Comply with accreditation standards

The Compliance Guide to The Joint Commission Leadership Standards provides accreditation professionals with in-depth guidance on how to prepare leadership and staff to comply with the accreditor’s Leadership standards. The book breaks down the Leadership chapter standard by standard to train leaders and staff on the roles they play in compliance, patient safety, and quality efforts.

The Leadership chapter of The Joint Commission’s standards is organized into four key sections that support effective performance:

• Leadership structure, which identifies and defines the various leadership components and responsibilities. This section addresses how the hospital or hospital system is structured. Many hospitals include a board, the CEO and senior hospital leaders, and the organized medical staff. They need to work together to deliver safe and high-quality care. This section defines the responsibilities of hospital leaders.
• Leadership relations, which addresses the relationships among the three leadership groups and their combined accountabilities. This section looks at how well the leaders work together, including in conflict resolution and development of the hospital’s mission, vision, and goals.
• Hospital or organizational culture and system performance, which comprises much of what occurs during the leadership session of the unannounced survey process. This section mandates and recognizes that leaders shape the organization’s culture. Culture dramatically affects how things are done in the hospital or healthcare system. It reflects the beliefs, attitudes, and priorities of the staff. In a culture of safety, everyone focuses on maintaining excellence in performance. The leadership structure has five pillars as its foundation: data use, planning, communication, changing performance (change), and people (staffing). Recognizing its importance, the standards in the hospital culture and system performance section focus on the framework and expectations of the hospital’s culture and systems. These serve as the pillars on which many processes, such as medication management, are based. If a high fall rate is detected, then the hospital needs to create a process or structure to reduce the fall rate. A proactive risk assessment can help with this process, and it can also help analyze a new process before it is implemented. This section looks at whether the hospital has these kinds of systems—including a non-punitive approach and a systems approach—in place.
• Operations, which looks at how the organization is run. Certain functions are particularly important to ensuring high-quality care and patient safety, and even leaders who are not involved in the day-to-day operations of the hospital make decisions that affect how the hospital operates. For example, leaders who are involved in drafting and implementing policies and procedures have a direct impact on patient safety. This section addresses those issues as well as the requirements for budgets, accountability of department directors, conflicts of interest, denial of care, ethical principles, contract management, patient flow, the patient safety program, quality assessment and performance improvement (QAPI), and clinical practice guidelines.

To learn more or order your copy, please click here.