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The Importance of Leadership: The Joint Commission’s New Hospital Accreditation Chapter on Patient Safety

By Frank Federico | Friday, October 24, 2014

On October 20, 2014, The Joint Commission (TJC) issued a new “Patient Safety Systems” chapter in the 2015 Comprehensive Accreditation Manual for Hospitals. In this post, IHI Executive Director Frank Federico, RPh, comments on the chapter's emphasis on leadership.


The Joint Commission’s new "Patient Safety Systems" chapter is a blueprint for leaders that uses existing standards to achieve an integrated approach to patient safety. According to the Joint Commission, “While this chapter does not include new accreditation requirements, it describes how existing requirements can be applied to achieve improved patient safety. It is also intended to help all health care workers understand the relationship between Joint Commission accreditation and patient safety.”

The chapter includes a description of the role of leaders, along with a list of the standards related to leadership, data collection, and patient rights. To provide clearer guidance on how all of the standards work together to ensure patient safety, it lists all of the standards related to leadership together in this one resource.

According to Ronald M. Wyatt, MD, MHA, Medical Director, Office of the Chief Medical Officer of The Joint Commission, TJC's goal is "to provide a patient safety chapter that lays out an integrated framework focused on the role of leadership, culture of safety, and performance improvement." He adds, "The chapter is intended to be forward leaning, contemporary, and to encourage staff to take proactive steps to reduce harm to zero."

For the first time, the Joint Commission is providing a standards chapter online. This makes this resource freely available to a variety of health care stakeholders, including leaders of accredited hospitals, non-accredited facilities, ambulatory care centers, nursing homes and other related settings, and patients.

IHI’s work on the crucial role leaders must play to improve health care quality and patient safety supports the Joint Commission standards. Below is a list of IHI resources on the role of leaders (all are available for free on IHI.org):

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