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TJC Leadership

Accreditation Sustainment 2020
Across
The hospital has a ____________ structure. LD.01.01.01
Leaders solicit comments from those who work in the hospital when _________ the operational and capital budgets. LD.04.01.03 EP1
The chief executive identifies a _____ leader at the executive level who participates in decision making. LD.01.04.01 EP5
The mission, vision, and goals of the hospital support the safety and quality of care, _______, and services. LD.02.01.01
Leaders act on or comply with reports or _________________ from external authorized agencies, such as accreditation, certification, or regulatory bodies. LD.04.01.01 EP3
Staff are held accountable for their _______________. LD.04.01.05 EP4
The governing body is ultimately ___________ for the safety and quality of care, treatment, and services. LD.01.03.01
The governing body, senior managers, and leaders of the organized medical staff work together to develop a written ______ that defines how conflict of interest involving leaders will be addressed. LD.02.02.01 EP2
The hospital has a systematic approach to change and performance _______. LD.03.05.01 EP1
Leaders regularly ______ the culture of safety and quality using valid and reliable tools. LD.03.01.01 EP1
Communication processes are _____ in fostering the safety of the patient and his or her quality of care. LD.03.04.01 EP1
Leaders evaluate how effectively data and information are used throughout the______. LD.03.02.01 EP2
Down
Planning activities focus on improving patient safety and health care quality and adapting to changes in the _________. LD.03.03.01 EP1
Leaders design work processes to focus individuals on safety and ____ issues. LD.03.06.01 EP1
Leaders review, approve, and manage the _______________ of policies and procedures that guide and support patient care, treatment, and services. LD.04.01.07 EP1
The hospital provides care, treatment, and services in accordance with licensure requirements, laws, rules, and ________. LD.04.01.01 EP2
Variances in staff, setting, or payment source do not affect outcomes of care, treatment, and services in a __________ way. LD.04.03.07 EP1
The hospital’s emergency services are directed and __________ by a qualified member of the medical staff. LD.04.01.05 EP6
The leaders provide and encourage the use of systems for blame-free internal reporting of a system or process failure, or the results of a proactive risk ______. LD.03.09.01 EP3
The hospital provides ______________ pain treatment modalities. LD.04.03.13 EP2
The organized medical staff is accountable to the governing body for the quality of care provided to________. LD.01.05.01 EP6
The grounds, equipment, and special activity areas are safe, ________ , and supervised. LD.04.01.11 EP4
Senior managers and leaders of the organized medical staff work with the ________ body to define their shared and unique responsibilities and accountabilities. LD.01.02.01 EP1
Emergency laboratory services are available 24 hours a day, _____ days a week. LD.04.03.01 EP26