JCAHO standards up the ante for leadership.

A group of medical staff officers and physicians representing their peers at a large tertiary care hospital convened its monthly meeting. Among the issues they discussed was a proposal by the president of the medical staff to require incoming officers to attend a weekend management workshop at a local university.

Having attended and enjoyed the workshop, the president felt that it would be advantageous for the officers in the changing health care environment to gain an insight into management concepts and practices, as well as the basics of business planning and leadership. The cost of the workshop would be covered by the medical staff fund because the knowledge gained from such a session would better equip the officers to succeed in their roles.

The proposal was rejected in short order.

Winds of change

Such a scenario may not be the norm in years to come. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) plans to bolster its leadership standards next year because "effective leadership is built upon the ongoing collaborative efforts of the organization's interdependent leadership components, typically the governing body, organized medical staff, and hospital management." (1)

JCAHO has published revisions of its leadership standards for several care venues: hospitals, critical access hospitals, laboratory services, home care, behavioral health care, long-term care, office-based surgery and ambulatory care. (2)

They are distinct from its medical staff standards, which address the organization of the medical staff, bylaws, rules and regulations, functions, departments, credentialing, privileging and reappointment, etc. The medical staff chapter is also being revised as some elements are incorporated into the leadership standards.

JCAHO's changes in the leadership chapter are based on the recommendations of the Leadership Accountabilities Task Force that was convened in 2004 to address issues relating to the responsibilities and accountabilities of leadership components.

One of the three components of leadership is the medical staff. There is a renewed emphasis on active participation of the medical staff in leading the mission, vision, planning and operations of the hospital, with representation through attendance and voice in its governing body, and collaboration among the three components

Why change?

The revised chapter incorporates enhanced leadership standards relative to safety, and emphasizes existing standards that promote a "systems approach" to preventing adverse events and medical errors.

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JCAHO aims to promote consistency among organizations by highlighting elements of safety and quality in its leadership chapter. It focuses on five key systems as pillars for effective implementation of safety and quality improvement efforts:

1. Data use

2. Planning

3. Communication

4. Improving performance

5. Skilled people

The prominence of safety in the leadership standards reflects JCAHO's efforts in this area. Its National Patient Safety Goals for 2006 include existing and new requirements in:

* Communication among caregivers

* Involvement of patients and families

* Patient identification

* Medication safety

* Wrong-site surgery

* Clinical alarm systems

* Health care-associated infection

* Reconciliation of medications

* Fall reduction

* Surgical fires

* Risk of falls

* Risk of influenza and pneumococcal disease

* Pressure ulcers (3)

But these goals cannot be attained without the participation of active-staff physician leaders with management and board in quality improvement efforts as demonstrated in a study of 2,193 hospitals. (4)

Therefore, a capable and empowered medical staff leadership is highly desirable.

Performance, recruitment

The proposed revisions of JCAHO's leadership standards require that each participant demonstrate competencies in relation to his/her assigned role.

One challenge for medical staff leaders is that many of these elements are typically lacking in their education and training. Elements rooted in other disciplines such as finance and law are prime examples.

But the very characteristics of successful physicians when it comes to patient care and academia may be an Achilles' heel in leadership roles as officers, chairs, or similar positions. They are the team leaders rather than team members. They are single-minded, accustomed to issuing directives, expecting others to follow them, and disapproving of those who do not.

Medical schools and residency programs focus on developing analytical minds that can make objective decisions independently, and urgently in an emergency. While these traits are valuable for any leader, members of the governing body and hospital administration may perceive them as the liabilities of impersonal and impatient individuals who are prone to criticize and loath to collaborate.

Some volunteers are surprised to find out that it takes time and effort to conduct the affairs of the medical staff. Others are apprehensive about organizational politics or additional responsibilities. The rising competition between physicians and hospitals, whether in the form of attrition of high-margin inpatient services by provider-owned specialty facilities or intrusion into their service area by hospital clinics, is straining relations between the two groups.

Preparing to lead

JCAHO's focus on leadership underscores its appreciation of the crucial role it plays in other businesses and the leader's portrait that evolved over time from an all powerful autocrat to a multi-skilled enabling servant who inspires peers and employees toward institutional goals.

According to the JCAHO, "In order to fulfill their roles, each leadership component contains active members who are competent in the following, or who have access to individuals with such competencies:

* Assessment of processes from a systems-based perspective

* Clinical, strategic and managerial decision making, based on internally and externally acquired data

* Integrated decision making based on collaboration, and open communication

* The ability to identify and resolve conflict

* The additional core competencies specific to their respective leadership component, as determined by the hospital

* Ability to develop a culture of strong teamwork among all levels of staff (1)

Most leadership skills other than character and vision are learned through mentorship, education and experience. JCAHO has proposed that members of the three leadership components receive training in several areas.

Opportunities abound for medical staff members to gain firsthand experience and receive mentorship by joining departmental or institutional committees. This process typically entails an increasing level of involvement over a number of years. Education in leadership is usually available through some other venue including workshops, seminars and courses. Professional development programs may be sponsored by the medical staff or the hospital, or offered by any number of vendors, professional societies and universities.

Shared values, organizational welfare, collaboration, motivation and communication are essential to impact the direction and culture of the organization. Furthermore, those without formal education in specific fields should study the basics of quality improvement, patient safety, finance and health law. Other important topics include negotiation, managing change, measuring performance, and embracing not only cultural but also functional diversity.

Some physicians have mastered time management but many who engage in medical staff leadership are overwhelmed by their heavy burden. Other reasons for derailment of successful leaders include overlooking the importance of people, rivalry, poor demeanor, and antagonism. (5)

Coaching to overcome these weaknesses and learn the competencies of work-life balance, prioritization of tasks, delegation, and work organization would yield not only stronger leadership skills but also superior work habits. (5,6)

Good, bad or ugly?

Earlier this year, JCAHO released a revised version of the leadership chapter (http://www.jointcommission.org/Standards/FieldReviews/) for a second field review. The revisions were based upon feedback from the field review that was conducted in October 2005. The redrafted chapter is clearer and includes logical edits such as adding informal interactions to regularly scheduled meetings. Some standards and elements of performance were reordered or split for clarity. Overall, the revised chapter shows improvements in intent and context.

JCAHO will raise the bar for leaders' performance standards. Some have objected to the draft changes citing a lack of clarity. It is not clear that the ultimate authority lies with the governing board in every instance, and there is some vagueness regarding which party is responsible for what. Also there are questions about the the potential authority and responsibility of the hospital governing body. (7,8)

The proposed revisions present the medical staff with an opportunity to shape the organization's mission, vision, safety and quality. New competencies are necessary for their leaders to become full partners in the collaborative decision making process. Hospitals have much at stake and those willing to embrace physician leadership may gain more than good will.

Full collaboration between the two groups may improve hospitals' market share and bottom line, and indeed, some facilities have pursued effectively this avenue to reduce competition. New business opportunities could mean success for both organizations and their clinical staff.

Amin Hakim, MD, CPE, is vice president of medical services at Group Health Incorporated, based in New York. He can be reached at 212-615-4785 or [e-mail].

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References

1. Joint Commission on Accreditation of Healthcare Organizations. "Overview of 2007 Hospital Leadership Chapter." Available at: http://www.jcaho.org..

2. Joint Commission on Accreditation of Healthcare Organizations. "Overview of 2007 Leadership Standards." Available at: http://www.jcaho.org.

3. Joint Commission on Accreditation of Healthcare Organizations. "2006 Critical Access Hospital and Hospital National Patient Safety Goals." Available at: http://www.jcaho.org

4. Weiner BJ, Shortell SM, and Alexander J. "Promoting Clinical Involvement in Hospital Quality Improvement Efforts: The effects of Top Management, Board, and Physician Leadership." Health Serv Res, 32(4), 1997.

5. Frankel LP. Overcoming Your Strengths: 8 Reasons Why Successful People Derail and How to Remain on Track. 1st ed. Pasadena, Calif.: Corporate Coaching International Publications. 2003.

6. Morgenstern J. Making Work Work: New Strategies for Surviving and Thriving at the Office. 1st ed. New York, N.Y.: Fire, Simon & Schuster, Inc. 2004.

7. Healthcare Trustees of New York State. "HTNYS Comments on JCAHO's Proposed Leadership Standards." Available at: http://www.hanys.org/news/weekly/102105_8.cfm.

8. Texas Hospital Association. "Letter to JCAHO re: Draft Hospital Leadership Accountability Standards." Available at: http://www.thaonline.org

By Amin Hakim, MD, CPE, FACPE 

Table 1 Key 2007 changes in JCAHO leadership standards.

Current
* Hospital identifies how it is governed; a standard.
* Governance has responsibility as applicable.
* Safety and quality programs are employed.
* Communication is effective within and without the hospital.
* Processes are measured, assessed and improved.

Proposed
* An element of the standard of leadership structure and the role of
  each component.
* Governance has ultimate responsibility for safety, quality, treatment
  and services.
* Culture of safety and quality in all processes and operations.
* Focus on regular and active communication among leaders, and
  communication that fosters safety and quality.
* A systems approach toward safety, and use of data to guide decision
  and understand variances.
* Collaboration among leaders in the decision-making process.
* Leaders learn and maintain competencies.
* Select standards were moved from other chapters (e.g., medical staff)
  into the leadership chapter.

Table 2 Elements of performance for leadership standard LD.1.70.

1. Develop and maintain the competencies, skills and effectiveness of
   individual leaders.
2. Orient leaders to hospital's:
   * Mission and vision
   * Safety and quality goals
   * Budget development and interpretation of financial statements
   * Population and its issues of concern
   * Individual and interdependent responsibilities and accountabilities
     of each leadership component
   * Applicable law and regulation
3. Provide training to all leaders in regard to:
   * Conflict identification and resolution
   * Assessment of system processes
   * Team-based concepts
   * Evidence-based decision making
   * Mutual respect
4. Consult and utilize external resources if an expertise does not exist
   within the leadership components.
5. Monitor, evaluate and improve the individual and collective
   performance and effectiveness of each leadership component.