The Joint Commission’s Comprehensive Accreditation Manual for Hospitals emphasized the importance of safety culture in its Patient Safety Systems chapter, which expanded to ambulatory care and office-based surgery settings as of Jan. 1, 2017.
Here are The Joint Commission's 11 tenets of safety culture, which the accrediting body defines 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."
1. Handle reports of adverse events, close calls and unsafe conditions in a transparent, nonpunitive way that facilitates learning.
2. Employ clear, fair and transparent risk-based strategies for recognizing human errors and system errors. Distinguish these errors from unsafe, blameworthy conduct.
3. Ensure CEOs and leaders adopt and model appropriate behaviors. They should also be advocates for eliminating intimidating behaviors.
4. Implement policies that support safety culture and encourage reporting of adverse events, close calls and unsafe conditions. Enforce and communicate these policies to all team members.
5. Acknowledge team members who report adverse events and close calls, identify unsafe conditions or provide helpful safety improvement suggestions.
6. Use a validated tool to determine an organizational baseline measure on safety culture performance.
7. Identify areas for improvement in quality and safety by analyzing safety culture survey results from across the organization.
8. Develop and implement unit-based quality and safety improvement initiatives using information from safety assessments and/or surveys. The initiatives should be designed to improve the safety culture.
9. Incorporate safety culture team training into quality improvement projects and organizational processes.
10. Evaluate system strengths and weaknesses, and determine priorities for enhancement or improvement.
11. Complete an organizational assessment of safety culture every 18 to 24 months to review and continue progress.