Accreditation

Safety culture becomes part of proposed leadership standards

Briefings on Accreditation and Quality, November 1, 2005

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Learning objectives: After reading this article, you will be able to

1. list six elements of safety and quality

2. identify potential tools to measure a culture of safety

3. explain who should determine a hospital's compliance with standards

After proposing to regulate a culture of safety in the National Patient Safety Goals earlier this year, the JCAHO has included the same measure in a draft of the 2007 leadership standards.

The JCAHO would hold leadership accountable for six elements of safety and quality, including

  • culture, which involves assessment and education, among other things

  • data use to improve safety

  • planning processes that focus on quality

  • communication of important safety information

  • changing performance

  • having the skills necessary to provide safe care

    Most hospitals already focus heavily on patient safety and quality, but the JCAHO standards would add some consistency.

    "A lot of this gets done, but it may not be in policy and procedure," says Timothy O'Kelley, RN, risk manager at Deaconess Hospital in Oklahoma City. "It's not well-organized, and it's not delineated."

    The JCAHO also changed several other standards in the chapter to get leadership more involved in setting the organization's mission and improvement activities. The standards were open for comment until October 14, when the JCAHO Professional and Technical Advisory Committee and board of commissioners made revisions, says Mark Forstneger, a spokesperson for the accreditor.

  • This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.

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