Applicable Joint Commission Standards

Standard LD.03.01.01
Rationale for LD.03.01.01

Leaders create and maintain a culture of safety and quality throughout the [organization]. Safety and quality thrive in an environment that supports teamwork and respect for other people, regardless of their position in the [organization]. Leaders demonstrate their commitment to quality and set expectations for those who work in the [organization]. Leaders evaluate the culture on a regular basis. Leaders encourage teamwork and create structures, processes, and programs that allow this positive culture to flourish. Disruptive behavior that intimidates others and affects morale or staff turnover can be harmful to [patient] care. Leaders must address disruptive behavior of individuals working at all levels of the [organization], including management, clinical and administrative staff, licensed independent practitioners, and governing body members.

Elements of Performance for LD.03.01.01

1. Leaders regularly evaluate the culture of safety and quality using valid and reliable tools.
2. Leaders prioritize and implement changes identified by the evaluation.
3. Leaders provide opportunities for all individuals who work in the hospital to participate in safety and quality initiatives.
4. The hospital has a code of conduct that defines acceptable, disruptive, and inappropriate behaviors.
5. Leaders create and implement a process for managing disruptive and inappropriate behaviors.
6. Leaders provide education that focuses on safety and quality for all individuals. (See also LD.04.04.05, EP 6)
7. Leaders establish a team approach among all staff at all levels.
8. All individuals who work in the hospital, including staff and licensed independent practitioners, are able to openly discuss issues of safety and
   quality.
9. Literature and advisories relevant to patient safety are available to all individuals who work in the hospital.
10. Leaders define how members of the population(s) served can help identify and manage issues of safety and quality within the hospital.

Medical Staff Standard
MS.4.00

Overview
Determining the competency of practitioners to provide high quality, safe patient care is one of the most important and difficult decisions an organization must make. The development and maintenance of a credible process to determine competency requires not only diligent data collection and evaluation, but also the actions by both the governing body and organized medical staff.

The credentialing and privileging process involves a series of activities designed to collect, verify, and evaluate data relevant to a practitioner’s professional performance. These activities serve as the foundation for objective, evidence-based decisions regarding appointment to membership on the medical staff, and recommendations to grant or deny initial and renewed privileges. In the course of the credentialing and privileging process, an overview of each applicant’s licensure, education, training, current competence, and physical ability to discharge patient care responsibilities is established.

Three new concepts are introduced in the revised credentialing and privileging standards. First, the revised credentialing and privileging standards have been informed throughout by the six areas of “General Competencies” developed by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Medical Specialties (ABMS) joint initiative. The areas of general competencies include the following:

• Patient Care
• Medical/Clinical Knowledge
• Practice-based Learning and Improvement
• Interpersonal and Communication Skills
• Professionalism
• Systems-based Practice.

Integrating these concepts into the standards allows the organized medical staff to expand to a more comprehensive evaluation of a practitioner’s professional practice.