Joint Commission International 6th Edition: Hospital Standards

Governance, Leadership and

Direction ( GLD )

Governance, Leadership and Direction (GLD) Overview

GLD Overview

• The term leaders is used to indicate that one or more individuals are accountable for the expectation(s)

• 33 Standards , 142MEs, 20 P.

• 10 Standard : revises language

• Eliminated 2 MEs: 1(3) ,7(1)

• 5 New MEs : 6.2,7,7.1, 15

• 6 Renumbered only

GLD 1-1.2

GLD 1 : Governance structure and authority are described in bylaws, policies and procedures, or similar documents.

GLD 1.1 The operational responsibilities and accountabilities of the governing entity are described in a written document(s).

GLD 1.2 Those responsible for governance approve and regularly receive and act on reports of the quality and patient safety program

Review from Annual Review and Minute of Meeting

GLD.1.1 :The governing entity’s responsibilities and accountabilities are primarily approving and periodically reviewing

• Mission • Strategic and operational plans and the

policies and procedures needed • Participation in health care professional

education and in research and the oversight of the quality of such programs;

• A capital and operating budget(s) and other resources required

• The chief executive(s), and providing for an annual evaluation of the individual's(s') performance

Chief Executive(s) Accountabilities GLD.2 A chief executive(s) is responsible for operating the hospital and complying with applicable laws and regulations

The education and experience match the requirements in the position description. manages the hospital’s day-to-day operations, including those responsibilities described in the position description. recommends policies, strategic plans, and budgets to the governing body. ensures compliance with approved policies. ensures compliance with applicable laws and regulations. responds to any reports from inspecting and regulatory agencies

Hospital Leadership Accountabilities

GLD.3 : Identified and is collectively responsible for defining the hospital’s mission and creating the programs and policies needed to fulfill the mission.

GLD.3.1 : Identifies and plans for the type of clinical services required to meet the needs of the patients served by the hospital

GLD.3.2 : ensures effective communication throughout the hospital.

GLD.3.3 : Ensures that there are uniform programs for the recruitment, retention, development, and continuing education of all staff.

GLD.3.2 – Leadership role in communication

Moved here from MCI chapter

Clear and consistent communication is a responsibility of leadership

Process, effectiveness and content

Measure of “effectiveness” of communication

GLD.4 – Leadership plans and implements quality program GLD.4.1 – Leadership reports to staff and governance

Develop and implement a quality program and select leadership for the program

At least quarterly report to governance

Six month review of sentinel events

Progress communicated to staff

Review minutes: governance, senior leadership, and quality departments

“Sustainability of Improvements”

Hospital Leadership for Quality and Patient Safety

GLD.5 – CEO and Leadership prioritize ; which hospitalwide processes will be measured, which hospitalwide improvement and patient safety activities will be implemented, how success of these hospitalwide efforts will be measured.

Focus on measurement for system improvement

Focus on research and education when present

Focus on full compliance with IPSGs

Evaluate the impact of Improvement

Hospital Leadership for Contracts

GLD.6 :Accountable for the review, selection, and monitoring of clinical or nonclinical contracts.

GLD.6.1 : Ensures that contracts and other arrangements are included as part of the quality improvement and patient safety program.

GLD.6.2 : Ensures that independent practitioners not employed by the hospital have the right credentials for the services provided to the patients

telemedicine, teleradiology, and interpretations of other diagnostics, such as electrocardiogram (ECG), electroencephalogram (EEG), pathology,

Hospital Leadership for Resource Decisions

GLD.7 : Makes decisions related to the purchase or use of resources—human and technical—with an understanding of the quality and safety (data) implications of those decisions;

medical equipment choices.

staffing choices.

uses the recommendations of professional organizations and other authoritative sources in making resource decisions. (ASC.6, PCI.3,PCI.7)

provides direction, support, and oversight of information technology resources.

monitors the results of its decisions and uses the data to evaluate and improve the quality of its resource purchasing and allocation decisions.

GLD.7.1 – Safety of supply chain GLD 7.1 : Seeks and uses data and information on the safety of

the supply chain to protect patient and staff from unstable, contaminated, defective, and counterfeit supplies.

outlines the steps in the supply chains for supplies defined as at most risk.

identifies any significant risk points in the steps of the supply chains.

makes resource decisions based on their understanding of the risk points in the supply chains.

process for performing retrospective tracing of supplies found to be unstable, contaminated, defective, or counterfeit.(new)

notifies the manufacturer and/or distributor when unstable, contaminated, defective, or counterfeit supplies are identified.(new)

Clinical Staff Organization and Accountabilities

• GLD.8 : Medical, nursing, and other leaders of departments and clinical services plan and implement a professional staff structure to support their responsibilities and authority.

support culture of safety and good communication between professionals; jointly plan and develop policies; clinical guidelines; and related protocols, pathways, and other documents that guide the delivery of clinical services; oversight of professional ethical issue oversee the quality of patient care.

Direction of Hospital Departments and Services

GLD.9 One or more qualified individuals provide direction for each department or service in the hospital • Each department is directed by an individual with

the training, education, and experience comparable to the services provided

• Recommend space, medical technology, equipment, staffing, and other resources needed

• recommend criteria for selecting professional staff

• provide orientation and training for all staff of the duties and responsibilities staff

Clinical Staff Organization and Accountabilities

GLD .10 Identifies, in writing, the services to be provided by the department, and integrates or coordinates those services with the services of other departments • use a uniform format and content for planning

documents. • documents describe the current and planned services

provided • documents guide the provision of identified services • address the staff knowledge and skills needed to assess

and to meet patient needs. • coordination and/or integration of services within and

with other departments and services Scope of service

Clinical Staff Organization and Accountabilities

GLD.11 : Department/service leaders improve quality and patient safety by

Participate in hospitalwide measurement and improvement priorities that relate to their specific department or service

implement quality measures to reduce variation and improve processes ,including implementation of measures found in the JCI Library of Measures or other resources for well-defined,

select measures based on the need for improvement, and once improvement has been sustained, select a new measure

quality measurement and improvement activities are integrated into and supported by structure of the organization

GLD.11.1 – Department/service leaders pick measures :

Measures are integrated into the yearly SQE evaluation of nurses, physicians and other health professionals

Consider measures from the JCI Library or Evidence base practice

Consider measures in pathways and clinical practice guidelines

Clinical Staff Organization and Accountabilities

GLD.11.1 : What Questions are Surveyors likely to ask?

How often is your staff evaluated?

6 month evaluation process

Does your yearly review contain information/discussion about departmental-specific goals? If so, what are the goals?

Answers could be: improve patient safety, reduce HAI’s, improve patient satisfaction

GLD.11.1 : What Questions are Surveyor likely to ask?

Do you include the clinical privileges of the departmental physicians in the evaluation?

interventional and surgical procedures volumes and outcomes

Is the evaluation related to the compliance of individual physicians to the clinical guidelines adopted by the department?

indicators from the International Library of Measures

Clinical Staff Organization and Accountabilities

GLD .11.2 : Department/service leaders select and implement clinical practice guidelines, and related clinical pathways, and/or clinical protocols, to guide clinical care • collectively determine at least five hospitalwide priority areas

on which to focus the use of clinical practice guidelines • follow the process in selecting and implementing clinical

practice guidelines • implement clinical guidelines and any associated clinical

pathways or clinical protocols for each identified priority • demonstrate how the use of clinical practice guidelines, clinical

pathways, and/or clinical protocols has reduced variation in processes and outcomes.

Organizational and Clinical Ethics

• GLD.12 Ethical framework management addresses operational and business issues, including marketing, admissions, transfer, discharge, and disclosure of ownership and any business and professional conflicts that may not be in patients’ best interests.

• GLD.12.1 Establishes a framework for ethical management that promotes a culture of ethical practices and decision making to ensure that patient care is provided within business, financial, ethical, and legal norms and protects patients and their rights

• GLD.12.2 Framework for ethical management addresses ethical issues and decision making in clinical care

Organizational and Clinical Ethics

GLD.13 and GLD.13.1- Culture of safety

Leadership promotes; culture of safety

code of conduct

Provide resources and education

Leadership understands what safety is and have identified key elements that impact safety in an organization

Measures are used to evaluate program

Evaluating Compliance GLD.13 and GLD.13.1

GLD.13.1 : Why might this standard be difficult to meet?

Requires top-down implementation

Culture of individual blame

Lack of organizational commitment

GLD.13.1 : What Questions are Surveyors likely to ask?

Are you aware of any improvement activities that have come as a result of reports from staff or the Culture of Safety survey?

Patient safety leadership walk-rounds conducted to address the improvement activities

Designation of a patient safety officer

Involve patients in safety activities

Mock adverse events for training

GLD.13.1 : What Questions are Surveyors likely to ask?

If you have a safety concern, how do you report it?

Emergency phone numbers & departmental chain of command

Incident reporting system

Health Professional Education and Human Subjects Research

• GLD.14 Health professional education, when provided within the hospital, is guided by the educational parameters defined by the sponsoring academic program and the hospital’s leadership.

Human Subjects Research

• GLD.15 Human subjects research, when provided within the hospital, is guided by laws, regulations, and hospital leadership

• established entry and/or transfer criteria for an admission to a specialized ward due to research and/or another specialized program to meet patient needs.

• GLD.16 Patients and families are informed about how to gain access to clinical research, clinical investigation, or clinical trials involving human subjects

• GLD.17 Patients and families are informed about how patients who choose to participate in clinical research, clinical investigations, or clinical trials are protected.

• GLD.18 Informed consent is obtained before a patient participates in clinical research, clinical investigations, or clinical trials

• GLD.19 The hospital has a committee or another way to oversee all research in the hospital involving human subjects

Q&A