The Joint Commission (which has always been the informal name for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and which will now be its formal name) has proposed disruptive behavior standards for Joint Commission accreditation, which it intends to apply in early 2007.

The new standard, LD.3.15, will state: “As a critical component of the culture of safety, leaders set expectations for behavior among those who work in the organization.” The new elements of performance will be as follows:

1.         The leaders develop a code of conduct that applies to everyone who works in the organization.

2.         The code of conduct defines desirable and disruptive behavior.

3.         All who work in the organization are educated about both desirable and disruptive behaviors.

4.         The leaders develop processes for managing disruptive behavior.

5.         Leaders identify the rules of individual leadership groups in managing disruptive behavior.

6.         The organized medical staff manages disruptive behavior exhibited by physicians or individuals who are granted clinical privileges.

7.         Leaders establish a fair hearing process for those who exhibit disruptive behavior.