On March 1, 2017, the Joint Commission issued a Sentinel Event Alert warning of the link between inadequate safety cultures within health care organizations and a rise in the occurrence of adverse events, and further urging health care organization leadership to adopt a culture of safety through formal initiatives and a top-down model behavioral approach. The Joint Commission directs health care organization leadership to specifically take charge in establishing and maintaining an effective safety culture.
In its Sentinel Event Alert, the Joint Commission outlines certain key actions that health care organization leadership should consider and adopt in establishing an robust safety culture, among other recommendations:
- Adverse Event Reporting. A health care organization’s adverse event reporting system should be accessible to everyone within the health care organization. The system should also demand follow-up education and learning surrounding adverse events. Leadership should encourage transparency and make concerted efforts to reduce reprisal and punishment for reporting potential or actual adverse events.
- Safety Policies and Training. Health care organization leadership should ensure that proper policies are established and enforced to support a healthy safety culture. At a minimum, such policies should address the method for adverse event reporting. In addition, the Joint Commission advises health care organizations to incorporate safety training into existing quality improvement projects and organizational processes. Such training would be particularly helpful in certain high-risk areas of the organization (e.g., operating rooms, ICUs, emergency rooms).
- Recognize Team Members for Reporting. Health care organization leadership should actively acknowledge and support individuals who identify adverse events, close calls, unsafe conditions, or who otherwise have helpful suggestions for general safety improvement. This information should be shared with all team members within the organization to encourage team members to identify potential safety concerns and work collaboratively to find actual and preventative solutions.
- Develop Unit-Based Quality and Safety Improvement Initiatives. The Joint Commission advises health care organizations to gather information from surveys and assessments to develop very specific unit-based quality and safety improvement initiatives. Based on its independent literature review, the Joint Commission identified certain tactics that may be helpful for building a safety culture, such as walkarounds, huddles, team safety briefings and planning sessions, debriefs to learn from identified errors or safety defects, and appointed safety ambassadors responsible for improving various aspects of safety culture within the health care organization.
- Risk Management. The Joint Commission also urges leaders to establish a transparent risk-based process for distinguishing between human error and error resulting from poorly designed systems or otherwise recklessness. Developing a means to appropriately distinguish between a mistake and a blameworthy, reckless action will enable both leaders and the health care organization as a whole to maintain an accountable safety culture.
- Repeated Evaluation of Progress. The Joint Commission urges health care organizations to review progress and improvement toward meeting any identified safety objectives every 18 to 24 months, for the purpose of building a broader strategic plan.
The Joint Commission urges leadership within health care organizations to consider its recommendations when implementing a formal safety program, and to ensure that leadership actively engage with team members to first develop a transparent, safety culture that can support a developed safety program.