You'll need more data, new skills for coming leadership standards

Collaboration is key to meeting requirements

The Joint Commission's new Leadership standards aren't effective until Jan. 1, 2009, but quality professionals will need to start preparing now to address new requirements for conflict management and disruptive behavior, skills required of leaders, communication among leaders, and creation of a culture of safety. A more explicit description of the role of medical staff leaders in addressing organization-wide issues also will be required.

"Play well with others" pretty much sums up The Joint Commission's new leadership standards, says Patrice Spath, RHIT, a health care quality specialist with Forest Grove, OR-based Brown-Spath & Associates. "While no one can deny that working together in a collegial manner is the right thing to do, achieving such an environment doesn't happen overnight — especially in those organizations with a long history of adversarial relationships among departments and disciplines," she says.

As a general rule, it takes three to seven years to change the culture of an organization, says Spath. "Organizations that haven't yet begun to meet the intent of the new leadership standards may find themselves behind the eight-ball two years from now," she says.

Safety is focus

Since the new Joint Commission Leadership Chapter focuses heavily on patient safety, safety issues will likely become the prominent focus of most performance improvement activities, says Nancy McLean, RN, BSN, MHSA, senior consultant at Courtemanche & Associates, a Charlotte, NC-based firm specializing in regulatory compliance.

"To meet this change in the standards, the quality professional, if not also functioning as the safety officer, will need to develop a strong collaborative relationship with the safety officer," says McLean.

By far, the biggest mistake people make when trying to change the organizational culture is to plunge ahead without establishing a high enough sense of urgency among all stakeholders, says Spath. "Don't overestimate how easy change will be, especially when changes may drive people out of their comfort zones," she says. "Meeting the new leadership standards will take more than holding a few meetings or sending out a few memos."

At University of Washington Medical Center in Seattle accountability for safety culture has already been integrated and defined with the governing board, senior leadership, and medical staff leadership, says Cindy Angiulo, MSN, RNC, assistant administrator of patient care services.

"In alignment with our patient- and family-centered care model at the medical center, we have also included patient and family advisors at this oversight level," says Angiulo.

On a regularly scheduled basis, formal multidisciplinary committees review performance improvement initiatives and outcomes, reported safety and quality issues, and oversight of key quality measures and safety indicators, adds Angiulo.

Quality professionals at Minneapolis-based Fairview Health Services are currently working to establish a policy for disruptive behavior that is consistent at all hospitals in the system, says Alison H. Page, MS, MHA, the organization's chief safety officer. Most of the hospitals already have policies addressing appropriate conduct and behavior expected of employees and medical staff.

"We have had policies in place to deal with disruptive behavior. We are doing more and I would like to see use of 'restorative justice' and 'just culture' principles," says Page. "We are moving to a better place on managing this issue, regardless of The Joint Commission."

Fairview's new policy underscores the connection between behavior and patient safety, and attempts to provide helpful details in terms of expected norms, says Page.

The organization also is working toward establishing policies and behavior expectations that prevent disruptive behavior from occurring in the first place, says Page. "For example, we are implementing team training, which focuses heavily on the need for respectful relationships amongst clinicians," says Page. "We believe patient safety and care quality are greatly enhanced when the organizational culture reflects healthy communication and professional, respectful behavior on the part of all practitioners."

New roles for quality

The new standards likely will place the quality professional in an investigative role in order to determine if a given conflict adversely affects quality and safety of care, says McLean.

"Governance, leadership, and the medical staff will need to determine who will be trained, or is already trained, in conflict management and will be given this responsibility," she says.

At first glance, the likely candidate for this role appears to be a behavioral health professional, but the standards state that the individual is charged with "protecting the safety and quality of care," notes McLean.

"Taken as a whole, the focus in the chapter is on safety and quality of care. The quality professional has long been the guardian of quality care," says McLean. "The additional responsibilities will slip easily into their current role."

Some additional training in conflict resolution may be required, but most quality professionals are already adept at this skill, and are aware of the importance of focusing on incidents and behaviors as opposed to individuals, says McLean.

The standards place a strong emphasis on collaborative relationships. "The proverbial three-legged stool model of hospital leadership, where each of the three major players — governance, leadership, and the medical staff — balance each other and carry equal influence, is being pushed to strong collaborative relationships with the new standards," says McLean.

The Leadership Relationships section focuses entirely on collaboration among governance, leaders, and the medical staff, adds McLean, with the goal of managing conflict between leadership groups to protect quality and safety of care.

"This is a forced collaboration, holding all three groups accountable for the priority focus of quality and safety of care," says McLean.

A few years ago, University of Washington Medical Center developed a professional collaboration policy for medical staff and physicians in training. The goal was to create an environment of professional collaboration that promotes communication, to improve clinical outcomes and patient safety. "It is this policy that identifies the accountability of medical staff to conduct themselves in a professional and cooperative manner," she says.

The policy also encourages prompt identification and resolution of alleged disrespectful or disruptive behavior. "Informal, collaborative efforts are used to restore a member's behavior to actions consistent with policies and professional standards," says Angiulo. The policy identifies a formal procedure for investigation and resolution, for cases in which behavior has not been appropriately modified by these informal efforts.

Your hospital's process should address whether records will be kept regarding any conflict resolution activities, says McLean. "In development of the process, remember to be sure to include all the requirements and be careful if you choose to put in additional requirements which are not required by The Joint Commission," she cautions.

Once any requirements appear in a policy or are a part of your process, you must follow these closely or risk getting a requirement for improvement for not following your own policy, warns McLean. "Once again, the quality professional is invaluable in helping to build the least restrictive process or policy that meets The Joint Commission standards," she says.

Data on conflicts

Quality professionals will need to gather data on how often interpersonal conflict and disruptive behaviors are occurring, says Spath. "Some hospitals have developed something like an incident report for these occurrences," she says.

You may also be involved in assisting the medical staff or hospital to develop definitions for conflicts and disruptive behaviors, adds Spath. She recommends taking these steps to prepare for the new Leadership requirements:

• Go through the standards and highlight all of the "must have" or "must do" requirements.

"Then, conduct a gap analysis," says Spath. "What do you already have in place? What still needs to be completed?"

• Identify the individuals or groups responsible for creating the new policies or performing the activities required by the leadership standards.

For instance, what department is responsible for coordinating the annual safety culture survey? What individuals/groups will review the survey results and determine how to respond to improvement opportunities?

• Define what constitutes a conflict or disruptive behavior that could affect safety and quality.

Conflict between people is a fact of life — and it's not necessarily a bad thing, says Spath. "However, it becomes a bad thing when it potentially interferes with the provision of quality patient care," she says.

Conduct that is often considered disruptive includes sexual harassment; shouting; using vulgar, profane or abusive language; and other forms of intimidating or abusive behavior, says Spath.

• Create a process for disclosing conflicts or disruptive behavior.

Determine how reports will be made, who will receive the reports, and how incidents will be investigated and resolved. Often, incidents involving physicians are reported to the chief of staff or department chief, and incidents involving hospital employees are reported to the CEO or a division senior leader.

"It should be clear how reports are investigated and what will be done if the physician or staff member has engaged in disruptive behavior," says Spath.

• Determine how you'll measure whether people are indeed "playing well" with one another.

"This is where the quality department plays an important role," says Spath. For example, the organization's leaders will need data that show whether the culture is changing for the better and if communication among caregivers has improved.

"Such information is not always easy to obtain. Start now to identify the measures of success," says Spath.

Some of these will be process measures, such as whether the conflict of interest policy is being followed as required. You will also need to identify outcome measures, such as the number of patient incidents attributed to communication breakdowns among the health care team.

"Measurement will need to continue for quite some time," says Spath. "Until changes sink down deeply into the culture, new approaches are fragile and subject to regression."

[For more information, contact:

Cindy Angiulo, MSN,RNC, Assistant Administrator, Patient Care Services, University of Washington Medical Center, 1959 NE Pacific, Seattle, WA 98195. Phone: (206) 598-4048. Fax: (206) 598-6576. E-mail:

Alison H. Page, MS, MHA, Chief Safety Officer, Fairview Health Services, 2450 Riverside Ave., Minneapolis, MN 55454. Phone: (612) 672-6396. Fax: (612) 672-6060. E-mail:

Nancy McLean, RN, BSN, MHSA, Senior Consultant, Courtemanche & Associates, PO Box 17127, Charlotte, NC 28227. Phone: (704) 573-4535. Fax: (704) 573-4538. E-mail:

Patrice L. Spath, BA, RHIT, Health Care Quality Specialist, Brown-Spath & Associates, P.O. Box 721, Forest Grove, OR 97116. Phone: (503) 357-9185. E-mail: Web:

The Texas Medical Association, Physician Health and Rehabilitation Committee has developed a model medical staff code of conduct policy, which is available on-line. The policy can be accessed at]