The Leadership Session is typically held midway through the survey, lasting approximately 60 minutes. Currently, it is recommended that those who are responsible and accountable for process design and implementation be present. It is also highly recommended that the CEO, medical staff leadership, governing board members, and clinical staff be invited. During this session, surveyors aim to explore leadership's responsibilities related to systems, infrastructure, and processes that contribute to quality and safe patient care and treatment. It is important to remember that these surveyors have been walking through your building and speaking with staff, so they are likely to have some preconceived notions about the leadership of the organization.
While surveying throughout the United States, our team has been seeing a common thread. You have noticed it if you read Becker’s Hospital Reviews. Healthcare is ever changing, and so is the leadership of organizations. Many organizations have new leaders who may or may not be experienced, and they may face a survey soon after their arrival at the organization.
What will be talked about at the Leadership session?
Topics that the surveyors are likely to address at this session include, but are not limited to, the following:
- Planning process
- Data collection/methodology/communication of data/implementation of changes
- Patient safety and quality
- Antibiotic stewardship program
- Pain management
- Safety culture within the organization
- Code of conduct and behavior of physicians and staff
- Workplace violence
- Managing near misses, close calls, and actual errors
- Health care equity and the organization's efforts to reduce health care disparities.
Once the Leadership Session is over, surveyors use the information shared with them at this session to compile, analyze, and organize the data, which will then be reflected in your final report. Surveyors may also take this time to request additional information to ensure compliance with the standards.
Tips for leadership to consider when attending the Leadership Session with the surveyors.
- This is your time to SHINE as leaders. Take pride in your organization, its mission, and your staff. BRAG about the wonderful things you have and are doing in your organization.
- Do not forget that the surveyors have been out talking with your staff and making observations. Do not state that all is well, and that you communicate with your staff when they may impart a quite different perspective.
- This session is interactive. It should not be the CEO doing all the talking.
- Assign members of the leadership team topics to speak on. Ensure that you have several people who can speak on the same topic, as there may be times when your designated person is unavailable. Take the Joint Commission Survey Activity Guide and use the questions provided to practice. You can even write the answers to all the questions in the Leadership Session section and provide them to everyone invited to that session so that anyone there can speak on those topics if they are comfortable.
- What I see that works: The CEO initiates the discussion (response), then hands the discussion off to one of their “experts”. Fellow team members need to contribute to the discussion. The surveyor will be looking to see if there is a real dialogue. This relates to my previous comments on communication.
- Do not be afraid to discuss challenges with a topic, but make sure you discuss what actions you have taken/implemented and what actions you are planning to go forward.
- Watch body language; the surveyors surely will. No crossed arms! Make good eye contact. Lean forward as you respond. Pay attention to the discussion.
- Silence those cell phones! No sidebar discussions.
- Acknowledge opportunities the surveyor brings up. Do not make excuses. Follow the surveyor’s lead as to how to respond. Ensure that you clearly state your organization’s commitment to patient safety and outline how you will address this issue. Remember, surveyors have been all around the country and have seen the good, the bad, and the ugly. They have seen best practices in their travels, and therefore, it is important to consider their recommendations.
- Surveyors will want to hear how leaders view and perceive these successes and opportunities and learn what they are doing to sustain the achievements, as well as encourage and support more of the same success.
- Be sincere and genuine with responses. Surveyors know when you are not.
- Know your hot topics and major opportunities and be ready to discuss your actions to address them.
- Do not go into this session without practicing prior to the survey. This is the time for leadership to impress the surveyors.
Summary
It is leadership's time to shine and the team's time to brag. You know what you do every day to provide safe, quality care for your patients. Take this opportunity to share your journeys with the surveyors. Listen to the surveyor's thoughts, ideas, and recommendations, as they have seen a lot and are knowledgeable about how to improve in areas where you might be struggling.
References
2025 The Joint Commission, Hospital Survey Activity Guide.
For questions or to learn more contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.
