Conflict Management: A Joint Commission Requirement

I recently had lunch with a person who works in the compliance world. He is very knowledgeable, but was surprised to learn that The Joint Commission requires hospitals to maintain a conflict management process for accreditation purposes.  So, in the event that others could use this information as well, here you go:

The Joint Commission mentions conflict management in several of it accreditation standards and elements of performance ("EPs").  Leadership Standard .01.03.01, EP 7, requires “a system for resolving conflicts among  individuals working in the hospital.” For 2009, the Joint Commission added a new Leadership Standard that called for a formal process of managing conflict between leadership groups to protect the quality and safety of care.  The rationale behind this addition was a recognition that conflict occurs even in well-functioning organizations, and while it may at times be productive, unresolved conflict at the leadership level, whether regarding practices, procedures, policies or otherwise, may adversely impact the quality of patient care.

The language of Standard LD.02.04.01* was originally issued as follows:

The [organization] manages conflict between leadership groups to protect the quality and safety of care. 

The related EPs were originally issued as follows:

1. Senior managers and leaders for the organized medical staff work with the governing body to develop an ongoing process for managing conflict among leadership groups.
2. The governing body approves the process for managing conflict among leadership groups.
3. Individuals who help the hospital implement the process are skilled in conflict management. Note: These individuals may be from either inside or outside the hospital. (*This EP was eliminated in July 2010.)
4. The conflict management process includes the following:

-          Meeting with the involved parties as early as possible to identify the conflict

-          Gathering information regarding the conflict

-          Working with the parties to manage, and, when possible, resolve the conflict

-          Protecting the safety and quality of care

5.   The hospital implements the process when a conflict arises that, if not managed, could adversely affect patient safety or quality of care.

What does this require from your organization? I suggest including the following:

·    Develop a conflict management policy, procedure and process with input from stakeholders and approved by the governing body.

·    Identify and document the process steps for addressing conflict from its earliest stages.

·    Educate your workforce, from volunteer staff to clinical staff to administration, on policy and procedure, and the impact on patient care and safety if a conflict is not addressed.

·    Process should involve information gathering and working with parties to resolve issues.

·    Identify resource(s) skilled in conflict management to assist your organization in meeting this standard.

·    And finally, reaffirm your organizational commitment to a culture of excellence and integrity, safety and quality, with an understanding that a unified care team is your best option for optimal patient care.