We would like to take a moment and share with you what the Joint Commission is looking for from the Senior Leadership and Governing Body.
How are Senior Leaders preparing?
Under the new survey process by Joint Commission, leadership is now being held accountable for findings within the organization. If the organization receives one (1) Conditional finding in any chapter, Leadership will also receive a finding – therefore there will be two (2) Conditional findings instead of one.
It is imperative for Senior Leadership and the Governing Body to give thought to the below questions and potentially have organized responses for certain topics and potential findings within the organization to ensure that all staff are on the same page speaking the same language. Remember the overarching theme of the Leadership Chapter is assessing risks – proactively, so consider how you can include the risk assessments completed by your organization into the discussion.
We want to share some of the questions/topics that may be discussed during the Leadership session in order to assist with preparation for the session before the survey team arrives.
- What do we do to prevent harm situations like those in the ‘zero harm’ video?
- How does the Board set the tone, create the culture and engage team members – making safety the first priority of this organization?
- How long would it take for Senior Leadership and the Board to find out a harm event has occurred?
- How does the Medical Staff Office and Leadership adopt a standard of “safety excellence” and avoid a culture of “barely compliant”?
- How does Senior Leadership and the Board ensure the Medical Staff is engaged?
- Describe your culture of safety, high reliability journey and zero harm efforts?
- How does this organization handle intimidation, bad behavior or workplace violence?
- How does the organization empower front line staff to go against intimidation, bad behavior or workplace violence?
The quicker an organization considers these questions, the better prepared they will be for the survey when the team arrives. The expectation is that Leadership is leading the organization in all facets, including safety, harm prevention and a ‘just’ culture approach.