Acing the Joint Commission Regulatory Visit: Running an Effective and Compliant Safety Program

Abstract

Ensuring the safety of patients and staff is a core effort of all health care organizations. Many regulatory agencies, from The Joint Commission to the Occupational Safety and Health Administration, provide policies and guidelines, with relevant metrics to be achieved. Data on safety can be obtained through a variety of mechanisms, including gemba walks, team discussion during safety huddles, audits, and individual employee entries in safety reporting systems. Data can be organized on a scorecard that provides an at-a-glance view of progress and early warning signs of practice drift. In this article, relevant policies are outlined, and instruction on how to achieve compliance with national patient safety goals and regulations that ensure staff safety and Joint Commission ever-readiness are described. Additional critical components of a safety program, such as department commitment, a just culture, and human factors engineering, are discussed. ©

Just Culture: The Foundation of Staff Safety in the Perioperative Environment

“…An organization committed to safety should address both patient and staff safety. Organizational leaders have a responsibility not only to develop safety plans but to ensure this commitment to safety is included in each team member’s job description and fully integrated into the employee code of conduct 1 . This consistency provides a foundation for all team members and defines the organizational expectation of being committed to safety.…”

“…These risks include being exposed to blood, other body fluids, and infectious materials; sustaining sharps and ergonomic injuries; interacting with aggressive patients and the patients’ family members; and inhaling surgical smoke. When the Occupational Safety and Health Administration was founded in 1971, its members acknowledged the need for leaders at health care organizations to provide a safe environment for their patients as well as their employees 1,2 . A core strategy for organizational leaders to establish safe environments for both patients and staff members is taking responsibility for creating and nurturing a culture of safety.…”

“…A core strategy for organizational leaders to establish safe environments for both patients and staff members is taking responsibility for creating and nurturing a culture of safety. Leaders can strive to reach this goal in their facilities by implementing a just culture —a model and framework in which staff members are empowered to share concerns, near misses, or errors freely without fear of punishment 1,3-7 …”

“…Providing the highest quality of care, ensuring safety in the care delivery model, and preventing harm are all hallmarks of today’s health care organizations 1 . Staff members working in the perioperative setting are exposed to many safety and environmental risks.…”