On July 9, The Joint Commission (TJC) issued a sentinel event alert, Issue 40, describing behaviors that undermine a culture of safety. By raising this to a sentinel event alert level, make no mistake that the spotlight will shine brightly on this issue during your next visit from TJC. The sentinel event alert highlights the new leadership standard, LD.03.01.01, effective January 1, 2009, that requires two elements of performance:

1. EP 4: The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors
2. EP 5: Leaders create and implement a process for managing disruptive and inappropriate behaviors