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Clear organizational goals, effective data use help leaders comply with leadership standards


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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 3rd Annual Association for Healthcare Accreditation Professionals Conference, which took place May 14–15 in Las Vegas.

“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 organizationwide 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.

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.

Data management

Although only one standard specifically mentions data and information (LD.03.02.01), data are used to support the decision-making for many other standards affecting hospital leaders, such as process management.

“Our organizations get totally overwhelmed by data. … It’s very easy for us to get down into the details and forget the big picture,” said Rohde. He recommended that staff members help hospital leaders understand what data are illustrating for any process being discussed by focusing on the following concepts:

  • Magnitude. Is this too much or too little?
  • Direction. Are we getting better or worse?
  • Variability. Is this contained or out of control?
  • Rate of change. Is this changing rapidly or slowly?

Using such concepts will help organizations comply with LD.01.03.01, which makes the hospital’s governing body ultimately responsible for quality care and treatment. Rohde said not to send the governing board confusing data that may cause a knee-jerk reaction and, ultimately, not benefit the hospital.

Policies and procedures

LD.04.01.07 asks leaders to make sure the organization has policies and procedures that support patient care. Often, facilities get the definition of policies and procedures confused. Policies should be changed once every five or 10 years, said Rohde. They require commitment from many groups in the organization and represent a commitment to the outside world.

Procedures, on the other hand, should be separate from policies. They should be more fluid and able to be changed more regularly.

“Our problem is not that we don’t have them, our problem is that we can’t change them,” said Rohde. “If we can’t change them, people don’t follow them, and if people can’t follow them, we have noncompliance.” The existence of out-of-date procedures encourages staff members to create workarounds.

Culture of safety and organizational goals

The bulk of the standards in the leadership chapter have to do with helping staff members deliver the safest care (LD.01.07.01, 02.01.01, 02.03.01, 03.01.01, 03.04.01, 03.06.01, 04.04.05, and 02.04.01). This is done by ensuring that organizational goals, perhaps in the form of a mission statement or rallying cry, is not only clearly stated, but infused in everyday care. Rohde suggested publishing the organization’s strategic plan so that all staff members know their roles.

“People are interested in ‘Where do I fit into the mission, goals, and values?’ ” said Rohde. “Certainly, there is some risk with sharing your vision and strategy with every member of the organization, but isn’t it also a bigger risk that if people don’t know where they fit into that strategic plan that [the organization is] not going to achieve it because [staff members] don’t know what to do?”

Ensuring that a robust reporting system is available to staff members is important, as is illustrating to staff members that communication of safety issues is a two-way street.

Leaders must also set expectations for staff members. Rohde listed six expectations as a good starting point: attention to detail, effective handoffs, clear and direct communication, inquisitiveness, team work, and adherence to the rules.

Culture of safety is a buzzword in the industry, but its meaning is truly important, said Rohde. “It’s not just a culture of safety, it’s a culture of high reliability,” he said. “It has to be, ‘We believe in getting it right the first time and every time.’ ” Too often, staff members forget to associate the business effectiveness argument when trying to get leadership buy-in to the culture of safety.

“If you get it right the first time and every time, think about the reduction in the cost of poor quality,” said Rohde. “Take advantage of hooking the culture of safety into business survival and business effectiveness.”