LD.03.01.01: Leadership evaluation of culture of safety

Accreditation Connection, January 23, 2009

Q. The new leadership standard LD.03.01.01 says leaders regularly evaluate the culture of safety and quality using valid and reliable tools. If we are due for survey in 2009, when must we complete our first evaluation, and what does The Joint Commission mean by the term “regularly”? Also, how do you determine whether a tool is valid and reliable?

A. The standard becomes effective January 1, 2009; therefore, using the usual Joint Commission practice for evaluating track records, you would need to accomplish your first evaluation sometime after the effective date on January 1, 2009.

Normally, The Joint Commission (formerly JCAHO) publishes a new standard, you learn about it, you develop the necessary implementation effort, and the official start date against which you are evaluated is the effective date.

For example, if a new standard starts January 1, 2009, and you are surveyed in May 2009, you would have four-plus months of track records for the new standard. However, I recently received an e-mail from a hospital that had asked this same question of The Joint Commission’s Standards Interpretation Group, and its official response was that the first evaluation should be completed by January 2009.

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