Editor's note: Each installment of Joint Commission Standards will review a chapter of the Comprehensive Accreditation Manual for Hospitals and may be distributed to staff as a teaching tool needed for Meeting the Challenge of Constant Readiness.

The Leadership chapter focuses on the framework leaders provide in meeting the needs of patients and community through effective planning, directing, coordinating, and offering and improving care, treatment and services.

The chapter addresses governance and management, planning and providing services, staff development, organ procurement, improving safety and quality of care, and the use of clinical guidelines. Revisions to the chapter are in progress for 2008 and include reformatting the chapter into four sections.

1. Leadership Structure - identifying and defining various components of leadership and the responsibilities associated with those.

2. Leadership Relationships - dealing with the relationship between leaders, including combined accountabilities, conflict resolution, and development of hospital's mission, vision and goals.

3. Organizational Culture and System Performance Expectations - focusing on framework and expectations for culture and systems that support patient safety and quality care through performance improvement.

4. Operations - addressing the functions important to patient safety and quality care.

Effective Jan. 1, 2008

LD.3.110 Leaders implement policies and procedures developed with the medical staff's participation for procuring and donating organs and other tissues.

According to the May 2007 issue of "Joint Commission Online," Element of Performance (EP) 12 of this standard has been revised to clarify the requirements respecting the procurement and donation of organs and other tissues. While this element does not require the hospital to have a service that provides for asystolic recovery or donation after death, it does require the hospital have a policy that addresses its response to such opportunities. The policy must be jointly agreed upon by the hospital, medical staff and its organ procurement organization (OPO).

The joint agreement is the problematic area that brings about this revision. There are occurrences when the hospital and medical staff agree not to provide asystolic recovery because of lack of resources or end-of-life ethical and quality of care issues and its OPO is not in agreement with their decision. To address this issue, but following has been added to EP 12:

"When the hospital and its medical staff agree not to provide for asystolic recovery and cannot achieve agreement with the designated OPO, the hospital documents its efforts to reach an agreement with its designated OPO, and the donation policy addresses the hospital's justification for not providing for asystolic recovery."

During the remainder of 2007, if a hospital cannot reach agreement with its OPO, it will not be cited. However, a policy that has been agreed upon by hospital and medical staff is still required, as well as evidence of OPO involvement in discussion during policy development.

Avoiding the Pitfalls

LD.3.90 Leaders develop and implement policies and procedures for care, treatment and services.

Thirteen percent of the hospitals surveyed in 2006 were not compliant with this standard. Most leaders have little trouble developing policies; the difficulty is in the implementation. Leadership issues arise when surveyors identify trends or problems related to policy implementation. The key elements of effective leadership, planning, directing and coordinating are then scrutinized.

LD.3.60 Communication is effective throughout the hospital.

Effective communication is identified by the Joint Commission as a significant part of preventing serious medical error. Hospital leadership's responsibility is to ensure processes are in place for communicating relevant information throughout the hospital in a timely manner. Effective communication crosses multiple chapters of the standards manual.

In the National Patient Safety Goals section alone, effective communication is addressed through read-back of verbal or telephone orders and critical reports, elimination of ambiguous abbreviations, the timeliness of reporting test results, the standardization of hand-off communication, patient and family education in falls reduction, and in communicating their concerns related to safety and care.

LD.3.70 The leaders define the required qualifications and competence of those staff who provide care, treatment and services, and recommend a sufficient number of qualified and competent staff to provide care, treatment and services.

A single set of criteria must be used for all who provide care, treatment or services within the hospital setting. For instance, the competency criteria and frequency of assessment of a scrub technician employed by the hospital and that of a scrub technician brought in by the surgeon to assist are the same. The assessment may be done by the hospital or the surgeon, but the hospital must determine the qualification and competence required are equal.

Jean Kalemba was previously director of performance improvement at Mountainside Hospital, Montclair, NJ.