Beginning in June, the Joint Commission announced changes to its survey process when assessing a hospital or critical access hospital’s culture of safety. The improvements will be implemented for all other programs by October 18, 2018.

There are no changes to standards or elements of performance; nor are there changes to TJC’s survey methods. Instead, it’s about improving the survey process. Why? One section from the announcement in TJC’s newsletter stands out: “The Joint Commission urges organizations to establish a safety culture that fosters trust in reporting unsafe conditions to ensure high-quality patient care.” Clearly, TJC sees trust as critical to building a culture of safety in an organization and recognized that current survey assessments were lacking in this area. Staff might still fear intimidation from leadership for reporting on issues. And, leadership might not have safety culture improvement goals incorporated into their own performance evaluations.

To traverse these trust gaps, TJC[1] now requires organizations to include their most recent Safety Culture Survey, along with appropriate supporting documents as listed in their Survey Activity Guide. Survey teams are expected to review the survey and results prior to the opening conference, or at the latest on the morning of the first day of the survey. On Safety Culture Survey Day 1, survey teams must screen “Zero Patient Harm IS Achievable,” for the leadership session. Finally, surveyors will be tracing safety culture as part of other survey activities and asking questions to assess safety culture.

While most organizations certainly welcome the clarity and strength of the survey changes, they do present additional paperwork (literally) challenges. Thankfully, there are tools to minimize the adoption of the new survey demands. Verge Health’s Converge platform, via its Compliance and Regulatory module, can administer and report on the AHRQ Culture of Patient Survey at no extra charge. In addition, Converge’s Compliance Rounding feature helps organizations build audits to assess and report on leadership and staff on safety culture knowledge.

While healthcare should applaud the progress[1] being made in building a culture of safety in hospitals, one in every 10 deaths in the US continues to be attributed to medical error[1]. TJC’s efforts to improve the culture of safety survey process are an important step forward in tackling this stubbornly persistent problem. Verge is ready to help.


[1] The Joint Commission: Accreditation and Certification, June 13, 2018.

[2] Fewer Medical Mistakes Saved Hospitals $2.9 B from 2014 to 2016, Becker’s Hospital Review, June 6, 2018.

[3] Expedite the Journey to High Reliability, Becker’s Hospital Review, June 6, 2018.

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