Q&A: How do I include my team in tracking compliance issues?

Q: I am having trouble getting staff involved in ongoing compliance readiness. Do you have any advice on how to orient staff to recognize and correct any compliance issues that might be in the organization?

A: Think about how complex a process it is for you to manage The Joint Commission’s requirements. Now imagine how difficult this is for staff members who don’t deal with it every day. The lingo and acronyms alone are worthy of their own dictionary! In addition to reviewing the charge to the teams, provide an overview of where the organization is relative to compliance. Aside from the team’s responsibilities, orient staff members to the tools that are available, the chart review process, scoring for compliance, and data collection. The more open you are, the more likely your staff will understand what you are trying to accomplish with ongoing readiness.

It is important as your teams move through the self-assessment process that a system of checks and balances is put in place. For example, if a staff member asks a question about a standard’s applicability in the organization or if the intent of an EP is unclear, it’s important that the staff member knows where to go to find the answer. This system of checks and balances can be in the form of a team member or oversight group to whom issues can be raised. Most importantly, your biggest system of checks and balances is the requirement for evidence of compliance. “Show me the data” to support compliance is a phrase that teams should adopt. You want to ensure that there are no surprises at the back end and that issues are raised when they are identified.

Editor’s Note: Do you have a question about clarifying RFIs, policy management, or survey-prep for our experts? E-mail your queries to Jaclyn Beck at jbeck@hcpro.com and receive one-on-one advice from our experienced advisory board. Submit a question and our credible sources will provide you with a timely answer.