Joint Commission Review Crosswalk for Chaplain Services

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in the analysis of data or a single undesirable event),it includes the adequacy of staffing, including nursestaffing, in its analysis of possible causes.Note 1: Adequacy of staffing includes the number,skill mix, and competency of all staff. In theiranalysis, hospitals may also wish to examine issuessuch as processes related to work flow; competencyassessment; credentialing; supervision of staff; andorientation, training, and education.PI.03.01.01 The hospital improves performance.Elements of Performance:1. Leaders prioritize the identified improvementopportunities. (See also PI.02.01.01, EP 8;MS.05.01.01, EPs 1-11)2. The hospital takes action on improvement priorities.(See also MS.05.01.01, EPs 1-11)3. The hospital evaluates actions to confirm that theyresulted in improvements. (See also MS.05.01.01,EPs 1-11)4. The hospital takes action when it does not achieve orsustain planned improvements. (See alsoMS.05.01.01, EPs 1-11)PI 04.01.01 The hospital uses data from clinical/servicescreening indicators and human resource screeningindicators to assess and continuously improve staffingeffectiveness.LEADERSHIPLD.03.02.01 The hospital uses data and information toguide decisions and to understand variation in theperformance of processes supporting safety and quality.Included in Chaplaincy’s Plan for CQI.Included in Chaplaincy’s Plan for CQI.Included in Chaplaincy’s Plan for CQI.12
Rationale:Data help hospitals make the right decisions. Whendecisions are supported by data, hospitals are more likelyto move in directions that help them achieve their goals.Successful hospitals measure and analyze theirperformance. When data are analyzed and turned intoinformation, this process helps hospitals see patterns andtrends and understand the reasons for their performance.Many types of data are used to evaluate performance,including data on outcomes of care, performance on safetyand quality initiatives, patient satisfaction, processvariation, and staff perceptions.IntroductionA hospital’s culture reflects the beliefs, attitudes, andpriorities of its members, and it influences theeffectiveness of performance. Although there may be adominant culture, in many larger hospitals diverse culturesexist that may or may not share the same values. In fact,diverse cultures can exist even in smaller hospitals.Hospital performance can be effective in either case.Successful hospitals will work to develop a culture ofsafety and quality.In a culture of safety and quality, all individuals arefocused on maintaining excellence in performance. Theyaccept the safety and quality of patient care, treatment,and services as personal responsibilities and work togetherto minimize any harm that might result from unsafe orpoor quality of care, treatment, and services. Leaders13
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Joint Commission Review Crosswalk for Chaplain Services

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