Q&A: Ongoing compliance success: Orient the team

Q: Do you have any suggestions for how to keep my survey readiness team organized and prepared for survey?

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 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 is 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 leader 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 data” to support compliance is a phrase that teams should adopt. You want to ensure that there are no surprised at the back end and that issues are raised when they are identified.