PREPARING FOR THE LEADERSHIP SESSION
This session is usually scheduled for the last day of your survey or if you have made
arrangements with the survey team to move it to accommodate senior leaders schedules it
may be done somewhat earlier. Your surveyors will be reluctant to move it too early
because they really need to make some observations first.
The primary focus of attention should be the concept of high reliability. While this
subject is not discussed in the standards, the Joint Commission has posted many articles,
video’s and other training materials about the subject to its public website. In addition
senior leaders at the Joint Commission have published articles on this subject that you
should download and share with senior leaders at your organization well before your
anticipated survey. Your leadership team should be well versed in the concept and be
able to discuss where you are in your journey to becoming a high reliability organization.
An essential article to share is an article by Mark Chassin MD, and Jerod Loeb, Ph.D
published in Health Affairs, 30, Number 4(2011). In this article they have designed a grid
to benchmark your organization on the path by evaluating 3 organizational
characteristics, Leadership, Safety Culture and Robust process improvement. The second
part of the grid is an evaluation of your organizations stage of maturity on the path to
high reliability, minimal, developing or approaching. Your senior leadership team should
be able to honestly evaluate their state of readiness.
There is a second article published December 2013 in the Joint Commission Journal of
Quality and Patient Safety by Peter Pronovost, et al from Johns Hopkins on their
demonstration of high reliability on accountability performance measures that should also
be downloaded and shared with your senior leadership team. They set a leadership goal to
meet or exceed a 96% compliance rate on all of the Joint Commission’s accountability
measures.
 Step 1 was a commitment from senior leaders to announce and commit to the
goal.
 Step 2 was a gap analysis and education using lean methodology.
 Step 3 was transparently reporting outcomes on performance measures in a ladder
like succession, from locally to eventually the health system board.
 Step 4 was developing a process for sustainability.
We believe it will be important to describe your efforts on these accountability measures
in the coming year, and or other initiatives you are undertaking to enhance quality and
safety.
533565544  Patton Healthcare Consulting  Glendale, AZ 85310  www.PattonHC.com  Page 1
A secondary focus of attention during this session will be what you are doing to
implement the standards in the Leadership chapter. In particular you will want to discuss
your efforts on the following:
1. Your culture of safety survey and what you sought to improve over the last 2
surveys, what you did to improve results and what you achieved.
2. Your efforts to improve patient flow in the organization and what improvements
have been made.
a. What you learned in the prior year about the boarded population in the ED
and what you are planning to do this coming year to reduce boarding.
3. Your clinical contracting process including how you evaluate contractor
performance and how senior leaders/medical staff are involved in providing
oversight of the process.
The third and most difficult part of the leadership session is the drill down that surveyors
will do relative to findings of noncompliance on standards. To prepare for this part of the
session you should have been taking careful notes during the morning briefing and
listening to the perceived problems identified by your surveyor escorts and scribes. As
you compile your list of potential RFI’s the leadership team should evaluate what they
knew about the issue, how they were managing it and what they were doing to improve
performance. Ideally you don’t want to be in a position of saying “we had no idea that
was happening in our hospital”. Instead you want to be in a position to state factually and
accurately that you were aware of the situation, you have made significant improvements,
but performance is not yet at our goal. Unfortunately during this part of the session you
are at risk of some secondary hits against leaders. In particular LD.04.01.05, EP 4, and A
element of performance is a risk point. The EP states: “Leaders hold staff accountable for
their responsibilities”. Thus if there are performance lapses found during tracers, and the
discussion leads back to what leaders knew and what they were doing you may get two
hits, one at the performance standard and this one in leadership. The impact of this can
also be more significant if a few core issues that TJC software points to a condition level
finding. If this is tripped, TJC will score the Medicare Condition of Participation out of
compliance and revisit your organization in 45 days to ensure that it has been fixed.
There are 3 performance issues we have seen frequently scored at the COP level that you
should ensure are perfect long before survey. These are:
1. Air handling in positive and negative pressure environments is accurate
2. High level disinfection processes and documentation is adherent to
manufacturers requirements and CDC guidelines
3. Documents required for the EC/LS review such as utility maps, design
diagrams and fire safety testing documentation is immediately available
We don’t usually recommend taking immediate corrective actions, using the Joint
Commission’s “observed and corrected onsite” or OCO, but in these 3 situations we
strongly advise that you fix these issues immediately if you can. You may be able to
avoid a follow up visit.
533565544 Patton Healthcare Consulting  www.PattonHC.com  Page 2 of 3
Lastly, a part of the leadership interview for many years is a discussion about the so
called 5 pillars of leadership:
 Use of data,
 Planning,
 Communicating,
 Changing performance and
 Staffing.
While this has been a key part of the discussion in the past, it is now de-emphasized.
However it is wise to remain prepared for potential discussion by seasoned surveyors
who follow practices they have employed for many years. These pillars of leadership
correspond to standards LD.03.02.01 – LD.03.06.01. If your surveyor goes down this
path we encourage you to discuss examples of initiatives launched in recent years that
facilitate a discussion of these 5 pillars.
POTENTIAL DISCUSSION ISSUES:













Leaders vision for PI
Role of the board in safety and quality
Role of the medical staff in PI
Responsibility for managing and monitoring effectiveness of change
Robust process improvement methodology
Measurement activities
Leadership commitment to safety
Process and tool used to evaluate the culture of safety
Evidence of trust and team work in your safety culture data
Reporting of unsafe conditions
Sharing reports and data with governance
Accountability for safety and quality
Leaders roles as champions for PI
533565544 Patton Healthcare Consulting  www.PattonHC.com  Page 3 of 3