Recruiting and training chapter leaders

As The Joint Commission shifted to a more integrated survey, many hospitals moved away from the chapter leader approach.

"In order to prepare well for a survey, you still need someone to own that chunk of content even if the content crosses multiple chapters," says Kate Fenner, managing director of Compass Clinical Consulting. "You had a team that was charged with responsibility and individuals who knew which content they owned."

Finances also play a role in some healthcare organizations' shift to the integrated approach. "When times get financially tough, senior leadership cuts back on the number of meetings and resources [are] pulled away from other things," says Sena Blickenstaff, principal with Blickenstaff Clinical Consulting. "The concept of chapter leaders is difficult for senior leaders to truly appreciate, so chapter leaders and committee works are dissolved."

Leadership's role in accreditation is key in ensuring the team is committed to regulatory compliance. "The significant deficit is that accreditation people need a strong executive sponsor to provide energy, focus, and impetus to get people focused on the task at hand," says Fenner.

This is an excerpt from an article in Briefings on The Joint Commission. Visit here to log in or subscribe.