New Standard Number: LD.01.03.01
The governing body is ultimately accountable for the safety and quality of care, treatment, and services.
(Note: The new numbering system is effective January 2009.)
Elements of Performance for LD.01.03.01
1. Leaders regularly evaluate the culture of safety and quality using valid and reliable tools.
2. Leaders prioritize and implement changes 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. (Also see
“Your Organization’s Code of Conduct Policy” article beginning on page 6.)
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. (See also LD.04.04.05, EP 6.)
7. Leaders establish a team approach among all staff at all levels.
8. All individuals who work 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 hospital.
10. Leaders define how members of the population(s) served can help identify and manage issues of safety and quality within
the hospital.
Current Standard Number: LD.3.10
Leaders create and maintain a culture of safety and quality throughout the organization.
Note: Please visit the Joint Commission’s Web site (http:\\www.jointcommission.org) to view the standard and revised numbering
system, effective January 2009.