Culture of Safety Survey

Question:

We were supposed to conduct our Culture of Safety Survey in late 2020 / early 2021. We have not done the survey and feel that due to the stress and staffing ratio this is not an optimal time to do the survey.

If we don’t conduct the Culture Of Safety Survey, would this roll up to condition level deficiency? What are your thoughts?

Answer:

First, it is unlikely that failure to do a timely culture of safety survey would roll up to a condition level deficiency on its own.  However, if there were a number of issues identified where it was perceived that leaders were not supporting staff, their ability to communicate near misses in a non-punitive environment, lack of concern for staff burn-out, lack of action taken on incidents or improvement opportunities along with the missing culture of safety survey, then the Joint Commission would probably throw the safety survey into the mix.  This could be condition level.  

The Joint Commission has published that the expectation is to repeat the culture of safety assessment every 18-24 months.  That was a point published in their Sentinel Event Alert #57 which should be reviewed.  That said, the Public Health Emergency has given you reason to prioritize your actions at this point.  

Our recommendation is to prepare for this by:

• Schedule the safety survey for later this year, ensure there is a paper trail to demonstrate its completion.  Document the leadership reason leading to the delay in the scheduled survey.
• Dig out the last safety survey results and carefully review the results and actions taken.  Pull and analyze other data related to culture of safety, this includes the numbers of self-reported incidents, etc.  Paint the picture that you have not suspended the reviewing and acting on data to improve the culture of safety.  Have a summary of this go up through leaders, and back to staff.  
• Look at previous recommendations and new opportunities to improve the culture of safety and summarize what you have done to improve this. Basically, you have reviewed and collected data and acted on this data to improve culture of safety during this pandemic.  To a degree, you have already implemented numerous initiatives during the pandemic to address the tenants of safe just culture.  Knit these together in that same summary you do for leaders and staff.  

Through the above summary, this shows leadership commitment to safety and taking credit for the efforts put in place this past year to address these.  There is documented logic as to why the house-wide safety survey was delayed, but that delay in no way slowed down leader’s efforts to measure and improve the culture of safety.  Being prepared will help.