Quality & Patient Safety

Revised Leadership ­standard LD.03.01.01

Briefings on Accreditation and Quality, April 1, 2012

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In 2009, The Joint Commission added Leadership standard LD.03.01.01, ”Leaders create and maintain a culture of safety and quality throughout the hospital,” to recognize that behavior that intimidates others and affects staff morale and turnover can also be damaging to patient care, and to require a formal process to manage unacceptable behavior in accredited hospitals. Elements of performance (EP) 4 and 5 of this standard contain language about ”acceptable, disruptive, and ­inappropriate behavior” of individuals working in healthcare organizations.

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