Quality & Patient Safety

Briefings on the Joint Commission, April 2012

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.

Effective July 1, the term ”disruptive behavior” in the glossary and in the two EPs in the Leadership standard will be revised to say ”behaviors that undermine a culture of safety.” The revision will be applicable to ambulatory care, behavioral healthcare, critical access hospitals, home care, hospitals, laboratories, long-term care, and office-based surgery accredited facilities, and will reflect a broader range of unacceptable behavior that healthcare facilities currently face.

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