2009 Joint Commission Leadership Standards

There is a separate chapter in The Joint Commission’s 2009 Comprehensive Accreditation Manual for Hospitals about leadership (LD). The LD standards affect all the individuals who are responsible for the overall governance of the hospital.

According to the glossary of the 2009 Hospital Accreditation Standards, the leader is “an individual who sets expectations, develops plans, and implements procedures to assess and improve the quality of the organization’s governance, management, and clinical and support functions and processes. At a minimum, leaders include members of the governing body and medical staff, the chief executive officer and other senior managers, the nurse executive, clinical leaders, and staff members in a leadership position within the organization.” This definition would include departmental/service leaders like directors/managers of clinical engineering, radiology, and the laboratory. The leader of the clinical engineering program in the hospital must be aware of the requirements in this chapter.

The leadership chapter is divided into four sections:

• Leadership Structure
• Leadership Relationships
• Hospital Culture and System Performance
• Leadership Operations

Leadership Structure

The standards in this section require a leadership structure that supports hospital operation and provision of care. It requires the hospital to identify the responsibilities of its leaders.

LD.01.03.01 states that the governing body is ultimately accountable for the safety and quality of care, treatment, and services provided in the hospital.

LD.01.04.01 outlines the responsibilities of the chief executive of the hospital.

LD.01.05.01 states that the medical staff is accountable to the governing body.

Leadership Relationships

The standards in this section require the leaders to work together and manage the conflicts that affect hospital performance. LD.02.01.01 requires that the mission, vision, and goals of the hospital support the safety and quality of care, treatment, and services. LD.02.01.01 EP3 calls upon the leaders to communicate the mission, vision, and goals to hospital staff and the patient population. The leader of the medical equipment management program should make sure that the medical equipment program supports the mission, vision, and goals of the hospital.

LD.02.03.01 states that the governing body, senior managers, and leaders of the organized medical staff regularly communicate with one another on issues of safety and quality. The leader of the medical equipment management program should participate in committees that involve safety, quality, and performance-improvement activities.

Hospital Culture and System Performance

LD.03.01.01 requires the leaders to create, maintain, and promote a culture of safety and quality in the hospital. This includes evaluating the culture of safety and quality using reliable methods; prioritizing changes identified during the evaluation; and providing education focusing on safety, quality, and other appropriate measures. The leader of the medical equipment program should implement measures that support and promote the culture of safety and quality with respect to medical equipment.

LD.03.02.01 requires the hospital to use data and information to make decisions and understand changes in the processes to sustain safety and quality. This would require that the medical equipment program performance indicators like use errors, repair rate, equipment-related incidents, and other indicators be used to monitor/measure the performance of the program. These indicators should be used to improve the safety and quality of the program.

LD.03.03.01 states that leaders use hospitalwide planning to establish structures and processes that focus on safety and quality.

LD.03.04.01 requires the hospital to communicate information related to safety and quality to the hospital staff, patients, and outside interested organizations.

LD.03.05.01 states that leaders implement changes in existing processes to improve the performance of the hospital.

LD.03.06.01 requires the hospital staff to focus on improving safety and quality.

Leadership Operations

LD.04.01.01 requires the hospital to be in compliance with applicable laws and regulations. For the leader of the clinical engineering program these will include Clinical Laboratory Improvement Amendments (CLIA) of 1988, Safe Medical Devices Act (SMDA) of 1990, federal medical device regulations, and state regulations—such as the California Code of Regulations and the Arizona Administrative Code, for example.

LD.04.01.05 requires that each department, service, or program have an effective leader who ensures that the program is managed properly and who holds the staff accountable for their responsibilities.

Read past ICC Prep and CCE Prep articles in the archives.

LD.04.01.11 requires the hospital to provide adequate space for care and service (such as adequate space for medical equipment service), equipment (such as medical and test equipment), and other resources.

LD.04.0.09 requires the leaders to monitor and manage contracted service, such as the management of outside medical equipment service contracts.

For detailed requirements, refer to The Joint Commission’s 2009 Comprehensive Accreditation Manual for Hospitals at www.jcrinc.com/Accreditation-Manuals/2009-CAMH-OFFICIAL-HANDBOOK/1377/.

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Arif Subhan, MS, CCE, is a senior clinical engineer, Masterplan, Chatsworth, Calif; adjunct assistant professor, biomedical engineering, University of Connecticut; and a member of 24×7’s editorial advisory board. For more information, contact .