Robert A. Wise, MD, vice president, Division of Standards and Survey Methods, The Joint Commission
Courtesy of The Joint Commission


Published 10/1/2010
Jennie McKee

Promoting a culture of safety

Joint Commission initiatives aimed at enhancing patient safety

When some orthopaedists think of The Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations), they may envision an organization focused on issuing requirements to physicians and healthcare organizations. But enhancing patient safety, rather than dictating rules and regulations, is at the heart of the organization’s mission, according to Robert A. Wise, MD, vice president of The Joint Commission’s Division of Standards and Survey Methods.

When AAOS Now spoke with Dr. Wise, he emphasized that AAOS members have an integral role in putting The Joint Commission’s patient safety initiatives into action. By being keenly engaged in issues that are central to improving patient safety—such as reducing errors and enhancing communication (both between physicians and patients and among physicians and other members of the healthcare team)—orthopaedists benefit patients and simultaneously reduce their own medical liability risk.

AAOS Now: What do you want AAOS members to know about the goals and processes of The Joint Commission?

Dr. Wise: The Joint Commission is more than just the group that expects surgeons to sign discharge summaries and perform other record-keeping tasks. We want to help AAOS members and other healthcare providers understand the cutting-edge processes that can improve the delivery of health care.

We build risk reduction strategies into the accreditation process. Our emphasis is on providing a roadmap for approaching the complexity of everything within a healthcare organization, both at the patient level and at higher levels—the systems and leadership levels. We encourage and hope to facilitate interactions among the governing body, the medical staff, and the hospital administration.

The Joint Commission is not involved in telling surgeons how to treat patients or perform surgery—we do not issue clinical practice guidelines. Surgeons work with their professional organizations to develop those.

AAOS Now: The Joint Commission advocates establishing and maintaining a “culture of safety.” What is it, and how can AAOS fellows contribute to it?

Dr. Wise: By “culture of safety,” we mean an environment or culture in which quality and safety of care is foremost in everyone’s minds. In an organization with a culture of safety, for example, anyone should feel empowered to raise his or her concerns about quality or safety. No hierarchy or chain of command dictates who is allowed to speak up. Maintaining a culture of safety helps reduce the risk of medical errors.

Orthopaedists—and the AAOS—made a significant contribution to promoting a culture of safety by participating in the development and promulgation of the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. Prior to developing the protocol, we heard for years that there was a continuing problem with wrong site, wrong procedure, and wrong person surgery. Often, these errors involved very good surgeons—some of the best in the field—not surgeons who weren’t paying attention or didn’t care. So, what does it mean when a competent surgeon is involved in an error like this? Asking that kind of question helped us shift our focus from the surgeon to how the overall system is operating.

We worked very closely with the AAOS to develop the Universal Protocol—many of the ideas came from the AAOS “sign your site” campaign. The Academy set the stage for a number of improvements in the current iteration of the Universal Protocol. Only with continued leadership from surgeons will these types of changes become integrated into the emerging culture of safety within healthcare organizations.

AAOS Now: What about the National Patient Safety Goals? How are they developed, and how can AAOS members help ensure compliance with them?

Dr. Wise: The Joint Commission collects information on a regular basis from the field as well as from the literature and the media on practical issues related to healthcare quality and safety. We then draw attention to these issues through the National Patient Safety Goals, which must be complied with as part of the accreditation process.

One area of interest to surgeons is the incidence of healthcare-associated infections (HAIs). Maintaining proper hand hygiene continues to be an issue in reducing the number of HAIs. Certain procedures, such as inserting a central line, also have a high infection risk. We use information from the literature and groups such as the Centers for Disease Control and Prevention to direct us to these areas. Orthopaedic surgeons can set an example for colleagues and staff and serve as champions for adopting protocols that encourage compliance with these measures.

AAOS Now: What about improving communication between physicians and patients? How does The Joint Commission address this issue, and what kind of buy-in is needed from AAOS members?

Dr. Wise: Our “Speak Up” campaign is specifically directed toward patients to help them be advocates for their own care. Patients often feel intimidated and don’t realize that they can speak up about the kind of care they want to receive. Our campaign addresses issues such as hand hygiene, medication safety, and understanding the kinds of questions patients should ask when they are discharged from the hospital.

For the “Speak Up” campaign to work, all members of the healthcare team, including physicians, must accept the patient’s right to speak up to receive the best care possible. For instance, if the patient does not see the surgeon wash his or her hands before a bedside visit in the hospital, the patient can ask the surgeon about it. It’s possible that the surgeon may have washed or used an alcohol-based hand rub before walking in, and the patient just did not see this occur.

Patients need to have permission from their physicians that it’s okay to ask this kind of question. Physicians must make it clear that they really do want patients to be advocates and that patients should feel they are an important part of the treatment team.

AAOS Now: Why does The Joint Commission encourage physicians to maintain a broad understanding of all the processes and systems at their healthcare organization?

Dr. Wise: Because surgeons are leaders of healthcare delivery teams, they must have a broad view of how health care is delivered. If we look again at the example of HAI, for instance, many issues can be associated with HAI rates at an institution—some directly associated with the physician and others associated with the institution’s systems, such as the temperature in the operating room, procedures for inserting and caring for catheters, and nursing care after surgery. It’s important for physicians and other members of the medical staff to understand system-wide outcomes—such as readmission and reoperation rates—and then try to understand what could be changed in the system to improve those rates.

AAOS Now: What kinds of tools can AAOS members obtain from The Joint Commission to improve patient safety?

Dr. Wise: A wide range of resources are available through The Joint Commission’s nonprofit affiliate, Joint Commission Resources. These resources include onsite consulting, accreditation manuals, books and e-books on a wide range of topics, and much more.

Another option is The Joint Commission Center for Transforming Healthcare. Its goal is to understand how healthcare organizations can establish and sustain solutions to these problems. The Center is a dynamic initiative involving many of the country’s top healthcare organizations that have come together to design solutions specific to problems in an individual healthcare organization. More information is available online, at

We encourage AAOS members and their healthcare organizations to take advantage of these resources to make continual improvements to patient safety.

Jennie McKee is a staff writer for AAOS Now. She can be reached at

Online tool can help improve hand hygiene
The Joint Commission Center for Transforming Healthcare recently developed the Targeted Solutions Tool™ (TST), an online, interactive application that provides a step-by-step process for measuring performance, identifying barriers to excellent performance, and implementing proven solutions. TST is available to all Joint Commission–accredited hospitals.

The first set of targeted solutions focus on improving hand hygiene. The improvement methods outlined in the complimentary, data-driven tool are aimed at increasing an organization’s hand hygiene compliance, thereby reducing the risk of healthcare-associated infections.

The TST also provides tips and guidance for sustaining a comprehensive improvement process. It will eventually include methods that address issues such as wrong site surgery, surgical site infections, and hand-off communications. Learn more at

Editor’s Note: Articles labeled Orthopaedic Risk Manager are presented by the Medical Liability Committee under the direction of contributing editor S. Jay Jayasankar, MD.

Articles are provided for general information and are not legal advice; for legal advice, consult a qualified

E-mail your comments to or contact this issue’s contributors directly.