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Get Out Your Yardstick: How to Evaluate the Culture of Safety and Quality in your Organization
TJC's 2009 Leadership chapter contains a new 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. In the BH manual, the standard/EP states: "Leaders regularly evaluate the culture of safety and quality." In the Hospital manual, the wording goes a bit further and states: "Leaders regularly evaluate the culture of safety and quality using valid and reliable tools."
With this new standard, TJC is emphasizing that the culture within an organization can impact 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
The value of a "culture of safety and quality" is easy to grasp. But, just how do you as an organization evaluate your own culture as it relates to safety and quality? Here are a few approaches organizations are using:
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 one published by the Agency for Healthcare Research and Quality (AHRQ Hospital Survey Toolkit). This is a 43 item (10 minute) survey 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
Since the AHRQ survey is hospital focused, many non-hospital based BH 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.
"How soon do we need to complete this evaluation?" is a common question.
First, remember that this standard (and the entire 2009 Leadership chapter) were published in the 2008 manuals to give organizations a year to gear up for the new requirements. The standard officially became effective on January 1, 2009. Thus, TJC expects organizations to be able to demonstrate in 2009 that they have actually completed the evaluation.
"What are surveyors looking for during the survey?" is another common question. So far, surveyors have been satisfied with both the "home grown" survey approach (as long as it directly relates to issues impacting safety/quality) as well as the use of a more formal instrument such as the AHRQ tool.
It's still early in 2009 and so we'll keep you posted on this challenging new standard and how organizations are dealing with it. Stay tuned! |
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 Changes to Unannounced Surveys for Behavioral Health: New 7 Days Notice for Many Organizations!
Effective immediately, The Joint Commission (TJC) has announced changes to its policy on unannounced surveys for certain types of Behavioral Health programs and organizations. The following types of programs and organizations will now receive 7 business days notice of their triennial survey:
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All methadone programs that are not part of a hospital
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All in-home behavioral health programs that are not part of a hospital
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All case management programs that are not part of a hospital
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All Assertive Community Treatment programs that are not part of a hospital
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All freestanding organizations with 10 or fewer staff
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All freestanding organizations with an average daily census of less than 100 clients
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All community based, freestanding behavioral health programs
In addition, all other BH programs that currently receive 5 business days notice (such as Foster Care) will now receive 7 business days notice.
Based on these changes, many Behavioral Health organizations will now get 7 business days notice of their surveys; a significant change from the unannounced survey policy that went into effect in 2006.
For the official announcement, see the March 2009 issue of Perspectives.
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Barrins & Associates provides Joint Commission consulting services for the Behavioral Healthcare industry. Our clients include both psychiatric hospitals and freestanding Behavioral Healthcare organizations. We specialize in providing Survey Preparation and Continuous Survey Readiness services exclusively for the Behavioral Healthcare industry. Barrins & Associates was founded by Anne Barrins who was a Joint Commission surveyor for 13 years. |
