Are JCI ‘Governance, Leadership, and Direction (GLD)’ standards directing us on how to run the hospital!

Safer and better quality care occurs when those in governance and management, health practitioners, non-clinical staff and consumers all work together at all levels of the health system with a common purpose. Safe patient care happens when healthcare service delivery organizations are functioning at the highest levels. Governing boards and senior leaders of healthcare organizations can ensure effective governance and meet their legal responsibilities with the Effective Governance for Quality and Patient Safety. Good leadership is important for the success of any organization. In a healthcare organization, good leadership is more than just important—it is absolutely critical to the organization’s success. Why is it so critical—but also challenging—in healthcare organizations? Who are the “leaders” in healthcare organizations? What is “good leadership” in healthcare organizations? And what is the “success” that healthcare organizations seek? These are the questions that Joint Commission accreditation standards on leadership attempt to answer and are the focus of this chapter discussion. The first leadership standards issued by The Joint Commission; the importance of the organization’s leaders working together has been a theme in the standards since 1994, when the first chapter on “leadership” was added to the standards. For many years prior to 1994, the standards included chapters on “Management,” “Governance,” “Medical Staff,” and “Nursing Services.” In fact, each department in the organization had its “own” chapter of standards, as if the good performance of each unit—governance, management, radiology, dietary, surgery, and so forth—would assure the success of the organization. The Joint Commission sought the advice of some of the nation’s leading healthcare management experts and clinical leaders from both practice and academia to redesign this unit-by-unit approach. They were unanimous in their advice: stop thinking of the healthcare organization as a conglomerate of units and think of it as a “system.” A system is a combination of processes, people, and other resources that, working together, achieve an end. JCI advisers explained that a healthcare organization, such as a hospital, could be imagined to be like a watch. A watchmaker could gather from around the world the best-in-class components—spring, regulator, bearings, and so forth—to assemble, but the resulting watch would be unlikely to run, let alone keep accurate time. It’s how the components work together that creates an accurate watch. In fact, for the watch to work perfectly it may be necessary to make compromises in how each component works; for example, a spring made of the strongest material may not be the best contributor to a delicate, accurate watch if it does not fit well with the other components. Healthcare organizations are not watches, but the analogy applies. If we want a healthcare organization to succeed, it must be appreciated as a system, the components of which work together to create success. It is not possible to determine what each component should be and do unless it is examined in the light of the goals for the system and the rest of the system’s components. For a healthcare organization, the primary goal is to provide high-quality, safe care to those who seek its help, whether they are patients, residents, clients, or recipients of care. While there are other goals for a healthcare organization, including financial sustainability, community service, and ethical business behavior, The Joint Commission’s primary focus is on the organization’s goals of providing high-quality, safe care to patients. Of course, this system view of healthcare organizations led to a different perspective on leadership. No longer was the focus to be on the performance of each group of leaders, but rather, on how the leaders in the organization work together to provide leadership for the organization that would enable the organization—as a system—to achieve its goals. During the decade following the introduction of the first “Leadership” chapter, the remaining standards in the “Governance” and “Management” chapters were fully integrated into the leadership standards and, by 2004, these two chapters disappeared entirely—the roles of the governing body and senior management contributing to the organization’s leadership rather than being silos within the organizational system. The JCI (Joint Commission International) accreditation standards for hospital in 5th edition is discussing about Governance, Leadership, and Direction (GLD). This GDL is the third chapter belongs to Section-III which contains total six chapters. The whole JCI manual book (5th edition) contains 304 standards and 1218 Measurable elements (MEs) which are compatible with local needs of the patient. However, this GLD chapter contains thirty three (33) standards and one hundred forty (140) measurable elements. The chapter also addresses four leadership groups, for examples (1) level-I: the Governing Body, (2) level-II: The Chief Executive, (3) level-III: Hospital Leadership and, (4) level-IV: Department/Service Leaders. Besides, GLD chapter also speaks about (5) Organizational and Clinical ethics, (6) Health professional education and Human subjects and finally, (7) Human Subjects Research.

(1) Level-I: the Governing Body: The governing body of a healthcare organization has the same responsibilities as the governing body of any enterprise, whether for-profit or not-for-profit: strategic and generative thinking about the organization and its mission, vision, and goals, and oversight of the organization’s functions, especially its financial sustainability, in the board’s fiduciary responsibility to the organization’s “owners.” But in healthcare organizations, the governing body has an additional fiduciary obligation to continuously strive to provide safe and high-quality care to the patients who seek health services from the organization. And, if the healthcare organization is a not-for-profit—as most hospitals are—the governing body has a responsibility to benefit the community, often called “community benefit.” The challenge for governing body members is that actions designed to meet one of these responsibilities may compromise meeting another of the responsibilities. While the obligation toward patients to “first, do no harm” is paramount, it is also true that the organization must be financially sustained in order to provide healthcare services—as is often said, “no margin, no mission.” The decisions facing governing body members may truly be “life and death” decisions, far beyond the business decisions of most boards. That is why they often rise to become ethical dilemmas and uncertainties, either between governing body members or even within a member’s mind. That is why policies on conflict of interest, managing conflict, and accessible mechanisms to resolve ethical concerns are necessary to enable the governing body to function effectively. The definition of Governance may consist of many configurations. For example, governance may be a group of individuals (such as a community board), one or more individual owners, or in the case of public hospitals, the Ministry of Health. There is an entity (for example, a ministry of health), an owner(s), or a group of identified individuals (for example, a board or governing body) responsible for overseeing the hospital’s operation and accountable for providing high-quality health care services to its community or to the population that seeks care. This entity’s structure, responsibilities, and accountabilities are described in a document(s) that identifies how they are to be carried out. Also described is how the governing entity will be evaluated against specific criteria. The hospital’s governance structure is represented or displayed in an organizational chart or other document that shows lines of authority and accountability. The individuals represented on the chart are identified by title or name. The governing entity’s responsibilities and accountabilities are described in a document(s) that identifies how they are to be carried out. The governing entity has important responsibilities that must be carried out for the hospital to have clear leadership, to operate efficiently, and to provide high-quality health care services. These responsibilities are primarily at the approval level and include

• approving and periodically reviewing the hospital’s mission and ensuring that the public is aware of the hospital’s mission;
• approving the hospital’s various strategic and operational plans and the policies and procedures needed to operate the hospital on a daily basis;
• approving the hospital’s participation in health care professional education and in research and the oversight of the quality of such programs;
• approving or providing a capital and operating budget(s) and other resources required to operate the hospital and to meet the hospital’s mission and strategic plan; and
• appointing or approving the hospital’s chief executive(s), and providing for an annual evaluation of the individual's(s') performance using an established criteria and process

The governance structure approves or provides for all of the hospital’s programs and policies and allocates resources to meet the hospital’s mission. One important accountability is to carry out all responsibilities in a manner that supports the continual improvement in quality and patient safety. This important investment in quality needs to be planned, provided adequate resources, and monitored for progress. Thus, governance approves the quality program on an annual basis, and on a regular basis receives quality reports. The reports can be global in nature or focus on a particular clinical service, a patient group, or some operational aspect. Thus, over a period of time, all aspects of the quality program, including adverse events and sentinel events, are presented to governance for their information and discussion. When the discussion results in actions, such as allocation of additional resources, those actions are recorded in minutes and are reexamined at a future meeting(s). The governance of the hospital consists of three (03) standards, and thirteen (13) measurable elements, and the standards are:

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

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

3.     Standard GLD. 1.2: Those responsible for governance approve the hospital’s program for quality and patient safety and regularly receive and act on reports of the quality and patient safety program.

(2)Level-II: Chief Executive(s): The most senior hospital executive, commonly termed the chief executive, is a position occupied by one or more individuals selected by governance to manage the organization on a day-to-day basis. This position is most commonly occupied by a physician, an administrator, or both working together. In academic medical centers, the dean of the medical school may be at this executive level in the hospital. Effective leadership is essential for a hospital to be able to operate efficiently and to fulfill its mission. Leadership is what individuals provide together and individually to the hospital and can be carried out by any number of individuals. The chief executive(s) is responsible for the hospital’s overall, day-to-day operations. This includes the procurement and inventory of essential supplies, maintenance of the physical facility, financial management, quality management, and other responsibilities. The education and experience of the individual(s) matches the requirements in the position description. The chief executive(s) cooperates with hospital leadership to define the hospital’s mission and to plan the policies, procedures, and clinical services related to that mission. Once approved by the governing body, the chief executive(s) is responsible for implementing all policies and ensuring that all policies are complied with by the hospital’s staff. The chief executive(s) is responsible for the hospitals: (1) compliance with applicable laws and regulations; (2) response to any reports from inspecting and regulatory agencies; and (3) processes to manage and to control human, financial, and other resources. This part consists of one (01) standard, and six (06) measurable elements, and the standard is:

1.     Standard GLD. 2: A chief executive(s) is responsible for operating the hospital and complying with applicable laws and regulations.

(3) Level III: Hospital Leadership: Hospital leadership comes from many sources. The governing body names the chief executive(s). The chief executive(s) may name others to hospital leadership. Hospital leadership may have formal titles, such as Medical Director or Director of Nursing, may be leaders of clinical or nonclinical departments or services, or may be informally recognized for their seniority, stature, or contribution to the hospital. It is important that hospital leadership is recognized and brought into the process of defining the hospital’s mission. Based on that mission, hospital leadership works collectively and collaboratively to develop the programs, policies, and services needed to fulfill the mission. When the mission and policy framework are set by owners or agencies outside the hospital, hospital leadership works collaboratively to carry out the mission and policies. The standards assign to hospital leadership a variety of responsibilities intended to collaboratively guide the hospital in meeting its mission. Most frequently, hospital leadership consists of a chief medical officer representing the medical staff of the hospital, a chief nursing officer representing all levels of nursing in the hospital, senior administrators, and any other individuals the hospital selects, such as a chief quality officer or vice president of human resources. In larger hospitals with different organizational structures, such as divisions, hospital leadership may include the leaders of these divisions. Each hospital identifies hospital leadership, and standards describe the accountability of this group. This part describes the responsibilities of clinical staff, however they are formally or informally organized. In academic medical centers, the leader of medical education and leader of clinical research may be a part of hospital leadership. Hospital leadership determines with the leaders of the various clinical departments and services in the hospital the diagnostic, therapeutic, rehabilitative, and other services that are essential to the patient population. Hospital leadership also plans with the department/service leaders the scope and intensity of the various services to be provided by the hospital directly or indirectly. When applicable to the mission, hospital leadership plans and participates with the community, local hospitals, and others in meeting community health care needs. The services planned reflect the strategic direction of the hospital and the perspective of the patients cared for by the hospital. Planning patient care services also involves hospital leadership defining its communities and patient populations, identifying community needs for services, and planning ongoing communication with those key community stakeholder groups. The communications may be directly to individuals or through public media and through agencies within the community or third parties. The types of information communicated include information on services, hours of operation, and the process to obtain care; and information on the quality of services, which is provided to the public and to referral sources. Besides, to coordinate and to integrate patient care, hospital leadership develops a culture that emphasizes cooperation and communication. Formal (for example, standing committees, joint teams) and informal (for example, newsletters and posters) methods for promoting communication among services and individual staff members are used. Coordination of clinical services comes from an understanding of each department’s mission and services and collaboration in developing common policies and procedures. Hospital leadership recognizes that staff retention, rather than recruitment, provides greater long-term benefit. Retention is increased when hospital leadership supports staff advancement through continuing education. Thus, hospital leadership plans and implements a uniform program and processes related to recruitment, retention, development, and continuing education for each category of staff. This section contains four (04) standards and fifteen (15) measurable elements; and the standards are:

1.     Standard GLD. 3: Hospital leadership is identified and is collectively responsible for defining the hospital’s mission and creating the programs and policies needed to fulfill the mission.

2.     Standard GLD. 3.1: Hospital leadership identifies and plans for the type of clinical services required to meet the needs of the patients served by the hospital.

3.     Standard GLD. 3.2: Hospital leadership ensures effective communication throughout the hospital

4.     Standard GLD. 3.3: Hospital leadership ensures that there are uniform programs for the recruitment, retention, development, and continuing education of all staff

(4) Level IV: Department/Service Leaders: For effective and efficient daily delivery of clinical services and management of the organization, hospitals are most frequently divided into cohesive subgroups such as departments, services, or units, each under the direction of a department/ service leader(s). This section describes the expectations of these department/service leaders. Typically, the subgroups consist of clinical departments such as medicine, surgery, obstetrics, pediatrics, and others; one or more nursing subgroups; diagnostic services or departments such as radiology and clinical laboratory; pharmacy services, both centralized and distributed throughout the hospital; and ancillary services such as transportation, social work, finance, purchasing, facility management, and human resources, among others. Most larger hospitals also have managers within these subgroups. For example, nursing may have a manager of the operating theatres and one for outpatient services, the department of medicine may have managers of each patient clinical unit, and the hospital business office may have managers for the different business functions such as bed control, billing, and purchasing, among others. Finally, there are requirements in the GLD chapter that touch on all of the levels described above. These requirements are include the culture of safety, ethics, and health professional education and research when present. Leadership and planning begins with the governing body of the hospital, along with those who manage and lead the clinical and managerial activities of the hospital on a daily basis. Collectively, these persons represent the leaders of the departments and services of the hospital. Hospital leadership is responsible for establishing and providing ongoing support for an organizational commitment to quality. Hospital leadership develops the quality and patient safety program for governance approval, and through its vision and support, shapes the quality culture of the hospital. Hospital leadership selects the approach to be used by the hospital to measure, assess, and improve quality and patient safety. Also, hospital leadership determines how the program will be directed and managed on a daily basis, such as a quality department, and ensures that the program has adequate resources to be effective. Hospital leadership also implements a structure and process for the overall monitoring and coordination of the program throughout the hospital. These actions ensure coordination among all the department and services in measurement and improvement efforts. Coordination can be achieved through a quality management council/committee, or some other structure. Coordination encourages a system-wide approach to quality monitoring and improvement activities while reducing duplication of effort; for example, two departments’ independently measuring similar processes or outcomes. Hospital leadership is also responsible for seeing that at least quarterly quality reports are prepared for governance review and discussion and for seeing that the actions of governance related to the quality program reports are carried out. In addition to the quarterly quality reports, at least once every six months, the quality report to governance includes (a) the number and type of sentinel events and associated root causes; (b) whether the patients and families were informed of the event; (c) actions taken to improve safety in response to events; and (d) if the improvements were sustained. Due to staff and resource limitations, not every process within a hospital can be measured and improved at the same time. Thus, a primary responsibility of hospital leadership is to set hospital-wide measurement and improvement priorities. These are measurement and improvement efforts that impact or reflect activities in multiple departments and services. Hospital leadership provides focus for the hospital’s quality measurement and improvement activities, including measurement and activities regarding the hospital’s full compliance with the International Patient Safety Goals. Priorities may focus on the achievement of strategic objectives; for example, to become the leading regional referral center for cancer patients. Similarly, hospital leadership may give priority to projects that increase efficiency, reduce readmission rates, eliminate patient flow problems in the emergency department, or create a monitoring process for the quality of services provided by contractors. Hospital leadership considers priorities at a system level to spread the impact of improvements broadly throughout the hospital; for example, improving the hospital’s medication management system. The priority-setting process includes the consideration of available data on which systems and processes demonstrate the most variation in implementation and outcomes. Hospital leadership ensures that, when present, clinical research and medical education programs are represented among the priorities. This section describes fourteen (14) standards and fifty eight (58) measurable elements; and standards are:

1.     Standard GLD. 4: Hospital leadership plans, develops, and implements a quality improvement and patient safety program.

2.     Standard GLD. 4.1: Hospital leadership communicates quality improvement and patient safety information to governance and hospital staff on a regular basis.

3.     Standard GLD. 5: Hospital leadership prioritizes which hospital-wide processes will be measured, which hospital-wide improvement and patient safety activities will be implemented, and how success of these hospital-wide efforts will be measured

4.     Standard GLD. 6: Hospital leadership is accountable for the review, selection, and monitoring of clinical or nonclinical contracts.

5.     Standard GLD. 6.1: Hospital leadership ensures that contracts and other arrangements are included as part of the hospital’s quality improvement and patient safety program.

6.     Standard GLD. 6.2: Hospital leadership ensures that independent practitioners not employed by the hospital have the right credentials for the services provided to the hospital’s patients.

7.     Standard GLD.7: Hospital leadership makes decisions related to the purchase or use of resources—human and technical—with an understanding of the quality and safety implications of those decisions.

8.     Standard GLD.7.1: Hospital leadership seeks and uses data and information on the safety of the supply chain for drugs, medical technology, and supplies to protect patients and staff from contaminated, fake, and diverted products.

9.     Standard 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

10. Standard GLD.9: One or more qualified individuals provide direction for each department or service in the hospital

11. Standard GLD.10: Each department/service leader identifies, in writing, the services to be provided by the department, and integrates or coordinates those services with the services of other departments

12. Standard GLD.11: Department/service leaders improve quality and patient safety by participating in hospital-wide improvement priorities and in monitoring and improving patient care specific to the department/service.

13. Standard GLD.11.1: Department/service leaders of clinical departments or services select and implement quality and patient safety measures specific to the scope of services provided by the department or service and useful in the evaluation of the physicians, nurses, and other professional staff participating in the clinical care processes

14. Standard GLD.11.2: Department/service leaders select and implement clinical practice guidelines, and related clinical pathways, and/or clinical protocols, to guide clinical care.

(5) Organizational and Clinical ethics: Hospitals face many challenges in providing safe, high-quality health care. With advances in medical technology, financial constraints, and increasing expectations, ethical dilemmas and controversies are much more common. Hospital leadership has a professional and legal responsibility to create and promote an environment and culture that operate within an ethical framework. The ethical framework must apply to both the hospital’s business and clinical activities alike. Hospital leadership must demonstrate ethical behaviors and develop guidelines for organizational performance and conduct. Hospital leadership’s actions and the hospital’s guidelines for ethical behavior must be congruent with the hospital’s vision, mission, and value statements; personnel policies; annual reports; and other documents. The framework supports the hospital’s health care providers, other staff, and patients and family when confronted by ethical dilemmas in patient care, such as interprofessional disagreements and disagreements between patients and their health care practitioners regarding care decisions. Such support is readily available and includes ethics resources and training for health care providers and other staff. In addition, national and international norms related to human rights and professional ethics must be taken into consideration when creating an ethical framework and guiding documents. The hospital operates within this framework to disclose ownership and any conflicts of interest; honestly portray its services to patients; protect confidentiality of patient information; provide clear admission, transfer, and discharge policies; bill accurately for its services and ensure that financial incentives and payment arrangements do not compromise patient care; encourage transparency in reporting organizational and clinical performance measures; establish a mechanism by which health care providers and other staff may report clinical errors and raise ethical concerns with impunity, including disruptive staff behavior related to clinical and/or operational issues; support an environment that allows free discussion of ethical concerns without fear of retribution; provide an effective and timely resolution to ethical conflicts that arise; ensure nondiscrimination in employment practices (see Glossary) and provision of patient care in the context of the cultural and regulatory norms of the country; and reduce disparities in health care access and clinical outcomes. Besides, safety and quality thrive in an environment that supports teamwork and respect for other people, regardless of their position in the hospital. Hospital leadership demonstrates their commitment to a culture of safety and set expectations for those who work in the hospital. Behaviors that are not consistent with a safe culture or that intimidate others and affect morale or staff turnover can be harmful to patient care. Key features of a program for a culture of safety include acknowledgment of the high-risk nature of a hospital’s activities and the determination to achieve consistently safe operations; an environment in which individuals are able to report errors or near misses without fear of reprimand or punishment; encouragement of collaboration across ranks and disciplines to seek solutions to patient safety problems; and organizational commitment of resources, such as staff time, education, a safe method for reporting issues, and the like, to address safety concerns. Hospital leadership evaluates the culture on a regular basis using a variety of methods, such as formal surveys, focus groups, staff interviews, and data analysis. Hospital leadership encourages teamwork and creates structures, processes, and programs that allow this positive culture to flourish. Hospital leadership must address undesirable behaviors of individuals working at all levels of the hospital, including management, clinical and administrative staff, licensed independent practitioners, and governing body members. This part consists of five (05) standards and twenty (20) measurable elements; standards are:

1.     Standard GLD. 12: The hospital’s framework for ethical 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.

2.     Standard GLD. 12.1: Hospital leadership 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.

3.     Standard GLD. 12.2: The hospital’s framework for ethical management addresses ethical issues and decision making in clinical care

4.     Standard GLD. 13: Hospital leadership creates and supports a culture of safety program throughout the hospital.

5.     Standard GLD. 13.1: Hospital leadership implements, monitors, and takes action to improve the program for a culture of safety throughout the hospital

(6) Health Professional Education and Human Subjects Research: please note that this standard applies to hospitals that provide health professional education but do not meet the eligibility criteria for Academic Medical Center Hospital accreditation. Frequently, hospitals incorporate a teaching role in their mission and are the clinical setting for portions of medical, nursing, other health care practitioners, and other student training. For example, students and trainees in medicine may spend a few months gaining clinical experience in a community teaching hospital, or a nursing program may be based in the hospital. These hospitals serve an important role; however, they are not considered academic medical center hospitals for the purpose of these standards. When the hospital participates in these types of training programs, the hospital provides a mechanism(s) for oversight of the program(s); obtains and accepts the parameters of the sponsoring academic program; has a complete record of all students and trainees within the hospital; has documentation of the enrollment status, licensure or certifications achieved, and academic classification of the students and trainees; understands and provides the required level of supervision for each type and level of student and trainee; and integrates students and trainees into the hospital’s orientation, quality, patient safety, infection prevention and control, and other programs. This section contains one (01) standard and six measurable elements; the standard is:

1.     Standard 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.

(7) Human Subjects Research: please note that this standard applies to hospitals that conduct human subjects’ research but do not meet the eligibility criteria for Academic Medical Center Hospital accreditation. Human subjects’ research on a large scale or small scale is a complex and significant endeavor for a hospital. Hospital leadership recognizes the required level of commitment and personal involvement required to advance scientific inquiry in the context of protecting the patients for whom they have made a commitment to diagnose and treat. Hospital leadership’s commitment to human subjects research is not separate from their commitment to patient care—commitment is integrated at all levels. Thus, ethical considerations, good communications, responsible leaders, regulatory compliance, and financial and nonfinancial resources are components of this commitment. One such resource is indemnity insurance to adequately compensate patients for adverse events due to the research protocol. Hospital leadership recognizes the obligation to protect patients irrespective of the sponsor of the research. A hospital that conducts clinical research, clinical investigations, or clinical trials involving human subjects provides information to patients and families about how to gain access to those activities when relevant to the patients’ treatment needs. When patients are asked to participate, they need information on which to base their decisions. That information includes expected benefits; potential discomforts and risks; alternatives that might also help them; and procedures that must be followed. Patients are informed that they can refuse to participate or withdraw participation and that their refusal or withdrawal will not compromise their access to the hospital’s services. The hospital has policies and procedures for providing patients and families with this information. This part contains five (05) standards and twenty two (22) measurable elements and standards are:

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

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

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

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

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

Overall Required Written Policies (Including Those Required in English) in GLD: The standards listed in the tables identify a requirement for twenty (20) written documents for GLD and the first one should be in English. In some cases, that document is in the form of a policy and procedure. In other cases, the document is less formal but addresses the issue identified in the standard. In many cases, a number of standards requirements or MEs can be combined into one policy and procedure. Hospitals may find it useful to group all related policies and procedures. The surveyor(s) may not need to review all these documents in detail. However, to facilitate the review, it is best to gather all of the documents into one book or identify each document by the corresponding standard number(s) if they are part of a larger document. Some of these documents need to be provided to JCI surveyors in English, and these documents are indicated in the “In English?” column in the tables. Other documents do not need to be translated. For non-English documents, the survey team will have one member able to read the documents, or alternatively, the survey team may request that one or more individuals be available to describe the contents of the document and answer questions concerning the document.

Closed Patient Medical Record Review on GLD: This session is held to validate the hospital’s compliance with the documentation track record started with 4 months for initial surveys and 12 months for triennial surveys.

• The survey team leader may request 5 to 10 closed records for review. The records will be requested if the surveyor(s) wants to validate the hospital’s documentation track record (4-month or 12-month) and/or to ensure compliance with documentation or patient care process requirements due to situations or information identified during the tracer activities.
• The survey team will also indicate the time period for selecting the records, typically the past 4 or 12 months. Hospital staff should acquaint the survey team with the hospital’s practice and expectation regarding the completion of a patient record following discharge of the patient.
• For the Closed Patient Medical Record Review, hospital leaders should provide one staff member with a translator (if needed) for each surveyor involved in the Closed Patient Medical Record Review. To assist the surveyor(s), the selected staff person(s) should be knowledgeable about the medical record and the clinical care processes. Academic medical center hospitals are encouraged to include residents and fellows in the record review.
• The surveyor(s) will review the selected records with the assistance of the hospital representative, as needed, to complete the form. One column of the form is completed for each record reviewed. If more than five records are reviewed, the surveyor(s) will use another form.
• For each documentation requirement, the surveyor(s) will check “Y” (yes) on the form to indicate that the required element is present, “N” (no) if the element is not present or “NA if the element is not applicable to that patient’s record.
• The survey team aggregates the completed review forms to score the standards. The findings from the active or open review of patient records are integrated into aggregation and scoring.
• For GLD, the required data validation form (GLD.18) listed in the table will be checked by surveyor to validate GLD standards.
• The survey team leader retains the forms to support the survey findings.

Healthcare organizations also have a unique characteristic. That is, the chief executive is not the only part of the organization’s leadership that is directly accountable to the governing body. In healthcare, because of the unique professional and legal role of licensed independent practitioners within the organization, the organized licensed independent practitioners—in hospitals, the medical staff—are also directly accountable to the governing body for the patient care provided. So the governing body has the overall responsibility for the quality and safety of care, and has an oversight role in integrating the responsibilities and work of its medical staff, chief executive, and other senior managers into a system that achieves the goals of safe, high-quality care, financial sustainability, community service, and ethical behavior. This is also the reason that all three leadership groups—the governing body, chief executive and senior managers, and leaders of the medical staff—must collaborate if these goals are to be achieved. Besides, the members of the governing body of a healthcare organization face both extra challenges and extra rewards. The rewards can not only outweigh the challenges, but can be fulfilling to a degree not often experienced in other endeavors. Decentralization through the establishment of hospital governing boards has been touted as an effective way to improve the quality and efficiency of hospitals in low-income countries at national level. Although several studies have examined the process of decentralization, few have quantitatively assessed the implementation of hospital governing boards and their impact on hospital performance. Strengthening hospital governing boards to perform essential activities could result in improved hospital performance, in a variety of areas including quality and finance. Moreover, the healthcare delivery system is going through a period of unprecedented change. In order to achieve the Triple Aim of better health and healthcare at an affordable cost, some new delivery models will require new levels of collaboration and partnership between physician and hospital or health system executives who organize care, and physicians who are at the front lines of care delivery. Healthcare leadership between clinicians and managers must be advanced to establish new ways to deliver efficient and coordinated care. While challenges exist, they are not insurmountable when professionalism, respect and cooperation are at the core of this partnership and when the vision is clear how best safety and quality of care to meet the needs of their patients and communities that they are privileged to serve.

The GLD standards will guide to establish those relationships and cooperation with one goal: Patient Safety First!