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Joint Commission Disruptive Behavior Standard

LD.03.01.01

Leaders create and maintain a culture of safety and quality throughout the hospital.

Elements of Performance

   1.  Leaders regularly evaluate the culture of safety and quality using valid and reliable tools.
   2.  Leaders prioritize and implement change identified by the evaluation.
   3.  Leaders provide opportunities for all individuals who work in the hospital to participate in safety and quality initiatives.
   4.  The hospital has a code of conduct that defines acceptable, disruptive, and inappropriate behaviors.
   5.  Leaders create and implement a process for managing disruptive and inappropriate behaviors.
   6.  Leaders provide education that focuses on safety and quality for all individuals.
   7.  Leaders establish a team approach among all staff at all levels.
   8.  All individuals who works in the hospital, including staff and licensed independent practitioners, are able to openly discuss issues of safety and quality.
   9.  Literature and advisories relevant to patient safety are available to all individuals who work in the hospitals.
  10. Leaders define how members of the population(s) served can help identify and manage issues of safety and quality within the hospital.

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