The Compliance Guide to The Joint Commission Leadership Standards

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The Compliance Guide to The Joint Commission Leadership Standards

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The Compliance Guide to The Joint Commission Leadership Standards

Sue Dill Calloway, RN, MSN, JD

The Compliance Guide to The Joint Commission Leadership Standards provides accreditation professionals with in-depth guidance on how to prepare leadership and staff to comply with the accreditor’s Leadership standards. The book breaks down the Leadership chapter standard by standard and provides hospitals with a plethora of tools and policies to train leaders and staff on the roles they play in compliance, patient safety, and quality efforts.

This book provides:

-          Clear explanations of the Leadership standards

-          How-to strategies for developing and implementing a leadership plan

-          Tips for creating a culture of safety

-          Three customizable and downloadable PowerPoint training presentations

-          Updated tools and policies to help compliance


Table of Contents:

Chapter 1: The Leadership Session During the Survey and Introduction

Chapter 2: The Leadership Standards

Chapter 3: Leadership Relationships

Chapter 4: Hospital Culture and System Performance

Chapter 5: Operations

Appendix: Tools and Samples

  • Assessment of Community Health Needs
  • Outline for a Leadership Plan
  • Seven Steps for a Single Level of Care
  • Scope of Services Criteria—Clinical Departments Checklist
  • Scope of Services Criteria—Nonclinical Departments Checklist
  • Sample Format for a Performance Improvement Plan
  • Sample Patient Safety Plan
  • Sample Organizational Chart
  • Sample Bylaws of the Board of Trustees
  • Sample Complaint/Grievance Review
  • Sample Capital Expenditure Request Form
  • Sample Organ, Tissue, Eye Procurement Policy and Procedure
  • Sample Quality Management Plan
  • Sample Quality Management Forms: Process Improvement QAPI Summary
  • Sample Quality Management Forms: Quality Management Department Decision-Making Tools
  • Sample Quality Management Forms: Quality Review Department Request for Consideration for a TQM Team
  • Sample Quality Management Forms: Rapid Cycle Improvement Worksheet
  • Patient Safety Report Card to the Board
  • Patient Safety Plan
  • Incident Reporting Administrative Policy
  • Incident Reporting Administrative Policy: Incident Report Addendum
  • Incident Reporting Administrative Policy: Adverse Drug Event—IV Infiltration Incident Report
  • Incident Reporting Administrative Policy: Equipment Malfunction Incident Report
  • Incident Reporting Administrative Policy: Medication Error Incident Report
  • Incident Reporting Administrative Policy: Miscellaneous Incident Report
  • Incident Reporting Administrative Policy: Patient/Visitor Fall Incident Report
  • Root Cause Analysis Incident Investigation Tool
  • Three PowerPoint presentations to help you train leadership and staff


About the Author:

Sue Dill Calloway, RN, MSN, JD, is a well-known speaker, nurse, attorney, and president of patient safety and healthcare consulting and education. She is the past director of risk management and patient safety for The Doctors Company and the past chief learning officer for the Emergency Medicine Patient Safety Foundation. She has given many presentations locally and nationally to nurses, physicians, and attorneys on medical and legal issues, and has authored more than 1,000 articles and 100 books. She has been a medico-legal consultant for more than 35 years and conducts educational programs for nurses, physicians, and other healthcare providers on topics such as The Joint Commission, CMS, documentation, medication errors, patient safety, and risk management.

Published, December 2014