Leadership chapter changes: Defining top roles, relationships

CLICK to Email
CLICK for Print Version

As of January 1, 2009, a revised Leadership standards chapter takes effect, detailing requirements for hospital leadership to build a greater culture of safety and adopt a more active role in the quality of care provided at facilities, as well as the quality of relationships between staff members. Some might say these changes have been building for more than a decade.

In the mid-1990s, a shift happened in hospitals and the focus turned to patient safety, Richard A. Sheff, MD, CMSL, chair and executive director of The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, said during the August 6 audio conference, “The Joint Commission 2009 Leadership Standards: Prepare for Major Changes and New Responsibilities.”

That focus aimed to prevent patient harm, Sheff said. And The Joint Commission (formerly JCAHO) has recognized that leadership is key in this prevention.

The accrediting organization has gone so far as to regulate relationships between leaders—a move that seems unquantifiable and yet very necessary in today’s medical world.

“LD.2 is literally titled Leadership Relationships,” Sheff said. “This is a stunning idea, that we have to have performance standards for people to have a good relationship with each other. But we are facing so much conflict in healthcare—we are seeing open competition, hostility, and low trust.”

LD.4.40 requires the implementation of a patient safety program throughout the hospital.

“We’ve now realized that culture is critical and leadership is critical,” Sheff said. “This is why the latest version [of the leadership standards] has focused on culture and leadership. We need to collaborate or we are not going to meet the goals of patient-centered efficacy. It’s not just one doctor and one nurse, or one nurse and one pharmacist. Leadership needs to own communication throughout the organization. Culture drives behavior.”

What hasn’t changed, Sheff said, is that “the buck still stops with the board.” The board is the entity that is charged with the overall performance of the facility. The question is how to create effective leadership for management and for physician leaders on the medical staff.

“This is what The Joint Commission wants,” Sheff said. “Effective leadership, collaborative leadership. Coming together without a fight. We must find ways to work together, to play together in the same sandbox.”

A look at the standards

The revised standards bring requirements for structure to areas that have traditionally been seen as soft or not measurable.

“You’re going to see that the Leadership section is right out of organizational culture and system performance,” said Sue Dill Calloway, RN, MSN, JD, director of hospital risk management at OHIC Insurance Company, The Doctor’s Company, in Columbus, OH, who also spoke at the audio conference. “We’re talking about how we use data, communicate throughout our facility, how we change things when changes need to be made.”

The Leadership chapter requires that every organization has a structured leadership, and that the governing board is responsible for safety and quality of care.

Dill Calloway explained that leadership is essentially broken down into three tribes: the board, medical staff leadership, and senior management.

Leadership should be composed of individuals in senior leadership positions with clearly defined responsibilities, Dill Calloway said.

Most hospitals make use of an organizational chart to identify the lines of authority and provide leaders from all segments of the facility with a chance to have their voices heard.

Structuring the board

Various sections of the new chapter target specific components of the leadership structure. LD.1.20 focuses on the board.

“Put into writing what the board’s responsibilities are,” Dill Calloway said.

Bylaws for the board should establish that the board is responsible for policies and procedures, as well as maintaining quality and planning. Document the goals and scope of service in the facility and record minutes to demonstrate how this scope of services was approved.

Additional documentation to include:
  • Board minutes at the start of a new CEO’s tenure, showing how the CEO was selected
  • A statement that the medical staff has a right to be represented and heard at board meetings
  • Documentation of the board’s input on conflict management policies and processes

Look to LD.1.40 for direction on the CEO’s role. Most hospital executive boards select the facility’s CEO or president.

Dill Calloway recommends ensuring that the board’s minutes document the process of that selection.

According to the standards, the CEO should formulate and evaluate a recruitment and retention plan.

“Recruiting and retaining staff is not just the responsibility of human resources anymore,” Dill Calloway said.

The CEO should ensure that there is a nurse executive on the senior management team, remain involved with financial reports, and ensure that the information and support system is functioning.

Direction for the medical staff can be found in LD.1.50.

“You’ve got to have a single organized medical staff. It needs to be self-governing, and it needs governing principles,” Dill Calloway said. “The medical staff is always responsible to oversee staff with medical privileges.”

LD.1.70 spells out what knowledge leaders should have to do their jobs well.

“All leaders need to have certain knowledge to do their jobs,” Dill Calloway said.

This standard looks at accountability of leaders to support the mission of the hospital and provide high-quality care.

Element of performance 3 states that the board needs to provide leaders with access to information and training in areas where they will need additional skills or expertise.

“In order to demonstrate this goal, they need to define the body of knowledge that the board members will need, senior management will need, and medical staff leaders will need, and show that they’re being trained in these standards,” said Sheff.

Editor’s note: A complete recording of “The Joint Commission 2009 Leadership Standards: Prepare for Major Changes and New Responsibilities” is available online at

A follow-up presentation on implementation strategies for The Joint Commission’s Leadership standards will take place in January 2009.

New standard numbering

As of January 1, 2009, The Joint Commission’s standards will be renumbered in the Comprehensive Accreditation Manual for Hospitals and other manuals. The Leadership chapter’s changes include:

  • LD.1.10: Now under LD.01.01.01 (EP 2, 3), LD.01.03.01 (EP 4–6), and LD.01.04.01 (EP 1)
  • LD.1.20: Now under LD.01.03.01 (EP 1–7, 12), LD.02.04.01 (EP 12), and LD.03.02.01 (EP 7)

The Joint Commission has posted history tracking reports for these changes on its official Web site at