1. Hader, Richard RN, CNA, CHE, CPHQ, PhD, FAAN, Editor-in-Chief, Senior Vice President and Chief Nurse Officer

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The rules and requirements that regulatory agencies impose on organizations can drive any healthcare leader crazy!! The Centers for Medicare and Medicaid Services, the Department of Health and Human Services, and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) continually issue new rules, necessitate increased documentation, implement mandatory safety standards, and-most recently-require public reporting of the level of success in achieving clinical outcome measures.

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This most recent development allows regulatory agencies to enter your organization at any time and expect to immediately evaluate patient care delivery. Why are they pressuring an already taxed system? As leaders, are we struggling to meet these regulations for fear of reprisal from governing authorities, or are we working to exceed requirements because it's the right thing to do?


To achieve practice excellence, we need to expect that excellence is nonnegotiable. Organizational culture must move from that of simply meeting regulatory requirements to that of implementing best practices to improve patient care. We need to start viewing the standards and criteria of regulatory agencies as a blueprint for success, not a prescription for failure.


Case in point: JCAHO now uses an unannounced survey process. Organizations no longer have months to prepare staff. This dramatic alteration in methodology requires us to be in a constant state of readiness, or we'll jeopardize the accreditation process. Intimidating? Yes. It necessitates that we ingrain within the fabric of our organizations the need to provide excellence in care with each and every interaction. All healthcare team members must be held accountable, at all times, to perform to the best of their ability.


Remember, staff education regarding performance standards is our responsibility. Tailor periodic and repetitive educational sessions to specific staff needs to build an infrastructure that promotes continual learning and increases the likelihood that the staff will perform at a consistently high level. Tap creative strategies such as educational fairs, daily reminders, virtual training, and peer teaching.


In addition, staff members need to recognize that their leaders consider quality care an organizational priority. To demonstate your commitment, consider employing forums, weekly newsletters, leadership rounding, and regular unit-meeting attendance. Displaying a relentless attention to detail, sharing results of achievement, and insisting on changing processes are active measures that help sustain quality.


It's been more than a decade since my organization first began the journey to achieve Magnet status from the American Nurses Credentialing Center. During our initial preparation, we constantly asked ourselves why we desired to weave the principles of the Magnet Recognition Program throughout our organization's culture. We chose to carefully analyze our strengths and identify areas for improvement. The leaders' focus remained on improving the nursing work environment so that patients could reap the benefits of being cared for by highly educated and engaged professionals. If we hadn't achieved the Magnet distinction, our efforts wouldn't have been wasted because we knew we were following a guide to success.


Meeting standards for the sake of passing an inspection or receiving an award won't drive the future needs of your organization. Doing your best to achieve great things for patient care will prevail because it's the right thing to do.