Joint Commission Coming Attractions

The Joint Commission is always on the move. Changes are driven by CMS and by Joint Commission initiatives focused on improving quality and patient safety. This year several features several new or revised survey activities.

Near the top of the list is the new validation survey process being tested by CMS. The new process for all accreditation organizations (AO) includes on site validation by a CMS team during a scheduled Joint Commission or other AO. The CMS team will be the same size as the AO team. The intent is for the CMS team to evaluate the work of the AO team to determine how well the AO team evaluates compliance with the Medicare Conditions of Participation. CMS participation will be unannounced to both the accrediting organization and the hospital. Not all validation surveys will be done in this manner. The others will be done in the traditional manner with a CMS team following an accreditation team within a few days or weeks.

The Joint Commission innovations include a more integrated mobile survey technology platform (MST). The new software integration is designed to encourage surveyors to use tablet devices throughout their work day to record findings as they work rather than taking notes and transcribing them later. The integration allows the surveyors to access many more resources, such as standards interpretation guidance, seamlessly. The new capability has the potential to further improve surveyor consistency and reduce the amount of time surveyors spend preparing documentation after completing the days on site.

Several standards changes are in the works. These are best tracked through the Joint Commission web site ( The proposed changes are posted for comment and, when finalized, posted with the effective date. Checking the site frequently is the best way to maintain alignment with the changing standards during the years between surveys.

The Leading the way to Zero initiative is entering version 2.0 for 2019. The updated approach is focusing on harvesting proven practices from organizations that achieve sustainable reductions in adverse patient events. The case studies will form a resource library for all accredited organizations. This will be tied into the standards for the safety culture assessment. During surveys questions are likely during the leadership conference as well as tracers. Individual staff members are likely to be asked about their knowledge of and participation in activities designed to build a strong culture of safety.

Recently published survey data shows that hospitals surveyed over the course of most of 2018 received an average of 32.4 RFI’s. The most frequently cited issue for the EC standards was EC.02.01.01 EP 1 for ligature risk issues. This is likely to be the case during 2019 as the focus on creating ligature safe environments in dedicated behavioral health units in acute care hospitals may be even more intense.

More on this topic shortly. If you have specific questions please contact me at

Being a Leader

Successful leaders are not, as many argue, born. Anyone can learn the habits that engage everyone around them. Being a leader is not holding a position with a lofty title in an organization chart. It is demonstrating habits that others relate to and seek out. A leader is able to draw people to a cause and inspire them to follow. There are many lists of what it takes to be a successful leader. Some of my personal favorites are as follows.

Number one in my book is to be approachable. Another word for approachable is vulnerable. Vulnerability is tricky because many people mistake it for weakness. As a leadership behavior, vulnerability is the root of accountability, hope, empathy, and authenticity. Being approachable means, above all, that you demonstrate that everyone is worth your time and attention.

Hard on the heels of approachable is positive. Everyone around you is fighting personal battles you know nothing about. Those battles drag them down and create barriers. Demonstrating enthusiastic hope for the future in an increasingly pessimistic world makes you a shining beacon. Being positive helps them refocus and draw out their best talents and capabilities.

Integrity and accountability are next. A phrase used to describe integrity is walk the walk. Accountability means accepting the consequences of your decisions. Together integrity and accountability mean you own your decisions and actions. You don’t deflect blame to others. Many people struggle with accountability. Being accountable is hard. In the end it is always the right thing. Mahatma Gandhi said it best - “It is wrong and immoral to seek to escape the consequences of one’s acts.”

People worth following are humble. Humility is difficult to find in the world today. A couple of quotes that I refer to frequently are “A great man is always willing to be little” - Ralph Waldo Emerson and “A true genius admits that he knows nothing” - Albert Einstein. If you can learn to avoid putting yourself above others you can become a leader.

Finally people who are leaders understand that talent means nothing. Experience earned with hard work in a humble manner is everything. Only through experience gained in this way can leaders earn the trust of others. Hard won experience leads to authenticity. Authentic leaders are self-aware. They know and understand themselves. They know that vulnerability gives them a genuineness that helps them connect with people. Authenticity creates leaders with the ability to lead with grace. For me, a quote in the book True Grit by Charles Portis and later in the movie with Jeff Bridges and Hailee Steinfeld sums it up. “You must pay for everything in this world, one way and another. There is nothing free except the grace of God.” Those who are willing to pay the price of experience and apply these principles can learn to lead with grace.

New Website

Welcome to the new website for The Ode Keil Consulting Group. I am excited to be hosted by a new company that offers more flexible and easy to use capabilities. I can now more easily publish posts, news articles and other information that may be helpful to facilities managers and others as they work to achieve excellent survey outcomes and to manage their departments efficiently.

I read a wide variety of publications. I frequently find timely tips or suggestions related to accreditation preparation, management, performance improvement and other aspects of being a successful manager. I now have a way to connect my readers to that content.

I have always believed that life is a journey that requires constant learning, flexible thinking and a willingness to change. My writings over the years reflect that philosophy.

Tune in often as I will add content frequently.