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Clear Organizational Goals and Effective Data Use Help Leaders Comply with Leadership Standards

Heather Comak, for HealthLeaders Media, June 17, 2009

Compliance with The Joint Commission's 2009 leadership standards requires an understanding of how intertwined the concepts are with a hospital's everyday activities.

"When we really think about it, the leadership things really form the foundation for everything else," said Ken Rohde, senior consultant for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, at the recent 3rd Annual Association for Healthcare Accreditation Professionals Conference.

"If you have weaknesses in your leadership area, it's going to manifest itself everywhere," said Rohde. Strong leadership in the hospital setting is imperative to not only surviving, but thriving in today's world of changing values, regulatory issues, and economic climate, he said.

The importance of focusing efforts

Staff members and departmental managers must show leaders what they need to focus on to stay in compliance with the standards. Providing leaders with the necessary tools and convincing them to lead by example will allow a hospital to provide high-quality care and keep in line with regulations.

High-reliability organizations strive for more than compliance with standards, said Rohde. They aim to deliver the highest-quality care to every patient. However, paying attention to certain topics will ensure compliance with the standards and force hospitals to put patient care and staff cooperation first and allow the organization to focus on its priorities.

Process management

There are some leadership standards (LD.03.05.01, 04.04.03) that deal specifically with process improvement or design. A few others call for prioritization of performance improvement activities (LD.04.04.01), program management (LD.04.01.05), and organization-wide planning (LD.03.03.01).

Rohde encouraged attendees to make a list of the processes that must be improved and, from that, create a top 10 list. It's important that there be only one list so every staff member in the hospital knows the organization's focus and does not spend time tending to other issues.

"Prioritization: If you don't do that, all we're doing is making a list of 200 number one priorities," said Rohde. It is the job of leadership to decide what should and, more importantly, should not go on the top 10 list.

"It's really easy for someone to waltz into your office and tell you another 10 things to add to the list, but it's hard to say, ‘I know we have risk here and that accreditors may be looking for this, but this is just not going to happen,'" Rohde said. A top 10 list can open up valuable communication about the organization's goals too.
Part of effective process management is change management, said Rohde. This shows that leaders have considered the directions that making a process change might take.

Read more of Ken's advice for compliance with the Leadership standards by visiting Briefings on Patient Safety on the HCPro Web site.


Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailing hcomak@hcpro.com.

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