Governance responsibilities and accountabilities are described in written documents. Those responsible for governance approve the organization's mission statement. Do those responsible for governance ensure the periodic review of the organization's mission?
Governance responsibilities and accountabilities are described in written documents. Those responsible for governance approve the organization's mission statement. Do those responsible for governance ensure the periodic review of the organization's mission?
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Governance responsibilities and accountabilities are described in written documents. Those responsible for governance approve the organization's mission statement. Do those responsible for governance ensure the periodic review of the organization's mission?
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online from Scribd
Joint Commission International Accreditation Hospital Survey Process Guide
Accreditation Preparedness Checklist: Governance, Leadership, and Direction (GLD)
If No, Action(s) Compliant If Yes, Needed to with Evidence of Achieve Due Person Standard and Measureable Element(s) standard? Y/N Compliance Compliance Date Responsible Standard GLD.1 Governance responsibilities and accountabilities are described in bylaws, policies and procedures, or similar documents that guide how they are to be carried out. 1. Is the organization’s governance structure described in written documents? Are those responsible for governance and managing identified by title or name? 2. Are governance responsibilities and accountabilities described in the documents? 3. Do the documents describe how the performance of the governing entity and managers will be evaluated and any related criteria? 4. Is there an annual documented performance evaluation of governance? Standard GLD.1.1 Those responsible for governance approve and make public the organization’s mission statement. 1. Do those responsible for governance approve the organization’s mission? 2. Do those responsible for governance ensure the periodic review of the organization’s mission?
Joint Commission International Accreditation Hospital Survey Process Guide Accreditation Preparedness Checklist: Governance, Leadership, and Direction (GLD) If No, Action(s) Compliant If Yes, Needed to with Evidence of Achieve Due Person Standard and Measureable Element(s) standard? Y/N Compliance Compliance Date Responsible 3. Do those responsible for governance make public the organization’s mission? Standard GLD.1.2 Those responsible for governance approve the policies and plans to operate the organization. 1. Do those responsible for governance approve the organization’s strategic and management plans and operating policies and procedures? 2. When approval authority is delegated, is it is defined in governance policies and procedures? 3. Do those responsible for governance approve organization strategies and programs related to health care professional education and research? Do they provide oversight of the quality of such programs? Standard GLD.1.3 Those responsible for governance approve the budget and allocate the resources required to meet the organization’s mission. 1. Do those responsible for governance approve the organization’s capital and operating budget(s)? 2. Do those responsible for governance allocate the resources required to meet the organization’s mission?
Joint Commission International Accreditation Hospital Survey Process Guide Accreditation Preparedness Checklist: Governance, Leadership, and Direction (GLD) If No, Action(s) Compliant If Yes, Needed to with Evidence of Achieve Due Person Standard and Measureable Element(s) standard? Y/N Compliance Compliance Date Responsible Standard GLD.3.2 The leaders identify and plan for the type of clinical services required to meet the needs of the patients served by the organization. 1. Do organization plans describe the care and services to be provided? 2. Are the care and services to be offered consistent with the organization’s mission? 3. Do leaders determine the type of care and services to be provided by the organization? 4. Do leaders have a process for reviewing and approving, before use in patient care, those procedures, technologies, and pharmaceutical agents identified as experimental? Standard GLD.3.2.1 Equipment, supplies, and medications recommended by professional organizations or by alternative authoritative sources are used. 1. Does the organization use the recommendations of professional organizations and other authoritative sources to identify the equipment and supplies it will need to provide the planned services? 2. Are recommended equipment, supplies and medications obtained as appropriate?
Joint Commission International Accreditation Hospital Survey Process Guide Accreditation Preparedness Checklist: Governance, Leadership, and Direction (GLD) If No, Action(s) Compliant If Yes, Needed to with Evidence of Achieve Due Person Standard and Measureable Element(s) standard? Y/N Compliance Compliance Date Responsible 3. Are recommended equipment, supplies and medications used? Standard GLD.3.3 The leaders are accountable for contracts for clinical or management services. 1. Is there a process for leadership accountability of contracts? 2. Does the organization have a written description of the nature and scope of services provided through contractual agreements? 3. Do services provided under contracts and other arrangements meet patient needs? 4. Do clinical leaders participate in the selection of clinical contracts and provide accountability for clinical contracts? 5. Do management leaders participate in the selection of management contracts and provide accountability for management contracts? 6. When contracts are renegotiated or terminated, does the organization maintain the continuity of patient services?
Joint Commission International Accreditation Hospital Survey Process Guide Accreditation Preparedness Checklist: Governance, Leadership, and Direction (GLD) If No, Action(s) Compliant If Yes, Needed to with Evidence of Achieve Due Person Standard and Measureable Element(s) standard? Y/N Compliance Compliance Date Responsible 2. Do medical, nursing, and other leaders participate in relevant quality improvement and patient safety processes? 3. Is professional performance measured as part of clinical performance improvement? Standard GLD.3.5 Organization leaders ensure that there are uniform programs for the recruitment, retention, development, and continuing education of all staff. 1. Is there a planned process for staff recruitment? 2. Is there is a planned process for staff retention? 3. Is there a planned process for staff personal development and continuing education? 4. Is the planning collaborative and does it include all departments and services in the organization? Standard GLD.4 Medical, nursing, and other leaders of clinical services plan and implement an effective organizational structure to support their responsibilities and authority. 1. Is there an effective organizational structure(s) used by medical, nursing, and other leaders to carry out their responsibilities and authority?
Joint Commission International Accreditation Hospital Survey Process Guide Accreditation Preparedness Checklist: Governance, Leadership, and Direction (GLD) If No, Action(s) Compliant If Yes, Needed to with Evidence of Achieve Due Person Standard and Measureable Element(s) standard? Y/N Compliance Compliance Date Responsible 2. Is the structure(s) appropriate to the organization’s size and complexity? 3. Do the organizational structure(s) and processes support professional communication? 4. Do the organizational structure(s) and processes support clinical planning and policy development? 5. Do the organizational structure(s) and processes support oversight of professional ethical issues? 6. Do the organizational structure(s) and processes support oversight of the quality of clinical services? Standard GLD.5 One or more qualified individuals provide direction for each department or service in the organization. 1. Is each department or service in the organization directed by an individual with the training, education, and experience comparable to the services provided? 2. When more than one individual provides direction, are the responsibilities of each are defined in writing?
Joint Commission International Accreditation Hospital Survey Process Guide Accreditation Preparedness Checklist: Governance, Leadership, and Direction (GLD) If No, Action(s) Compliant If Yes, Needed to with Evidence of Achieve Due Person Standard and Measureable Element(s) standard? Y/N Compliance Compliance Date Responsible Standard GLD.5.1 The directors of each clinical department identify, in writing, the services to be provided by the department. 1. Have department or service directors selected and do they use a uniform format and content for planning documents? 2. Do the departmental or service documents describe the current and planned services provided by each department or service? 3. Do each department’s or service’s policies and procedures guide the provision of identified services? 4. Do each department’s or service’s policies and procedures address the staff knowledge and skills needed to assess and meet patient needs? Standard GLD.5.1.1 Services are coordinated and integrated within the department or service and with other departments and services. 1. Is there coordination and integration of services within each department or service? 2. Is there coordination and integration of services with other departments and services?
Joint Commission International Accreditation Hospital Survey Process Guide Accreditation Preparedness Checklist: Governance, Leadership, and Direction (GLD) If No, Action(s) Compliant If Yes, Needed to with Evidence of Achieve Due Person Standard and Measureable Element(s) standard? Y/N Compliance Compliance Date Responsible Standard GLD.6 The organization establishes a framework for ethical management that ensures that patient care is provided within business, financial, ethical, and legal norms and that protects patients and their rights. 1. Do organization leaders establish ethical and legal norms that protect patients and their rights? 2. Do the leaders establish a framework for the organization’s ethical management? 3. Do the leaders consider national and international ethical norms when developing the organization’s framework for ethical conduct? Standard GLD.6.1 The organization’s framework for ethical management includes marketing, admissions, transfer, and discharge, and disclosure of ownership and any business and professional conflicts that may not be in patients’ best interests. 1. Does the organization disclose its ownership? 2. Does the organization honestly portray its services to patients? 3. Does the organization provide clear admission, transfer, and discharge policies? 4. Does the organization accurately bill for services?
Joint Commission International Accreditation Hospital Survey Process Guide Accreditation Preparedness Checklist: Governance, Leadership, and Direction (GLD) If No, Action(s) Compliant If Yes, Needed to with Evidence of Achieve Due Person Standard and Measureable Element(s) standard? Y/N Compliance Compliance Date Responsible 5. Does the organization disclose, evaluate, and resolve conflicts when financial incentives and payment arrangements compromise patient care? Standard GLD.6.2 The organization’s framework for ethical management supports ethical decision making in clinical care and nonclinical services. 1. Does the organization’s framework for ethical management support those confronted by ethical dilemmas in patient care? 2. Does the organization’s framework for ethical management support those confronted by ethical dilemmas for nonclinical services? 3. Is support readily available? 4. Does the organization’s framework provide for safe reporting of ethical and legal concerns?