture
The Joint Commission’s Patient Safety Chapter defines a 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.”
Sentinel Event Alert 57 recognizes that a strong safety culture begins with leadership. In a press release from the Joint Commission, Ana Pujols McKee, MD, TJC’s executive vice president and chief medical officer, explains, “Establishing and improving safety culture is just as critical as the time and resources devoted to revenue and financial stability, system integration and productivity–because a lack of safety culture can have serious consequences for patients, staff and other stakeholders.”
Establishing and Improving Safety Culture in Healthcare
Released in advance of Patient Safety Awareness Week (March 12-18, 2017), Sentinel Event Alert 57 provides resources and recommendations to help healthcare organizations — and their leadership — build and continuously improve their safety culture. Namely, TJC recommends that leaders take the following actions to establish and continuously improve their organization’s safety culture:
TJC’s Recommendations for Building a Safety Culture
- Apply a transparent, non-punitive approach to reporting and learning from adverse events, close calls and unsafe conditions.
- Use clear, just, and transparent risk-based processes for recognizing and distinguishing human errors and system errors from unsafe, blameworthy actions
- CEOs and all leaders must adopt and model appropriate behaviors and champion efforts to eradicate intimidating behaviors.
- Establish, enforce and communicate to all team members the policies that support safety culture and the reporting of adverse events, close calls and unsafe conditions.
- Recognize care team members who report adverse events and close calls, who identify unsafe conditions, or who have good suggestions for safety improvements.
- Determine an organizational baseline measure on safety culture performance using a validated tool.
- Analyze safety culture survey results from across the organization to find opportunities for quality and safety improvement.
- Use information from safety assessments and/or surveys to develop and implement unit-based quality and safety improvement initiatives designed to improve the culture of safety.
- Embed safety culture team training into quality improvement projects and organizational processes to strengthen safety systems.
- Proactively assess system strengths and vulnerabilities and prioritize them for enhancement or improvement.
- Repeat organizational assessment of safety culture every 18 to 24 months to review progress and sustain improvement.
TJC has also created and shared a handy infographic to illustrate these recommendations.
Read More about Sentinel Event Alert 57: The essential role of leadership in developing a culture of safety
- Joint Commission news release: New Sentinel Event Alert on Establishing and Improving Safety Culture in Health Care
- Infographic: 11 Tenets of a Safety Culture
- Full text: Sentinel Event Alert 57: The essential role of leadership in developing a culture of safety
- TJC Patient Safety Systems Chapter for the Hospital program
Has your organization experienced a serious patient safety event? Or do you have concerns about whether your organization truly has a culture of safety? Don’t wait for the next adverse or sentinel event to occur. Equip your organization to make safety your top concern. Contact us for a confidential conversation about your questions and concerns and how a Patient Safety Assessment can help you take ownership of your safety strategies and practices and achieve a culture of safety.
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