Accreditation Tip of the Month
By John Rosing, M.H.A., FACHE, Vice President and Principal, Patton Healthcare Consulting
The reformatted 2009 Joint Commission Hospital Standards include a restated Leadership Chapter requirement for hospital organizations to manage conflicts that arise between governance, the organized medical staff, and senior managers in the organization. Leadership standard LD.02.04.01 has five elements of performance that will be easily scored by a surveyor as non-compliant unless you take definitive steps to create a formal conflict resolution process.
This restated expectation is not to be confused with a more traditional employee “grievance” policy or medical staff “Joint Conference Committee” bylaw provision that you may already have on the books. Rather, this requirement addresses situations when conflict arises among leaders and requires that the board has approved a “process” for conflict resolution.
When a Joint Commission standard or element of performance calls for a “process” or a “method” or an “approach,” you should recognize these nouns as Joint Commission code language for “you better have something in writing, such as a policy, that you can show the surveyor.” In this case, as is often the case, it is also wise to bullet-proof your policy and your organization from a Joint Commission Requirement for Improvement (RFI)—deliberately address the precise specifications in the elements of performance by parroting back the language of each element of performance in your written policy. For example, with this standard I would create a simple policy that begins with these two introductory paragraphs that together address each of the five elements of performance:
Anonymous Hospital recognizes that unmanaged or unresolved conflict among leadership groups is detrimental to the organization and may ultimately compromise the quality and safety of care provided within the organization. Therefore, senior managers, leaders of the organized medical staff, and members of the governing body have developed an ongoing process for managing conflict that may arise among leadership of the hospital. This process has been approved by the governing body.
Individuals who help implement this process are judged to be competent and skilled in conflict management. The conflict management process is designed to be objective, information driven, and responsive in identifying and resolving conflict as early as possible in order to protect the safety and quality of care provided by the organization. This process is implemented whenever a conflict arises that, if not managed, could adversely affect patient safety or the quality of care provided within the hospital.
Your written policy should then continue to a new section that actually spells out an approach to conflict resolution developed by governance, the Medical Executive Committee, and administration, and then approved by the board. This approach may be one that your organizational is already using, or you may find a suitable model through a literature search. Examples can easily be found on the Internet.
Remember, in this case as is often the case with a Joint Commission standard, they stop short of prescribing use of any particular process. Thus, the actual conflict resolution process you select should not in this instance be the focus of the surveyor’s attention or scoring. Rather, compliance is achieved by paying close attention to the elements of performance and incorporating them into your policy and process as I have suggested in the two paragraphs noted above.