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Meeting the Joint Commission’s orientation requirements is critical for a successful survey. Surveyors review your orientation process and related documentation during the Human Resources/Competence Assessment session. Thus, it’s important to understand TJC’s orientation requirements and make sure you include those in your orientation process.

So, let’s review those requirements as well as some common pitfalls and survey strategies.

Joint Commission Orientation Standards

TJC’s requirements for staff orientation are similar in both the Hospital Standards (HR.01.04.01) and the Behavioral Health Care and Human Services Standards (HR.01.03.01.) Specifically, they require you to do the following:

Orient your staff to key safety content before they provide care, treatment, or services. Key safety content includes important patient care policies, environmental safety, and infection control.

For this requirement, you must determine what’s important enough to include in initial orientation  and what can wait until later. For example, behavior de-escalation would be essential for initial orientation in most behavioral health settings.

Orient your staff on the following topics:

# 1:  Their specific job duties and responsibilities. This should include a review of their job description as well as a hands-on orientation to their daily job duties.

Also, the Hospital standards specifically require you to include job duties related to infection control and managing pain.

# 2: Sensitivity to cultural diversity. For this one, you need to find the right content and module that fits your organization and your patient population. To hear more about TJC’s initiatives in this area, listen to Take 5: TJC’s New Diversity and Inclusion activities.

# 3: Patient rights. This includes orienting staff to your patient rights policies, the role of your Patient Advocate, and your complaint/grievance process.

Compliance Challenges

We see some common survey challenges related to orientation. So, here’s a heads-up on those:

No orientation for contract staff. Remember, the Joint Commission orientation requirements apply to both employees and contractors. TJC has clarified that in their FAQ Contract Staff – Applicability of Human Resource Standards.

The orientation for contactors needn’t be as extensive as your staff orientation. However, it should include a basic orientation to the contractor’s role, safety procedures, and any other job related duties.

Another informative TJC FAQ on this topic is Competency Assessment vs. Orientation.

No departmental orientation. Frequently, we see that organizations have strong documentation of their agency orientation but are weak when it comes to departmental orientation. Often, the departmental orientation is informal, not documented,  or can’t be located during survey.

Hence, it’s important to ensure departmental orientation is occurring consistently.  Moreover, that there’s documentation of it in a location you can access during survey.

No orientation for medical staff.  We’ve seen some recent survey findings regarding not doing orientation for medical staff. Here’s an example:

“In 2 of 7 medical staff/credentialing files, there was lack of compliance with orientation. One physician who started nine months ago had no evidence in his file indicating he received an orientation to emergency preparedness policies or procedures.  Another physician who started six months ago and is actively seeing patients also had no documentation of orientation.”

So, be sure your medical staff has an orientation tailored to their role and duties and that there’s documentation of same.

Organization-Specific Requirements for Orientation

Keep in mind: TJC surveys you not only for compliance with their standards but also with your own requirements. For example, you may require all staff to have an orientation to your playground equipment and related safety procedures. If so, the surveyors will hold you to that – even though it’s not a Joint Commission orientation requirement.

Survey Management Strategies

The following tips apply to the Human Resources/Competence Assessment Session where surveyors review your orientation process along with staff training and competence assessment:

  • Make sure your HR and Staff Training files are well organized and easy to review. Disorganized files are frustrating for surveyors.
  • Be aware of the “high profile” files surveyors typically select. Get those in order now:
    • Contractors
    • Dietician
    • Food Service Director
    • Infection Control Coordinator
    • Pharmacist
    • X-ray technicians
    • “One of a kind” therapists: music, art, activities
  • Audit your files on an ongoing basis for compliance with TJC HR requirements.
  • During survey, review beforehand any files you  provide to surveyors. You may be able to locate some missing documentation and avoid a citation.

Barrins & Associates Consultation & Resources

Our Mock Surveys include a robust HR/Competence Assessment Session. We have an audit tool we share with clients.

Many clients use the tool on an ongoing basis to stay prepared for surveys. They report fewer findings on their actual TJC surveys. Always a welcome outcome!

Also, for additional updates on Joint Commission Human Resource requirements, see our recent posts: