Revisions to the Leadership Chapter Standards

Accreditation Monthly, October 7, 2005


Dear Colleague,

Organizations have until Friday, October 14 to submit online comments to JCAHO on proposed revisions to the Leadership chapter standards. If approved by the JCAHO Board of Commissioners in 2006, the new standards would take effect in January 2007.

The proposed revisions are posted currently for field review on the JCAHO website and may be accessed by visiting

I for one believe the new standards are well written and long overdue. In the revisions the JCAHO raises the "leadership accountability bar" for six elements of safety and quality, including:

  • culture, which involves assessment and education, among other things
  • data use to improve safety
  • planning processes that focus on quality
  • communication of important safety information
  • changing performance and sustaining the gain
  • people, which involves having the skills necessary to provide safe care

Most hospitals already focus heavily on patient safety and quality, but these new JCAHO standards would specify that leadership of the organization be the principle force driving, measuring, and continuously improving the effort. For instance, gone will be the day that responsibility for safety and quality rested solely with one or two professionals in the Quality or Performance Improvement department.

The standards are clear in defining leadership to include the three components of the "three-legged stool"-governance, medical staff, and management-all working and leading collaboratively in pursuit of patient safety and quality.

A new expectation to cultivate and maintain a culture of safety has been added to the chapter along with increased emphasis on moving toward a "systems" approach to anticipate and prevent human errors and harm to the patient. The proposed standards and elements of performance speak to the importance of achieving "Sustained Process Execution - Five Steps to Performing the Right Thing Well," as outlined in my Accreditation Monthly article last month on the topic of wrong patient, wrong procedure, or wrong site errors in surgery.

To review, the Five Steps are:

  1. Design the process well to prevent error and harm to the patient.
  2. Teach the process design to all applicable staff.
  3. Validate their competency.
  4. Adequately measure staff conformance to the process design.
  5. If you detect undesired variation, intervene to investigate the cause of the variation, such as a flaw in the process or a need to ensure staff is held accountable to perform the process as designed.

    If leadership is persistent in applying each of the Five Steps, the organization is on the path to Sustained Process Execution and I can assure you that each of your management metrics-patient satisfaction, error rates, risk management incidents, profitability, employee satisfaction, core measure compliance, average length of stay and resource use, complication rates, etc.-not to mention JCAHO Continuous Readiness status-will begin to trend in the right direction.


    John Rosing
    Practice Director of Accreditation
    and Regulatory Compliance
    The Greeley Company

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