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Get survey ready for standard LD.2.20

Accreditation Connection, December 10, 2004

The standard LD.2.20 requires that an organization maintain effective leadership in every department, program, service, and site. During an on-site visit, expect surveyors to scrutinize your departments by looking for evidence of structure that supports the smooth operation of the departments. In a well-integrated hospital, your services fit together like pieces in a well-sewn quilt, and coordinate with one another to provide a continuum of care.

To comply with LD.2.20, it's especially important for the chief executive officer (CEO) to work with your management staff to establish the line of authority for the planning, management, operations, and evaluation at each service level.

Many hospitals have a written leadership plan, which shows administrative and clinical staff how the hospital's leadership is organized. This shows the clear lines of responsibility and accountability within and between the departments and administration. Your CEO, the board, and senior leadership should look at short-and long-term plans, hospital operations, and program efficiency and effectiveness. It's also important to have plans in place in the event a key leader, such as the vice president of patient care services retires. In this situation,

*  the hospital will be ready to post the position and will have a number of applicants lined up

*  the job description will contain information about the appropriate training and education requirements of the chief nursing position

*  this person's administrative and clinical direction will be well defined in both policy and job description, which specifies that the person must have a master's degree in nursing and five years' experience in a similar position

*  this person will go through an introductory period evaluation and an annual review process, which assesses whether the leader is indeed ensuring effective and efficient operations across the patient care services

For a comprehensive look at all of the leadership standards, get a copy of the HCPro book, "Leadership: Tools to Prepare Your Leaders for JCAHO Survey," by Sue Dill Calloway, RN, ESQ. on www.hcmarketplace.com.

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