SDS Accreditation Update

Surgery managers must prepare for changes to Joint Commission leadership standards

Ambulatory surgery managers in hospitals, surgery centers, and offices face new requirements in 2009 under a revised chapter of leadership standards from The Joint Commission (TJC).

"The focus is on accountability for the quality and safety of care," says Sue Dill Calloway, MSN, JD, RN, director of hospital patient safety at OHIC Insurance Co./The Doctors Company, Columbus, OH.

Go through the standards individually to determine compliance, Calloway advises. "This might take a little more time than you thought, so I encourage the leadership team to get started right away," she says. (To access the standards, go to Under "Standards," click on "Pre-Publication Standards.")

This also will help prepare you for the leadership session that lasts about one hour.

Assess culture of safety

One of the biggest challenges for outpatient surgery managers will be the requirement to regularly assess the organization's culture of safety, says Maureen Carr, project director, Division of Standards and Survey Methods at TJC.

Offices and surgery centers are asked to assess the culture and take action on the results, she says. Hospital-based programs are required to use a validated tool for a regular assessment. Tools can include surveys or focus groups, for example, Carr says. The Agency for Healthcare Research and Quality has developed a free survey. (To access survey, go to

Focus on staff perceptions, Carr says. You can examine how often safety issues are reported within the organization, for example, she says.

Another challenge for all providers is complying with the leadership standards related to disruptive behavior, Carr says. This standard address this behavior by any staff person or board member, she emphasizes. "We're asking organizations to create a code of conduct on what is acceptable and unacceptable behavior, and a process for managing it," Carr says.

The code of conduct should stipulate that staff people speak with each other and behave in a manner that isn't threatening or intimidating, she says. It should explain acceptable and unacceptable behavior, says Calloway. "Facilities can't accept disruptive behavior anymore," she says. "There needs to be a process so if it occurs, I have a channel to report it to so the matter gets taken care of." Educate your staff on this code, Calloway advises.

More new requirements

Leaders will be required to communicate regarding issues of safety and quality, Carr says.

"They should be talking regularly about [performance improvement] activities, any reported safety incidents, solutions that they have come to on safety issues, issues that might be specific to specific populations they service, and input from those populations," she says.

The organization also must identify the kinds of knowledge and information that leaders need to function well. "For example, leaders must be oriented to the mission, safety and quality goals, the decision-making processes within the organization, how budgetary and financial issues are addressed, issues of their population served, and accountabilities of leaders within the organization," Carr explains.

The governing bodies must provide leaders with access to information and training in areas where they need skills and expertise. "That can be an in-house briefing," Carr says. "For example, a person may be unfamiliar with financial issues, and you may want to go over basic principles."