Effective Date: January 9, 2017 Overview: The safety and quality of care, treatment, and services depend on many factors, including the following: - A culture that fosters safety as a priority for everyone who works in the hospital - The planning and provision of services that meet the needs of patients - The availability of resources human, financial, and physical for providing care, treatment, and services - The existence of competent staff and other care providers - Ongoing evaluation of and improvement in performance Management of these important functions is the direct responsibility of leaders; they are, in effect, responsible for the care, treatment and services that the hospital provides to its patients. In hospitals with a governing body, governance has ultimate responsibility for this oversight. In larger hospitals, different individuals or groups may be assigned different responsibilities, and they bring with them different skills, experience and perspectives. In these situations, the way that the leaders interact with each other and manage their assigned accountabilities can affect overall hospital performance. In smaller hospitals, these responsibilities may be handled by just one or two individuals. This chapter addresses the role of leaders in managing these diverse and, at times complex, responsibilities. Leaders shape the hospital s culture, and the culture, in turn, affects how the hospital accomplishes its work. A healthy, thriving culture is built around the hospital s mission and vision, which reflect the core values and principles that the hospital finds important. Leaders must ask some basic questions in order to provide this focus: How does the hospital plan to meet the needs of its population(s)? By what ethical standards will the hospital operate? What does the hospital want to accomplish through its work? Once leaders answer these questions, the culture of the hospital will begin to take shape. Leaders also have an obligation to set an example of how to work together to fulfill the hospital s mission. By dedicating themselves to upholding the values and principles of the hospital s mission, leaders will be modeling to others how to collaborate, communicate, solve problems, manage conflict, and maintain ethical standards, essential practices that contribute to safe health care. On a more practical level, leaders oversee operations and guide the hospital on a day-to-day basis. They keep operations running smoothly so that the important work of the hospital serving its population can continue. To meet their obligations effectively, leaders must collaborate, which means working together in a spirit of collegiality to achieve a common end. Many hospitals have three leadership groups the senior managers, governing body, and organized medical staff who work together to deliver safe, high quality care. The senior managers direct the day-to-day operations of the hospital; the governing body determines what resources the hospitals needs and then secures those resources. The members of the organized medical staff are licensed to make independent decisions about the diagnosis and treatment of their patients and, in doing so, influence the choice and use of many of the hospital s resources. Proactive Risk Assessment: By undertaking a proactive risk assessment, a hospital can correct process problems and reduce the likelihood of experiencing adverse events. A hospital can use a proactive risk assessment to evaluate a process to see how it could fail, to understand the consequences of such a failure, and to identify parts of the process that need improvement. The term process applies broadly to clinical procedures, such as surgery, as well as processes that are integral to patient care, such as medication administration. The processes that have the greatest potential for affecting patient safety should be the primary focus for risk assessments. Proactive risk assessments are also useful for analyzing new processes before they are implemented. Processes need to be designed with a focus on quality and reliability to achieve desired outcomes and protect patients. A hospital s choice of which process it will assess may be based in part on information published periodically by The Joint Commission about frequently occurring sentinel events and processes that pose high risk to patients. A proactive risk assessment increases understanding within the organization about the complexities of process design and management and what could happen if the process fails. If an adverse event occurs, the organization may be able to use the information gained from the prior risk assessment to minimize the consequences of the event and to avoid simply reacting to them. Although there are several methods that could be used to conduct a proactive risk assessment, the following steps make up one approach: 1. Describe the chosen process (for example, through the use of a flowchart). 2. Identify ways in which the process could break down or fail to perform its desired function, which are often referred to as failure modes. 3. Identify the possible effects that a breakdown or failure of the process could have on patients and the seriousness of the possible effects. 4. Prioritize the potential process breakdowns or failures. 5. Determine why the prioritized breakdowns or failures could occur, which may involve performing a hypothetical root cause analysis. Page 1 of 47
6. Design or redesign the process and/or underlying systems to minimize the risk of the effects on patients. 7. Test and implement the newly designed or redesigned process. 8. Monitor the effectiveness of the newly designed or redesigned process. About This Chapter: This chapter is divided into four sections: "Leadership Structure," "Leadership Relationships," "Hospital Culture and System Performance Expectations," and "Operations." The hospital s culture, systems, and leadership structure and relationships all come together to shape and drive its operations. The standards in the "Leadership Structure" section identify and define the various leadership groups and their responsibilities. The standards in "Leadership Relationships" address not only relationships, which include the leaders combined accountabilities, but also communication among leaders, conflict management and the development of the hospital s mission, vision, and goals. The standards in the "Hospital Culture and System Performance Expectations" section focus on the framework for the hospital s culture and systems. These standards also demonstrate how leaders help shape the culture of a hospital and how culture, in turn, affects important systems within the hospital (for example, data use, planning, communication, changing performance, staffing). The standards in the "Operations" section address the functions that are important to patient safety and high-quality care, treatment, and services. Some leaders may not be directly involved in the day-to-day operations of the hospital, but the decisions they make and the initiatives they implement do affect operations. Chapter Outline: I. Leadership Structure A. Leadership Structure (LD.01.01.01) B. Leadership Responsibilities (LD.01.02.01) C. Governance Accountabilities (LD.01.03.01) D. The Chief Executive Responsibilities (LD.01.04.01) E. Medical Staff Accountabilities (LD.01.05.01) II. Leadership Relationships A. Mission, Vision, and Goals (LD.02.01.01) B. Conflict of Interest Among Leaders (LD.02.02.01) C. Conflict Management (LD.02.04.01) III. Organization Culture and System Performance Expectations A. Culture of Safety and Quality (LD.03.01.01) B. Using Data and Information (LD.03.02.01) C. Organizationwide Planning (LD.03.03.01) D. Communication (LD.03.04.01) E. Change Management and Performance Improvement (LD.03.05.01) F. Staffing (LD.03.06.01) IV. Operations A. Administration (LD.04.01.01, LD.04.01.03, LD.04.01.05, LD.04.01.06, LD.04.01.07, LD.04.01.11) B. Ethical Issues (LD.04.02.01, LD.04.02.03, LD.04.02.05) C. Meeting Patient Needs (LD.04.03.01, LD.04.03.07, LD.04.03.09, LD.04.03.11) D. Managing Safety and Quality (LD.04.04.01, LD.04.04.03, LD.04.04.05, LD.04.04.07) Icon Legend: CMS CMS Crosswalk D Documentation is required EP applies to Early Survey Option NEW EP is new or changed as of the selected effective date. Page 2 of 47
LD.01.01.01: The hospital has a leadership structure. Rationale: Every hospital has a leadership structure to support operations and the provision of care. In many hospitals this structure is formed by three leadership groups: the governing body, senior managers, and the organized medical staff. In some hospitals there may be two leadership groups, and in others only one. Individual leaders may participate in more than one group. Introduction: Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.05.01 Each hospital, regardless of its complexity, has a structured leadership. The leadership structure may consist of distinct groups, or leaders may act as a whole. Individual leaders may participate in more than one group and may have several different roles. A leadership group is composed of individuals in senior positions with clearly defined, unique responsibilities. These groups might include governance, management, and medical staff and clinical staff. Not every hospital will have all of these groups, and an individual may be a member of more than one group. Many leadership responsibilities directly affect the provision of care, treatment, and services, as well as the day-to-day operations of the hospital. In some cases, these responsibilities will be shared among leadership groups, and in other cases, a particular leader or leadership group has primary responsibility. Regardless of the hospital s structure, it is important that leaders carry out all their responsibilities. A variety of individuals may work in the hospital, including licensed independent practitioners, staff, volunteers, students, and independent contractors. These standards describe the overall responsibility of the governing body for the safety and quality of care, treatment, and services provided by all of these individuals. In hospitals, the organized medical staff is responsible for overseeing the quality of care provided by individuals with privileges. The structure of the organized medical staff and its responsibilities are covered in the Medical Staff (MS) chapter. How well leaders work together is key to effective hospital performance, and the standards emphasize this. Leaders from different groups governance, senior management, and the organized medical staff bring different skills, experiences, and perspectives to the hospital. Working together means that leaders from all groups have the opportunity to participate in discussions and have their opinions heard. Depending on the topic and the hospital, individuals from different leadership groups may participate in decision making, and the governing body may delegate decision making to certain leadership groups. Final decisions, however, are always the ultimate responsibility of the governing body; this key principle is assumed in any standard that describes how leaders work together. 1 The hospital identifies those responsible for governance. 482.12 2 The governing body identifies those responsible for planning, management, and operational activities. 482.12(d)(7)(ii) 482.12 3 The governing body identifies those responsible for the provision of care, treatment, and services. (See also NR.01.01.01, EP 3) 482.22 Page 3 of 47
LD.01.02.01: The hospital identifies the responsibilities of its leaders. Rationale: Many responsibilities may be shared by all leaders. Others are assigned by the governing body to senior managers and the leaders of the organized medical staff. Hospital performance depends on how well the leaders work together to carry out these responsibilities. Introduction: Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.05.01 Each hospital, regardless of its complexity, has a structured leadership. The leadership structure may consist of distinct groups, or leaders may act as a whole. Individual leaders may participate in more than one group and may have several different roles. A leadership group is composed of individuals in senior positions with clearly defined, unique responsibilities. These groups might include governance, management, and medical staff and clinical staff. Not every hospital will have all of these groups, and an individual may be a member of more than one group. Many leadership responsibilities directly affect the provision of care, treatment, and services, as well as the day-to-day operations of the hospital. In some cases, these responsibilities will be shared among leadership groups, and in other cases, a particular leader or leadership group has primary responsibility. Regardless of the hospital s structure, it is important that leaders carry out all their responsibilities. A variety of individuals may work in the hospital, including licensed independent practitioners, staff, volunteers, students, and independent contractors. These standards describe the overall responsibility of the governing body for the safety and quality of care, treatment, and services provided by all of these individuals. In hospitals, the organized medical staff is responsible for overseeing the quality of care provided by individuals with privileges. The structure of the organized medical staff and its responsibilities are covered in the Medical Staff (MS) chapter. How well leaders work together is key to effective hospital performance, and the standards emphasize this. Leaders from different groups governance, senior management, and the organized medical staff bring different skills, experiences, and perspectives to the hospital. Working together means that leaders from all groups have the opportunity to participate in discussions and have their opinions heard. Depending on the topic and the hospital, individuals from different leadership groups may participate in decision making, and the governing body may delegate decision making to certain leadership groups. Final decisions, however, are always the ultimate responsibility of the governing body; this key principle is assumed in any standard that describes how leaders work together. 1 Senior managers and leaders of the organized medical staff work with the governing body to define their shared and unique responsibilities and accountabilities. (See also NR.01.01.01, EP 3) LD.01.03.01: The governing body is ultimately accountable for the safety and quality of care, treatment, and services. Rationale: The governing body s ultimate responsibility for safety and quality derives from its legal responsibility and operational authority for hospital performance. In this context, the governing body provides for internal structures and resources, including staff, that support safety and quality. Introduction: Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.05.01 Each hospital, regardless of its complexity, has a structured leadership. The leadership structure may consist of distinct groups, or leaders may act as a whole. Individual leaders may participate in more than one group and may have several different roles. A leadership group is composed of individuals in senior positions with clearly defined, unique responsibilities. These groups might include governance, management, and medical staff and clinical staff. Not every hospital will have all of these groups, and an individual may be a member of more than one group. Page 4 of 47
Many leadership responsibilities directly affect the provision of care, treatment, and services, as well as the day-to-day operations of the hospital. In some cases, these responsibilities will be shared among leadership groups, and in other cases, a particular leader or leadership group has primary responsibility. Regardless of the hospital s structure, it is important that leaders carry out all their responsibilities. A variety of individuals may work in the hospital, including licensed independent practitioners, staff, volunteers, students, and independent contractors. These standards describe the overall responsibility of the governing body for the safety and quality of care, treatment, and services provided by all of these individuals. In hospitals, the organized medical staff is responsible for overseeing the quality of care provided by individuals with privileges. The structure of the organized medical staff and its responsibilities are covered in the Medical Staff (MS) chapter. How well leaders work together is key to effective hospital performance, and the standards emphasize this. Leaders from different groups governance, senior management, and the organized medical staff bring different skills, experiences, and perspectives to the hospital. Working together means that leaders from all groups have the opportunity to participate in discussions and have their opinions heard. Depending on the topic and the hospital, individuals from different leadership groups may participate in decision making, and the governing body may delegate decision making to certain leadership groups. Final decisions, however, are always the ultimate responsibility of the governing body; this key principle is assumed in any standard that describes how leaders work together. 1 The governing body defines in writing its responsibilities. 482.12 D 2 The governing body provides for organization management and planning. 482.12(d)(7)(i) 482.12 3 The governing body approves the hospital's written scope of services. (See also PC.01.01.01, EP 7) Note: For hospitals that use Joint Commission accreditation for deemed status purposes: If emergency services are provided at the hospital, the hospital complies with the requirements of 42 CFR 482.55. For more information on 42 CFR 482.55, refer to the "Medicare Requirements for Hospitals" appendix. 482.12(f)(1) 482.26 482.27(a)(2) 482.51(a) 482.52 482.52(a) 482.52(b) 482.53(a) 482.54 482.55 482.56 482.56(a) 482.57(a) 482.54 482.53 482.53 D 4 The governing body selects the chief executive responsible for managing the hospital. Page 5 of 47
482.12(b) 5 The governing body provides for the resources needed to maintain safe, quality care, treatment, and services. (See also NR.01.01.01, EP 3) 482.12(e)(1) 482.52(b) 482.53(a) 482.53(c) 482.54 482.55 482.56(a) 482.57(a) 482.21(e)(1) 482.54 482.53 482.53 6 The governing body works with the senior managers and leaders of the organized medical staff to annually evaluate the hospital s performance in relation to its mission, vision, and goals. 482.21(e)(1) 8 The governing body provides the organized medical staff with the opportunity to participate in governance. 482.12(d)(7)(ii) 482.12(a)(10) 9 The governing body provides the organized medical staff with the opportunity to be represented at governing body meetings (through attendance and voice) by one or more of its members, as selected by the organized medical staff. 482.12(a)(10) 10 Organized medical staff members are eligible for full membership in the hospital s governing body, unless legally prohibited. 482.12(a)(10) Page 6 of 47
LD.01.04.01: A chief executive manages the hospital. Rationale: Not applicable. Introduction: Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.05.01 Each hospital, regardless of its complexity, has a structured leadership. The leadership structure may consist of distinct groups, or leaders may act as a whole. Individual leaders may participate in more than one group and may have several different roles. A leadership group is composed of individuals in senior positions with clearly defined, unique responsibilities. These groups might include governance, management, and medical staff and clinical staff. Not every hospital will have all of these groups, and an individual may be a member of more than one group. Many leadership responsibilities directly affect the provision of care, treatment, and services, as well as the day-to-day operations of the hospital. In some cases, these responsibilities will be shared among leadership groups, and in other cases, a particular leader or leadership group has primary responsibility. Regardless of the hospital s structure, it is important that leaders carry out all their responsibilities. A variety of individuals may work in the hospital, including licensed independent practitioners, staff, volunteers, students, and independent contractors. These standards describe the overall responsibility of the governing body for the safety and quality of care, treatment, and services provided by all of these individuals. In hospitals, the organized medical staff is responsible for overseeing the quality of care provided by individuals with privileges. The structure of the organized medical staff and its responsibilities are covered in the Medical Staff (MS) chapter. How well leaders work together is key to effective hospital performance, and the standards emphasize this. Leaders from different groups governance, senior management, and the organized medical staff bring different skills, experiences, and perspectives to the hospital. Working together means that leaders from all groups have the opportunity to participate in discussions and have their opinions heard. Depending on the topic and the hospital, individuals from different leadership groups may participate in decision making, and the governing body may delegate decision making to certain leadership groups. Final decisions, however, are always the ultimate responsibility of the governing body; this key principle is assumed in any standard that describes how leaders work together. 1 The chief executive provides for the following: Information and support systems. 3 The chief executive provides for the following: Physical and financial assets. 5 The chief executive identifies a nurse leader at the executive level who participates in decision making. (See also NR.01.01.01, EP 3 for specific nurse leader responsibilities) Page 7 of 47
LD.01.05.01: The hospital has an organized medical staff that is accountable to the governing body. Rationale: Not applicable. Introduction: Introduction to Leadership Structure, Standards LD.01.01.01 Through LD.01.05.01 Each hospital, regardless of its complexity, has a structured leadership. The leadership structure may consist of distinct groups, or leaders may act as a whole. Individual leaders may participate in more than one group and may have several different roles. A leadership group is composed of individuals in senior positions with clearly defined, unique responsibilities. These groups might include governance, management, and medical staff and clinical staff. Not every hospital will have all of these groups, and an individual may be a member of more than one group. Many leadership responsibilities directly affect the provision of care, treatment, and services, as well as the day-to-day operations of the hospital. In some cases, these responsibilities will be shared among leadership groups, and in other cases, a particular leader or leadership group has primary responsibility. Regardless of the hospital s structure, it is important that leaders carry out all their responsibilities. A variety of individuals may work in the hospital, including licensed independent practitioners, staff, volunteers, students, and independent contractors. These standards describe the overall responsibility of the governing body for the safety and quality of care, treatment, and services provided by all of these individuals. In hospitals, the organized medical staff is responsible for overseeing the quality of care provided by individuals with privileges. The structure of the organized medical staff and its responsibilities are covered in the Medical Staff (MS) chapter. How well leaders work together is key to effective hospital performance, and the standards emphasize this. Leaders from different groups governance, senior management, and the organized medical staff bring different skills, experiences, and perspectives to the hospital. Working together means that leaders from all groups have the opportunity to participate in discussions and have their opinions heard. Depending on the topic and the hospital, individuals from different leadership groups may participate in decision making, and the governing body may delegate decision making to certain leadership groups. Final decisions, however, are always the ultimate responsibility of the governing body; this key principle is assumed in any standard that describes how leaders work together. 1 For hospitals that do not use Joint Commission accreditation for deemed status purposes: There is a single organized medical staff unless criteria are met for an exception to the single medical staff requirements. (Refer to the introduction to MS.01.01.01) 2 The organized medical staff is self governing. (Refer to the bulleted list describing self governance in the Overview to the "Medical Staff" [MS] chapter.) 4 The governing body approves the structure of the organized medical staff. 482.22(b) 482.22(b)(1) 6 The organized medical staff is accountable to the governing body. Page 8 of 47
482.12(a)(5) 482.22(b) 482.22 LD.02.01.01: The mission, vision, and goals of the hospital support the safety and quality of care, treatment, and services. Rationale: The primary responsibility of leaders is to provide for the safety and quality of care, treatment, and services. The purpose of the hospital s mission, vision, and goals is to define how the hospital will achieve safety and quality. The leaders are more likely to be aligned with the mission, vision, and goals when they create them together. The common purpose of the hospital is most likely achieved when it is understood by all who work in or are served by the hospital. Introduction: Introduction to Leadership Relationships, Standards LD.02.01.01 Through LD.02.04.01 How well leaders work together and manage conflict affects a hospital s performance. In fulfilling its role, the governing body involves senior managers and leaders of the organized medical staff in governance and management functions. Good relationships thrive when leaders work together to develop the mission, vision, and goals of the hospital; encourage honest and open communication; and address conflicts of interest. 1 The governing body, senior managers, and leaders of the organized medical staff work together to create the hospital s mission, vision, and goals. 2 The hospital's mission, vision, and goals guide the actions of leaders. 3 Leaders communicate the mission, vision, and goals to staff and the population(s) the hospital serves. Page 9 of 47
LD.02.02.01: The governing body, senior managers and leaders of the organized medical staff address any conflict of interest involving leaders that affect or could affect the safety or quality of care, treatment and services. Note: This standard addresses conflict of interest involving individual members of leadership groups. For conflicts of interest among staff and licensed independent practitioners who are not members of leadership groups, see Standard LD.04.02.01. Rationale: Conflicts of interest can occur in many circumstances and may involve professional or business relationships. Leaders create policies that provide for the oversight and control of these situations. Together, leaders address actual and potential conflicts of interest that could interfere with the hospital s responsibility to the community it serves. Introduction: Introduction to Leadership Relationships, Standards LD.02.01.01 Through LD.02.04.01 How well leaders work together and manage conflict affects a hospital s performance. In fulfilling its role, the governing body involves senior managers and leaders of the organized medical staff in governance and management functions. Good relationships thrive when leaders work together to develop the mission, vision, and goals of the hospital; encourage honest and open communication; and address conflicts of interest. 1 The governing body, senior managers, and leaders of the organized medical staff work together to define in writing conflicts of interest involving leaders that could affect safety and quality of care, treatment, and services. D 2 The governing body, senior managers, and leaders of the organized medical staff work together to develop a written policy that defines how conflict of interest involving leaders will be addressed. D 3 Conflicts of interest involving leaders are disclosed as defined by the hospital. LD.02.04.01: The hospital manages conflict between leadership groups to protect the quality and safety of care. Rationale: Not applicable. Introduction: Introduction to Leadership Relationships, Standards LD.02.01.01 Through LD.02.04.01 How well leaders work together and manage conflict affects a hospital s performance. In fulfilling its role, the governing body involves senior managers and leaders of the organized medical staff in governance and management functions. Good relationships thrive when leaders work together to develop the mission, vision, and goals of the hospital; encourage honest and open Page 10 of 47
communication; and address conflicts of interest. 1 Senior managers and leaders of the organized medical staff work with the governing body to develop an ongoing process for managing conflict among leadership groups. 5 The hospital implements the process when a conflict arises that, if not managed, could adversely affect patient safety or quality of care. LD.03.01.01: Leaders create and maintain a culture of safety and quality throughout the hospital. Rationale: Safety and quality thrive in an environment that supports teamwork and respect for other people, regardless of their position in the hospital. Leaders demonstrate their commitment to quality and set expectations for those who work in the hospital. Leaders evaluate the culture on a regular basis. Leaders encourage teamwork and create structures, processes, and programs that allow this positive culture to flourish. Behavior that intimidates others and affects morale or staff turnover undermines a culture of safety and can be harmful to patient care. Leaders must address such behavior in individuals working at all levels of the hospital, including management, clinical and administrative staff, licensed independent practitioners, and governing body members. Introduction: Introduction to Hospital Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01 A hospital s culture reflects the beliefs, attitudes, and priorities of its members, and it influences the effectiveness of performance. Although there may be a dominant culture, in many larger hospitals diverse cultures exist that may or may not share the same values. In fact, diverse cultures can exist even in smaller hospitals. Hospital performance can be effective in either case. Successful hospitals will work to develop a culture of safety and quality. In a culture of safety and quality, all individuals are focused on maintaining excellence in performance. They accept the safety and quality of patient care, treatment, and services as personal responsibilities and work together to minimize any harm that might result from unsafe or poor quality of care, treatment, and services. Leaders create this culture by demonstrating their commitment to safety and quality and by taking actions to achieve the desired state. In a culture of this kind, one finds teamwork, open discussions of concerns about safety and quality, and the encouragement of and reward for internal and external reporting of safety and quality issues. The focus of attention is on the performance of systems and processes instead of the individual, although reckless behavior and a blatant disregard for safety are not tolerated. Hospitals are committed to ongoing learning and have the flexibility to accommodate changes in technology, science, and the environment. The leaders provide for the effective functioning of the hospital with a focus on safety and quality. Leaders plan, support, and implement key systems critical to this effort. The Joint Commission has identified five key systems that influence the effective performance of a hospital: 1. Using data 2. Planning 3. Communicating 4. Changing performance 5. Staffing The following diagram illustrates the role of leadership in the performance of these systems. Page 11 of 47
Leadership provides the foundation for effective performance. The five key systems serve as pillars that are based on the foundation set by leadership and, in turn, support the many hospitalwide processes (such as medication management) that are important to individual care, treatment, and services. Culture permeates the entire structure. The five key systems are interrelated and need to function well together. The integration of these systems throughout the hospital will facilitate the effective performance of the hospital as a whole. Leaders develop a vision and goals for the performance of these systems and evaluate their performance. Leaders use results to develop strategies for future improvements. Performance of many aspects of these systems may be directly observable. But in many cases hospitals demonstrate compliance through performance in standards located in other sections of this manual. These Leadership standards are cited when patterns of performance suggest hospitalwide issues. The effective performance of these systems results in a culture in which safety and quality are priorities. The hospital demonstrates this through a proactive, nonpunitive culture that is monitored and sustained by related reporting systems and improvement initiatives. Many of the concepts in the following section have long existed in the standards. They are consistent with and complementary to many existing approaches to improvement, such as the Baldrige criteria and Six Sigma. 1 Leaders regularly evaluate the culture of safety and quality using valid and reliable tools. 2 Leaders prioritize and implement changes identified by the evaluation. Page 12 of 47
482.21(b)(2)(ii) 4 Leaders develop a code of conduct that defines acceptable behavior and behaviors that undermine a culture of safety. D 5 Leaders create and implement a process for managing behaviors that undermine a culture of safety. LD.03.02.01: The hospital uses data and information to guide decisions and to understand variation in the performance of processes supporting safety and quality. Rationale: Data help hospitals make the right decisions. When decisions are supported by data, hospitals are more likely to move in directions that help them achieve their goals. Successful hospitals measure and analyze their performance. When data are analyzed and turned into information, this process helps hospitals see patterns and trends and understand the reasons for their performance. Many types of data are used to evaluate performance, including data on outcomes of care, performance on safety and quality initiatives, patient satisfaction, process variation, and staff perceptions. Introduction: Introduction to Hospital Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01 A hospital s culture reflects the beliefs, attitudes, and priorities of its members, and it influences the effectiveness of performance. Although there may be a dominant culture, in many larger hospitals diverse cultures exist that may or may not share the same values. In fact, diverse cultures can exist even in smaller hospitals. Hospital performance can be effective in either case. Successful hospitals will work to develop a culture of safety and quality. In a culture of safety and quality, all individuals are focused on maintaining excellence in performance. They accept the safety and quality of patient care, treatment, and services as personal responsibilities and work together to minimize any harm that might result from unsafe or poor quality of care, treatment, and services. Leaders create this culture by demonstrating their commitment to safety and quality and by taking actions to achieve the desired state. In a culture of this kind, one finds teamwork, open discussions of concerns about safety and quality, and the encouragement of and reward for internal and external reporting of safety and quality issues. The focus of attention is on the performance of systems and processes instead of the individual, although reckless behavior and a blatant disregard for safety are not tolerated. Hospitals are committed to ongoing learning and have the flexibility to accommodate changes in technology, science, and the environment. The leaders provide for the effective functioning of the hospital with a focus on safety and quality. Leaders plan, support, and implement key systems critical to this effort. The Joint Commission has identified five key systems that influence the effective performance of a hospital: 1. Using data 2. Planning 3. Communicating 4. Changing performance 5. Staffing The following diagram illustrates the role of leadership in the performance of these systems. Page 13 of 47
Leadership provides the foundation for effective performance. The five key systems serve as pillars that are based on the foundation set by leadership and, in turn, support the many hospitalwide processes (such as medication management) that are important to individual care, treatment, and services. Culture permeates the entire structure. The five key systems are interrelated and need to function well together. The integration of these systems throughout the hospital will facilitate the effective performance of the hospital as a whole. Leaders develop a vision and goals for the performance of these systems and evaluate their performance. Leaders use results to develop strategies for future improvements. Performance of many aspects of these systems may be directly observable. But in many cases hospitals demonstrate compliance through performance in standards located in other sections of this manual. These Leadership standards are cited when patterns of performance suggest hospitalwide issues. The effective performance of these systems results in a culture in which safety and quality are priorities. The hospital demonstrates this through a proactive, nonpunitive culture that is monitored and sustained by related reporting systems and improvement initiatives. Many of the concepts in the following section have long existed in the standards. They are consistent with and complementary to many existing approaches to improvement, such as the Baldrige criteria and Six Sigma. 1 Leaders set expectations for using data and information to improve the safety and quality of care, treatment, and services. 482.21(b)(2)(i) 482.21 482.21(a)(1) 482.21(b)(1) 482.12(a)(10) Page 14 of 47
3 The hospital uses processes to support systematic data and information use. 482.21(b)(1) 4 Leaders provide the resources needed for data and information use, including staff, equipment, and information systems. 482.21(e)(4) 482.21(b)(1) 5 The hospital uses data and information in decision making that supports the safety and quality of care, treatment, and services. (See also NR.02.01.01, EPs 3 and 6; PI.02.01.01, EP 8) 482.21(b)(2)(i) 482.21(b)(1) 6 The hospital uses data and information to identify and respond to internal and external changes in the environment. 482.21(b)(1) 7 Leaders evaluate how effectively data and information are used throughout the hospital. 482.21(b)(1) LD.03.03.01: Leaders use hospitalwide planning to establish structures and processes that focus on safety and quality. Rationale: Planning is essential to the following: - The achievement of short- and long-term goals - Meeting the challenge of external changes - The design of services and work processes - The creation of communication channels - The improvement of performance - The introduction of innovation Planning includes contributions from the populations served, from those who work for the hospital, and from other interested groups or Page 15 of 47
individuals. Introduction: Introduction to Hospital Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01 A hospital s culture reflects the beliefs, attitudes, and priorities of its members, and it influences the effectiveness of performance. Although there may be a dominant culture, in many larger hospitals diverse cultures exist that may or may not share the same values. In fact, diverse cultures can exist even in smaller hospitals. Hospital performance can be effective in either case. Successful hospitals will work to develop a culture of safety and quality. In a culture of safety and quality, all individuals are focused on maintaining excellence in performance. They accept the safety and quality of patient care, treatment, and services as personal responsibilities and work together to minimize any harm that might result from unsafe or poor quality of care, treatment, and services. Leaders create this culture by demonstrating their commitment to safety and quality and by taking actions to achieve the desired state. In a culture of this kind, one finds teamwork, open discussions of concerns about safety and quality, and the encouragement of and reward for internal and external reporting of safety and quality issues. The focus of attention is on the performance of systems and processes instead of the individual, although reckless behavior and a blatant disregard for safety are not tolerated. Hospitals are committed to ongoing learning and have the flexibility to accommodate changes in technology, science, and the environment. The leaders provide for the effective functioning of the hospital with a focus on safety and quality. Leaders plan, support, and implement key systems critical to this effort. The Joint Commission has identified five key systems that influence the effective performance of a hospital: 1. Using data 2. Planning 3. Communicating 4. Changing performance 5. Staffing The following diagram illustrates the role of leadership in the performance of these systems. Leadership provides the foundation for effective performance. The five key systems serve as pillars that are based on the foundation set by leadership and, in turn, support the many hospitalwide processes (such as medication management) that are important to individual care, treatment, and services. Culture permeates the entire structure. The five key systems are interrelated and need to function well together. The integration of these systems throughout the hospital will facilitate the effective performance of the hospital as a whole. Leaders develop a vision and goals for the performance of these systems and evaluate their performance. Leaders use results to develop strategies for future improvements. Performance of many aspects of these systems may be directly observable. But in many cases hospitals demonstrate compliance through Page 16 of 47
performance in standards located in other sections of this manual. These Leadership standards are cited when patterns of performance suggest hospitalwide issues. The effective performance of these systems results in a culture in which safety and quality are priorities. The hospital demonstrates this through a proactive, nonpunitive culture that is monitored and sustained by related reporting systems and improvement initiatives. Many of the concepts in the following section have long existed in the standards. They are consistent with and complementary to many existing approaches to improvement, such as the Baldrige criteria and Six Sigma. 1 Planning activities focus on improving patient safety and health care quality. 482.62(g)(1) 3 Planning is systematic, and it involves designated individuals and information sources. 482.62(g)(1) 4 Leaders provide the resources needed to support the safety and quality of care, treatment, and services. 5 Safety and quality planning is hospitalwide. 6 Planning activities adapt to changes in the environment. 7 Leaders evaluate the effectiveness of planning activities. 482.12(a)(10) Page 17 of 47
LD.03.04.01: The hospital communicates information related to safety and quality to those who need it, including staff, licensed independent practitioners, patients, families, and external interested parties. Rationale: Effective communication is essential among individuals and groups within the hospital, and between the hospital and external parties. Poor communication often contributes to adverse events and can compromise safety and quality of care, treatment, and services. Effective communication is timely, accurate, and usable by the audience. Introduction: Introduction to Hospital Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01 A hospital s culture reflects the beliefs, attitudes, and priorities of its members, and it influences the effectiveness of performance. Although there may be a dominant culture, in many larger hospitals diverse cultures exist that may or may not share the same values. In fact, diverse cultures can exist even in smaller hospitals. Hospital performance can be effective in either case. Successful hospitals will work to develop a culture of safety and quality. In a culture of safety and quality, all individuals are focused on maintaining excellence in performance. They accept the safety and quality of patient care, treatment, and services as personal responsibilities and work together to minimize any harm that might result from unsafe or poor quality of care, treatment, and services. Leaders create this culture by demonstrating their commitment to safety and quality and by taking actions to achieve the desired state. In a culture of this kind, one finds teamwork, open discussions of concerns about safety and quality, and the encouragement of and reward for internal and external reporting of safety and quality issues. The focus of attention is on the performance of systems and processes instead of the individual, although reckless behavior and a blatant disregard for safety are not tolerated. Hospitals are committed to ongoing learning and have the flexibility to accommodate changes in technology, science, and the environment. The leaders provide for the effective functioning of the hospital with a focus on safety and quality. Leaders plan, support, and implement key systems critical to this effort. The Joint Commission has identified five key systems that influence the effective performance of a hospital: 1. Using data 2. Planning 3. Communicating 4. Changing performance 5. Staffing The following diagram illustrates the role of leadership in the performance of these systems. Page 18 of 47
Leadership provides the foundation for effective performance. The five key systems serve as pillars that are based on the foundation set by leadership and, in turn, support the many hospitalwide processes (such as medication management) that are important to individual care, treatment, and services. Culture permeates the entire structure. The five key systems are interrelated and need to function well together. The integration of these systems throughout the hospital will facilitate the effective performance of the hospital as a whole. Leaders develop a vision and goals for the performance of these systems and evaluate their performance. Leaders use results to develop strategies for future improvements. Performance of many aspects of these systems may be directly observable. But in many cases hospitals demonstrate compliance through performance in standards located in other sections of this manual. These Leadership standards are cited when patterns of performance suggest hospitalwide issues. The effective performance of these systems results in a culture in which safety and quality are priorities. The hospital demonstrates this through a proactive, nonpunitive culture that is monitored and sustained by related reporting systems and improvement initiatives. Many of the concepts in the following section have long existed in the standards. They are consistent with and complementary to many existing approaches to improvement, such as the Baldrige criteria and Six Sigma. 1 Communication processes foster the safety of the patient and the quality of care. 3 Communication is designed to meet the needs of internal and external users. Page 19 of 47
4 Leaders provide the resources required for communication, based on the needs of patients, the community, physicians, staff, and management. 5 Communication supports safety and quality throughout the hospital. (See also LD.04.04.05, EPs 6 and 12) 6 When changes in the environment occur, the hospital communicates those changes effectively. 7 Leaders evaluate the effectiveness of communication methods. LD.03.05.01: Leaders implement changes in existing processes to improve the performance of the hospital. Rationale: Change is inevitable, and agile hospitals are able to manage change and rapidly execute new plans. The ability of leaders to manage change is necessary for performance improvement, for successful innovation, and to meet environmental challenges. The hospital integrates change into all relevant processes so that its effectiveness can be sustained, assessed, and measured. Introduction: Introduction to Hospital Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01 A hospital s culture reflects the beliefs, attitudes, and priorities of its members, and it influences the effectiveness of performance. Although there may be a dominant culture, in many larger hospitals diverse cultures exist that may or may not share the same values. In fact, diverse cultures can exist even in smaller hospitals. Hospital performance can be effective in either case. Successful hospitals will work to develop a culture of safety and quality. In a culture of safety and quality, all individuals are focused on maintaining excellence in performance. They accept the safety and quality of patient care, treatment, and services as personal responsibilities and work together to minimize any harm that might result from unsafe or poor quality of care, treatment, and services. Leaders create this culture by demonstrating their commitment to safety and quality and by taking actions to achieve the desired state. In a culture of this kind, one finds teamwork, open discussions of concerns about safety and quality, and the encouragement of and reward for internal and external reporting of safety and quality issues. The focus of attention is on the performance of systems and processes instead of the individual, although reckless behavior and a blatant disregard for safety are not tolerated. Hospitals are committed to ongoing learning and have the flexibility to accommodate changes in technology, science, and the environment. Page 20 of 47
The leaders provide for the effective functioning of the hospital with a focus on safety and quality. Leaders plan, support, and implement key systems critical to this effort. The Joint Commission has identified five key systems that influence the effective performance of a hospital: 1. Using data 2. Planning 3. Communicating 4. Changing performance 5. Staffing The following diagram illustrates the role of leadership in the performance of these systems. Leadership provides the foundation for effective performance. The five key systems serve as pillars that are based on the foundation set by leadership and, in turn, support the many hospitalwide processes (such as medication management) that are important to individual care, treatment, and services. Culture permeates the entire structure. The five key systems are interrelated and need to function well together. The integration of these systems throughout the hospital will facilitate the effective performance of the hospital as a whole. Leaders develop a vision and goals for the performance of these systems and evaluate their performance. Leaders use results to develop strategies for future improvements. Performance of many aspects of these systems may be directly observable. But in many cases hospitals demonstrate compliance through performance in standards located in other sections of this manual. These Leadership standards are cited when patterns of performance suggest hospitalwide issues. The effective performance of these systems results in a culture in which safety and quality are priorities. The hospital demonstrates this through a proactive, nonpunitive culture that is monitored and sustained by related reporting systems and improvement initiatives. Many of the concepts in the following section have long existed in the standards. They are consistent with and complementary to many existing approaches to improvement, such as the Baldrige criteria and Six Sigma. 1 Structures for managing change and performance improvements exist that foster the safety of the patient and the quality of care, treatment, and services. Page 21 of 47
482.21 482.21(a)(1) 482.21(d)(1) 482.12(a)(10) 3 The hospital has a systematic approach to change and performance improvement. 482.21(d) 482.21 482.21(a)(1) 482.21(d)(1) 482.21(e)(1) 4 Leaders provide the resources required for performance improvement and change management, including sufficient staff, access to information, and training. 482.21(e)(4) 482.21(d)(1) 482.21(e)(1) 5 The management of change and performance improvement supports both safety and quality throughout the hospital. 482.21 482.21(a)(1) 6 The hospital's internal structures can adapt to changes in the environment. 7 Leaders evaluate the effectiveness of processes for the management of change and performance improvement. (See also PI.02.01.01, EP 13) 482.21 482.21(a)(1) 482.21(c)(3) 482.21(e)(2) 482.12(a)(10) Page 22 of 47
LD.03.06.01: Those who work in the hospital are focused on improving safety and quality. Rationale: The safety and quality of care, treatment, and services are highly dependent on the people who work in the hospital. The mission, scope, and complexity of services define the design of work processes and the skills and number of individuals needed. In a successful hospital, work processes and the environment make safety and quality paramount. This standard, therefore, applies to all those who work in or for the hospital, including staff and licensed independent practitioners. Introduction: Introduction to Hospital Culture and System Performance Expectations, Standards LD.03.01.01 Through LD.03.06.01 A hospital s culture reflects the beliefs, attitudes, and priorities of its members, and it influences the effectiveness of performance. Although there may be a dominant culture, in many larger hospitals diverse cultures exist that may or may not share the same values. In fact, diverse cultures can exist even in smaller hospitals. Hospital performance can be effective in either case. Successful hospitals will work to develop a culture of safety and quality. In a culture of safety and quality, all individuals are focused on maintaining excellence in performance. They accept the safety and quality of patient care, treatment, and services as personal responsibilities and work together to minimize any harm that might result from unsafe or poor quality of care, treatment, and services. Leaders create this culture by demonstrating their commitment to safety and quality and by taking actions to achieve the desired state. In a culture of this kind, one finds teamwork, open discussions of concerns about safety and quality, and the encouragement of and reward for internal and external reporting of safety and quality issues. The focus of attention is on the performance of systems and processes instead of the individual, although reckless behavior and a blatant disregard for safety are not tolerated. Hospitals are committed to ongoing learning and have the flexibility to accommodate changes in technology, science, and the environment. The leaders provide for the effective functioning of the hospital with a focus on safety and quality. Leaders plan, support, and implement key systems critical to this effort. The Joint Commission has identified five key systems that influence the effective performance of a hospital: 1. Using data 2. Planning 3. Communicating 4. Changing performance 5. Staffing The following diagram illustrates the role of leadership in the performance of these systems. Page 23 of 47
Leadership provides the foundation for effective performance. The five key systems serve as pillars that are based on the foundation set by leadership and, in turn, support the many hospitalwide processes (such as medication management) that are important to individual care, treatment, and services. Culture permeates the entire structure. The five key systems are interrelated and need to function well together. The integration of these systems throughout the hospital will facilitate the effective performance of the hospital as a whole. Leaders develop a vision and goals for the performance of these systems and evaluate their performance. Leaders use results to develop strategies for future improvements. Performance of many aspects of these systems may be directly observable. But in many cases hospitals demonstrate compliance through performance in standards located in other sections of this manual. These Leadership standards are cited when patterns of performance suggest hospitalwide issues. The effective performance of these systems results in a culture in which safety and quality are priorities. The hospital demonstrates this through a proactive, nonpunitive culture that is monitored and sustained by related reporting systems and improvement initiatives. Many of the concepts in the following section have long existed in the standards. They are consistent with and complementary to many existing approaches to improvement, such as the Baldrige criteria and Six Sigma. 1 Leaders design work processes to focus individuals on safety and quality issues. 483.15(g)(2) 482.58(b)(5) 3 Leaders provide for a sufficient number and mix of individuals to support safe, quality care, treatment, and services. (See also IC.01.01.01, EP 3) Note: The number and mix of individuals is appropriate to the scope and complexity of the services offered. Page 24 of 47