Assuming the mantle of leadership requires embracing the responsibility of establishing organizational practices derived from the mission, purpose, and goals of the organization. In health care settings, these practices are formalized through policy and procedure development, clinical care pathways and bundles, electronic health records, and more. The focus of this article is to make explicit for professional development educators the role they play in orienting leaders to their role as standard bearers and evaluators.
The function of standards development is to set in motion a formal statement that defines measurable behaviors that reflect a foundation for quality. Leaders hold the responsibility for setting standards, ensuring that their colleagues adhere to the behaviors reflected in the standards, and measuring the effects or outcomes associated with the norm. Standards help define the organizational culture and reputation that those seeking health services can expect, both minimally and optimally. When formalizing a standard, it should be made clear whether it reflects the minimum expectations (for which complete adherence is expected) or reflects the optimal standards (which exceeds the customary norms found in common practice, but for which an organization may want to distinguish itself by exceptional care).
Standards development is driven by many sources and represents many dimensions of organizational performance. The originating source for standards may come from federal or other regulatory agencies, such as the Occupational Safety and Health Administration, an agency that establishes standards for worker health and safety. Through its standards, the Joint Commission communicates a range of plant technology and safety norms that protect workers and patients and then extends into standards for clinical practices to include areas such as patient assessment and infection control. The Agency for Healthcare Research and Quality sets forth clinical standards that are research-driven compilations, which form the foundation for evidence-based clinical practices.
Not all standards are necessarily driven by evidence but still represent expectations to uphold. An organizational standard that defines the dress code for various types of workers is one such example of a human resource standard. Standards defining how illness, pregnancy, vacation, and other time-away events may be a combination of federal or state laws combined with preferred institutional norms.
The examples noted provide samples of sources that are references for or are written as standards, and, further, demonstrate the variability of subject matter that leaders must consider when developing standards. They also define three prominent areas in health care standards development: clinical care, human resources, and safety. Current leaders must possess knowledge of best practices, research findings, and regulatory expectations in a wide range of subject matters. Armed with current knowledge, leaders must translate knowledge into standards of care and practices using mechanisms for communication known within the organization. Standards expressed through policies, procedures, or practice protocols must be clear, simple, accessible, and easy for intended users to grasp. Users are not limited to providers. In light of transparency, standards may extend beyond practitioners and be available to the public, particularly regarding patient rights and responsibilities, which includes standards for patient incident reporting.
The Four-Point Framework for Developing Standards
As noted, standards can derive from multiple sources and represent a broad array of subject matter and scope. An organizing framework is offered to simplify the work of standards organization and development. The author developed this framework earlier in his career, and it continues to influence his thinking in helping leaders embrace their role and responsibilities in standards creation.
Primary standards are essential, fundamental, and vital minimal standards applied to all patients. Regardless of the clinical setting or disease classification, these standards are rooted in managing human dignity, maintaining function, and being safe. Included in primary standards are the norms set for pain management, skin and oral care, patient confidentiality, engagement and education regarding care decisions, and other foci that the leader establishes as primal to the care experience. Ideally, primary standards are set for an entire organization, making adherence and measurement consistent across service lines. Primary standards also ease providers who accept assignments on other units, forming the basis for uniformity in care.
Institutions vary widely in the procedures it allows to be performed. A procedure should be standardized to the extent that the patient can expect comparable behaviors across units and the providers who perform it. Procedural standards start with the identification of who is qualified to perform a task based on risk factors, under what circumstances or directives the procedure can be performed, and with the training, experience, or level of supervision needed for safe outcomes. The procedure should be carried out consistently with primary standards, provide a best-practice sequence of steps to follow, and elucidate the documentation and outcomes measurement requirements for postprocedure evaluation.
Patients who enter the hospital typically are categorized largely by disease and, in the case of surgical patients in particular, a defined hospital trajectory can be planned. This is seen frequently with patients who have had cataract surgery, orthopedic procedures, cardiovascular procedures, and more. Clinical experts define the projected course of treatment based on desired and anticipated outcomes. These trajectories are expressed as population-specific standards.
Not all clinical conditions are best expressed as medical diagnoses. Clinical populations, such as the elderly, may be subject to falls, creating a different type of population: those at risk for injury. Still other patients may have an undiagnosed inflammatory or infectious state that defies a specific diagnosis on admission, yet care management standards can be developed to protect staff and the patient from risk for cross-infection or advancement to sepsis.
Population-specific standards are based on evidence that is derived from disease-specific knowledge; others are based on principles linked to preventive health care and health promotion. The standards are reflected in care plans or pathways, clinical protocols, or care bundles. They may be expressed in written formats but are increasingly embedded in electronic health records.
Health care leaders are increasingly drawn into the policy arena to provide testimony and to shape health care delivery. When leaders address public audiences, it is to reflect on and ensure issues that address access to care, ensure care along the health continuum (including palliative and end-of-life needs), represent the needs of a population (as far-reaching as advocating for children with asthma or promoting practices to prevent premature births), and more. Many states are currently addressing the scope of practice for nurses, physicians, and other providers. Using knowledge from primary standards (minimum safe and effective care), procedural practices (to address the scope of practice), and population-specific standards (to influence vresources) prepares the leader for public policy conversations. In the case of public policy, standards are reflected in written testimony and eventually law.
We live in an age of accountability, rapid scientific advancement, resource management, and shifting care delivery options. At the core are standards that drive the behaviors used by providers to ensure quality and safety and mitigate risk. As experts, professional development educators bring to the organization scholarship, knowledge of clinical practice, emerging technologies, and regulatory demands. Leaders partner in unique ways with professional educators and bear the responsibility for setting, implementing, and evaluating standards to ensure mission success. The scope and depth associated with communicating standards is complex. This four-point framework is suitable to conceptualize and present standards to those responsible for upholding them.