What’s worse? Having a policy you don’t follow or not having a policy at all?

I thought of this conundrum recently while preparing a client for an upcoming Joint Commission survey. We were working through the new 2009 Leadership Chapter – addressing disruptive behavior, creating a culture of safety and managing conflicts. When asked to supply documentation, as is required in a number of standards in this chapter, the Vice-President dutifully complied by sharing various policies with appropriately matching titles. So far so good. But just like the Joint Commission, Navvis & Company utilizes Tracer Methodology when assessing a client’s readiness for a survey. It didn’t take long to realize, policies or not, this hospital had some work to do to meet the intent of the standards located in this chapter.

I know it can be easy to focus on the deliverable or the one item that says, when done, you can now check it off your list. Unfortunately, words like “culture” and “conflict” don’t lend themselves to easy solutions. But, I believe there’s a bright side. I think focusing on the documentation is causing us to miss opportunities. I say, let’s look at the new and improved Leadership Chapter as a gift from the Joint Commission. A gift to anyone who has struggled with getting hospital administration, the Board of Directors and the Medical Staff to sit around a table and work together to provide the best care possible. It’s really the answer for anyone who works in a facility where the same quality report is given three different times, to three distinct groups, on three separate days. What might happen if those three groups were all sitting in the room at the same time, hearing this information and working collaboratively to improve patient care? Now that’s a policy that writes itself!