Catalog Number : ncd1150
Title : The Joint Commission Leadership Standards
Speaker : Sue Dill

Webplay Recording Date : 9-14-2015
Webplay Price : $ 150 for two weeks viewing

Webinar Purpose:

This webinar will discuss the Joint Commission leadership standards. Contract management is a center of focus during the survey process. Many of the changes were to align with the CMS hospital CoP changes. There were also changes to the telemedicine law and standards. Each standard will be discussed with emphasis on the most problematic standards. There will be a discussion of a crosswalk to the CMS Hospital Conditions of Participation.

Webinar Objectives:

• Discuss that the Leadership Standards have a section requiring the hospital to have a conflict of interest policy
• Recall that policies and procedures and code of conduct are required on behavior that undermines a culture of safety (disruptive behavior)
• Describe that there are new changes to the patient flow standards in both 2013 and 2014
• Explain the undesirable effects of behavior that undermines a culture of safety can have on healthcare such as decreased morale and staff turnover
• Recall that there are standards on contract management

Target Audience:

Joint Commission Coordinator, Regulatory Affairs Officer, Ethics Committee, Social Workers, Consumer Advocates or Compliant Manager, Interpreting Services Director, Quality Improvement Coordinator, Board Members, CEO, CNO, CMO, COO, Nurses, Nurse Managers/Supervisors, Department Directors, Nurse Educators, PI Director, PI Staff, Compliance Officer Consumer Advocates, Risk Managers, Hospital Legal Counsel, Outpatient Director Patient Safety Officer, Marketing Director, Those involved in contract Management, ED Staff and those involved in patient flow

Here are a few of the topics that will be covered:

• Leadership Chapter
• Introduction
• Leadership structure
• Leadership responsibilities
• Board responsibility for quality and safety
• CEO management of hospital
• Medical Staff (MS) accountability to board
• Board, managers, and MS leaders have knowledge needed for their roles
• Mission, vision and goals support quality and patient safety
• Working together to meet mission, vision, and goals
• Conflict of interest
• Conflict of interest policy required
• Communication between Board, MS leaders, and senior managers
• Conflict management skills training
• Organizational culture and system performance
• Five key systems that influence performance; using data, planning, communicating, changing performance, and staffing
• Leaders create culture of safety and quality throughout hospital
• Code of conduct required and make new changes
• Disruptive behavior standard and requirements and now referred to as behavior that undermines a culture of safety
• Making literature available to staff
• Using data to guide decisions and look for opportunities for improvement
• Hospital wide planning to focus on quality and safety
• Hospital to provide accurate information on safety and quality
• Leaders implement change to improve hospital performance
• Staffing and staff need skills to provide good care to patients
• Operations issues
• Compliance with all laws
• Utilization Review plan
• Annual operating budget
• Policies and procedures guide and support patient care (hot problematic standard)
• Address conflicts of interest
• Ethical principles guide hospital’s business practice
• Needs of patients guide discharge or transfer policies
• Patient flow standard changes in 2013 and 2014
• Same level of care
• Space and equipment is available
• Contract services and monitoring
• Leaders set priorities for PI
• Implementing a patient safety program
• Revised patient flow tracer

Full tuition is refunded immediately on request if the participant has not been sent the program materials and instructions. Once the instructions (including access codes) have been sent, a full refund will be issued only after the program runs and it is verified that the participant did not access the program.