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CE Article: 2009 Leadership standards make patient safety a priority*

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Joint Commission calls on leaders to create and measure a culture of safety

After reading this article, you will be able to:

  • Identify updates to The Joint Commission's (formerly JCAHO) 2009 Leadership standards
  • Describe the results of the Agency for Healthcare Research and Quality's (AHRQ) 2008 Hospital Survey on Patient Safety Culture
  • Recall strategies for creating a culture of patient safety

Beginning in a few short weeks, The Joint Commission will expect nurse managers and other hospital leaders at accredited facilities to take patient safety a little more seriously. The Leadership (LD) standards, which have been updated for 2009, make clear that leadership teams are ultimately responsible for the safety of their patients—and they can now be surveyed on the topic.

"Part of the reason the Leadership standards have been modified as they have is to raise the priority of patient safety and to say it is the responsibility of leadership," says Richard A. Sheff, MD, CMSL, chair and executive director of The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.

The changes to this section of the Comprehensive Assessment Manual for Hospitals are a natural progression of what The Joint Commission has been talking about for years, says Larry Poniatowski, RN, BSN, CSHA, principal consultant for accreditation compliance services at The University HealthSystem Consortium in Oak Brook, IL. Poniatowski worked in The Joint Commission's Standards Interpretation Group for 12 years.

"It's kind of an evolution of the language. The Joint Commission for a number of years has said that senior leadership truly are responsible for what goes on in the organization," says Poniatowski. The 2009 standards are more detailed and set out specific responsibility requirements.

Create a culture of safety

The most notable addition to these standards is the inclusion of language about creating a culture of safety. Leaders are required to create and maintain a culture of safety as part of LD.3.10. To understand how to do this, it's necessary to define culture, Sheff says.

"Culture drives behavior, and behavior drives results," he says. "Is culture what we truly believe, our value statement, or how we behave? In truth, it's all three, but the most powerful part is how we behave." Because behavior is something learned and repeated every day, it is difficult to change. However, he says, it can be done.

As part of LD.3.10, leaders will be responsible for measuring the culture of their facility.
There are public domain surveys that can facilitate this process; the best-known is probably the Agency for Healthcare Research and Quality's (AHRQ) Hospital Survey on Patient Safety Culture. Read a summary of AHRQ's Hospital Survey on Patient Safety Culture 2008 Comparative Database Report.

"One of the requirements is [hospitals] need to measure culture using valid and reliable tools—that's a culture survey," says Jay King, founder of The Patient Safety Group and brother-in-law of Sorrel King, whose daughter Josie died as a baby from a medical error. The Kings have dedicated their lives to the prevention of medical errors. "The King family has been touting culture almost from the get-go: communication, the feel within a unit—whether it's frenzied or stressed—and the way a doctor talks to a nurse. You can sense these things when you're a patient, and we as patients feel they have a dramatic impact on outcomes," King says.

The Patient Safety Group strives to help organizations build and measure their cultures of safety. It offers two main tools to hospitals, one of which is the administration of AHRQ's culture survey. The Patient Safety Group will collect and analyze the data that a hospital collects from the survey and benchmark those data against other facilities.

As part of LD.3.10, along with measuring the organization's culture of safety, facilities will be required to make changes within the organization based on the results of those measurements.

"You have to say 'Oh look, we're strong on those areas and weak in those areas. What are we going to do to fix it?' " says Sheff. "The important part is then remeasuring, which is part of all performance improvement initiatives." Read more about LD standards and how nurse managers can improve safety by managing patient flow.

Prevent disruptive behavior

Another facet The Joint Commission has added to creating a culture of safety is the requirement that hospitals have a code of conduct that outlines how to manage disruptive staff behavior.

Disruptive behavior can not only make a hospital an unwelcoming environment for staff members, but can also affect patient safety, says Sheff.

"Physicians who intimidate and demean fellow workers undermine the culture of teamwork," he says. This type of behavior makes staff members less likely to "stop the line" or engage in questioning behavior, because they don't want to be reprimanded. There's also a lack of peer coaching and peer checking, which is a vital part of error prevention, Sheff adds.

Poniatowski notes that although the common conception of disruptive behavior may conjure up images of staff members screaming or throwing things at one another, disruptive behavior can also be a simple lack of cooperation.

"There's typically that passive-aggressive, uncooperative behavior," says Poniatowski. "For example, if I'm supposed to participate in the final timeout and I refuse to be in the room and cooperate, that disrupts the surgical procedure."

In its July 9 Sentinel Event Alert on disruptive behaviors, The Joint Commission suggested hospital leaders take the following actions to prevent these behaviors among staff members:

  • Provide education and training for healthcare providers about professional behavior and appropriate interactions with coworkers
  • Create accountability for maintaining appropriate behavior
  • Establish a zero-tolerance policy for disruptive behaviors and a means for enforcing this policy
  • Craft nonconfrontational methods for reporting and addressing inappropriate behavior

Many of these recommendations are a part of the 2009 Leadership standards. Read more about this Sentinel Event Alert. 

Additional standards hot spots

Another key area within the updated Leadership standards that facilities should pay close attention to is LD.1.30, which explicitly states that the governing body is accountable for safety and quality of care.

"Business as usual for leaders of the hospital is not good enough under these new standards," says Sheff. "It says, 'The buck stops here.' "

Also, LD.2.40 discusses the management of conflict between leadership groups to uphold high standards of care. By adding this to the Leadership standards, The Joint Commission is acknowledging that creating a culture of safety may cause some internal disagreements, Poniatowski says. "The Joint Commission recognized that moving toward a culture of safety and quality is going to probably engender some conflict," he says. This standard requires a mechanism for dealing with that conflict.

Avoid creating confusing policies

Many facilities fall into the trap of creating complicated policies and procedures to handle various hospital processes, says Sheff. This can hinder not only creating a culture of safety, but also keeping patients safe.

"The way that processes are designed is critical, because if you design your processes in a way that is overly complex, no one is going to be able to follow them," says Sheff.

Sheff says in his consulting work with The Greeley Company, all too often, a hospital staff member has created a policy that technically meets a standard but is so complicated that instead of following the policy, staff members create work-arounds to get the job done more efficiently. However, doing this can put patient safety in jeopardy.

"Management and leadership need to constantly work at simplifying processes, not just to meet a standard, but to find the right way to give good patient care and run a good hospital-and let regulatory compliance be a byproduct," says Sheff.

King says he is glad The Joint Commission has modified the Leadership standards, adding that it is a big step in making the culture of safety a priority.

"The Joint Commission now leaning heavily on more culture requirements is terrific," King says. "I don't want to see hospitals get overregulated, but I do think that this could have a big impact."

Ultimately, these changes are showing another commitment to patient safety, says Sheff.

"The message that everyone needs to take to heart is that patient safety is not just about meeting the patient safety goals, it's about leadership proactively evaluating, measuring, and managing culture to achieve high patient safety and high reliability," he says.


1. Agency for Healthcare Research and Quality. (2008). "Executive summary on the Hospital Survey on Patient Safety Culture." Available at

2. The Institute for Healthcare Improvement. (2004). "Leadership standard on managing patient flow." The Available at

3. The Joint Commission. (2008). "Behaviors that undermine a culture of safety." Available at

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