A new hospital accreditation standard that addresses conflict management was implemented recently by The Joint Commission ("TJC"). Leadership Standard LD.02.04.01 ("Standard") requires hospitals to "manage conflicts between leadership groups to protect the quality and safety of care." The new standard took effect January 1, 2009.

In its introduction to the Standard, TJC states, "Conflict commonly occurs even in well-functioning hospitals and can be a productive means for positive change. However, conflict among leadership groups that is not managed effectively by the hospital ... has the potential to threaten health care safety and quality. Hospitals need to manage such conflict so that health care safety and quality is protected. To do this, hospitals have a conflict management process in place."

The Elements of Performance ("EP") for LD.02.04.01 require that:

  • The hospital's senior managers and leaders of the organized medical staff work with the hospital's governing body to develop an ongoing process for managing conflict among leadership groups. (EP 1)
  • The hospital's governing body approves the conflict management process. (EP 2)
  • Individuals who help the hospital implement the process be skilled in conflict management. (EP 3)
  • The conflict management process include the following:

a. Meeting with the involved parties as early as possible to identify the conflict.

b. Gathering information regarding the conflict.

c. Working with the parties to manage and, when possible, resolve the conflict.

d. Protection of safety and quality of care (EP 4)

  • The hospital implement the process when a conflict arises that, if not managed, could adversely affect patient safety or quality of care. (EP 5)

With regard to EP 3, TJC notes that such individuals may be from either inside or outside the hospital and that conflict management skills can be acquired through various means, including experience, education, and training.

We recommend that hospitals consider taking the following actions with regard to LD.02.04.01:

  • Identify and review current policies/procedures related to conflict management and determine what, if any changes are required based upon the TJC criteria outlined above. Bear in mind that there may be multiple conflict resolution processes throughout the organization (e.g. human resource, medical staff, etc.) that require review, and possibly, consolidation/unification.
  • Ensure that hospital and medical staff leaders work with the board to develop and/or revise the conflict management process.
  • Document board approval of the conflict management process.
  • Identify and designate the individual(s) with conflict management skills who will help the hospital implement the its conflict management process. Keep in mind that such individual(s) may require additional training and/or that assistance from an outside third party may also be desired or necessary.
  • Educate hospital and medical staff about the conflict management process.
  • Implement the process when warranted and maintain appropriate documentation related thereto.

The American Health Lawyers Association has prepared a Toolkit for Managing Healthcare Conflict as a complimentary resource to assist hospitals with conflict management. The Toolkit helps healthcare organizations focus on early management of disputes and includes a sample conflict management policy.