Q&A: Ongoing compliance success: Orientation considerations

Q: Do you have any suggestions for how to conduct orientation on survey readiness?

A: You can make orientation a fun process. One organization created a game of “Joint Commission Jeopardy” modeled after the television game show to create excitement.

Review with the team and team leaders what evidence constitutes compliance with an EP. Provide examples in key areas, such as what it means when documentation is required and how to review an existing policy to capture all the necessary elements. For example, the changes to the NPSGs for surgical site infections (NPSG.07.04.01) and central line infections (NPSG.07.05.01) have modified the term “evidence-based practice” to “methods cited in scientific literature or endorsed by professional organizations.” Staff members need to understand how to interpret this requirement and how your practices are tied to literature or professional association endorsement.