Joint Commission changes how it assesses safety culture

The Joint Commission in June began implementing improvements in its assessment of safety culture in hospitals, including critical access hospitals. These improvements will be implemented for all Joint Commission accreditation programs by October 2018. To deliver on this task, surveyors will trace safety culture as part of survey activities and will ask questions to evaluate safety culture (see Table 1 for sample questions).

Table 1. Sample questions for assessing safety culture

Adding safety to the accreditation process

The focus on safety culture stems from the feedback of institutions that are accredited by The Joint Commission and its surveyors, both of which indicated that evaluating and improving how safety culture was assessed during the survey process was a critical next step in the journey toward high reliability in health care.

In its accreditation manuals, The Joint Commission 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.”1 Institutions with a robust safety culture have the following characteristics:

  • Communication based in mutual trust
  • Shared perceptions of the importance of safety
  • Confidence in the efficacy of preventive measures

The on-site survey will include safety culture-specific tracer activities. Tracers allow surveyors to sequentially analyze an institution’s systems or processes for delivering safe, high-quality care by following an individual patient or resident.2 Other survey process improvements include the following expectations:

  • An organization will be expected to include its most recent Safety Culture Survey with the required documents listed in the Survey Activity Guide. Surveyors will want to review this guide before the opening conference or as early in the survey process as possible. Helpful resources for completing a Safety Culture Survey include Sentinel Event Alert, Issue 57, “The essential role of leadership in developing a safety culture,”3 as well as the accompanying infographic on the “11 tenets of a safety culture.” 4
  • On survey day one, the survey team will provide a link to the video Zero Patient Harm IS Achievable and ask the institution to make audiovisual arrangements to show the video at the leadership session.5 Some organizations may ask to view it again at the organization exit conference. Surveyors also can show the video to small groups on tablet devices if the institution’s technology is unable to accommodate larger presentation.

Creating a culture of safety in the operating room (OR) is important. However, achieving some aspects of a safety culture can be more challenging than others.

In a study published in the Journal of Patient Safety in June 2017—“Safety culture in the operating room: Variability among perioperative healthcare workers”—Marc Philip T. Pimentel, MD, MPH, and colleagues examined results after the Hospital Survey on Patient Safety Culture was administered at a single tertiary care hospital in 2014.6

The survey was administered to attending surgeons, surgery trainees, anesthesia attendings, anesthesia trainees, nurses, and technicians—with a total of 431 respondents. The authors of this study reached the following conclusions:6

  • The highest positive scores were for teamwork within the hospital units (69 percent) and organizational learning and continuous improvement (57 percent)
  • The lowest scores were for feedback and communication about an error (34 percent) and hospital handoffs and transitions (30 percent)
  • Attending physicians were scored as perceiving the strongest overall safety culture, while nurses and technicians were scored as seeing the least amount of safety culture

A 2013 article in Becker’s Hospital Review listed 10 interventions for improving the safety culture, including the following:7

  • Create a collaborative governance structure “that engages all the stakeholders with a vested interest in OR operations—surgeons, anesthesia, nursing, and hospital administration”
  • Implement a daily huddle process to “ensure that all elements of a safe, efficient surgery are in place the day before a procedure”
  • Educate staff on team building and communication skills through use of crew resource management
  • Use a safe surgery checklist to reduce the number of surgical complications, such as wrong site surgery or surgical site infections
  • Record all errors or near misses and put together a protocol to report those issues to the appropriate individual or group
  • Establish the concept of a “just culture” in an organization; that is, adopt a learning culture instead of a punitive one, defining unacceptable behavior and building trust among team members


The Joint Commission also has created resources establishing a safety culture in institutions, such as with Sentinel Event Alert, Issue 57. Its companion piece, “11 tenets of a safety culture,” includes the following recommendations:3

  • Apply a transparent, nonpunitive approach to reporting and learning from 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, and who share these free lessons with all team members (for example, through a feedback loop)
  • Proactively assess system strengths and vulnerabilities, and prioritize them for enhancement or improvement
  • Repeat organizational assessment of the safety culture every 18 to 24 months to review progress and sustain improvement

These improvements reflect the increasing attention that The Joint Commission has placed on encouraging a culture of safety because it is likely to positively affect the quality of care patients receive at health care institutions.


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.


  1. The Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals. Patient Safety Systems Chapter. Oakbrook Terrace, IL. January 2018. (Manual and corresponding updates are subscription-based.)
  2. The Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals. Glossary. Oakbrook Terrace, IL. January 2018. (Manual and corresponding updates are subscription-based.)
  3. The Joint Commission. Sentinel Event Alert, Issue 57: The essential role of leadership in developing a safety culture. Available at: Accessed July 31, 2018.
  4. The Joint Commission. Sentinel Event Alert, Issue 57: The 11 tenets of a safety culture. Available at: Accessed July 31,
  5. The Joint Commission. Zero Patient Harm IS Achievable. Available at: Accessed July 31, 2018.
  6. Pimentel MPT, Choi S, Fiumara K, Kachalia A, Urman RD. Safety culture in the operating room: Variability among perioperative healthcare workers. J Patient Saf. June 1, 2017 [Epub ahead of print].
  7. Becker’s Hospital Review. Clinical leadership & infection control. How hospitals can improve the culture of safety in the surgical suite: 10 interventions to mitigate risk and create a culture of safety in the OR. Available at: Accessed July 31, 2018.

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