Anyone would expect TJC surveyors to ask how staff protect patient safety, not just in clinical areas but in the entire organization. But what about revenue cycle jobs and determining if someone is qualified to work in that department? These became key areas of focus during a recent survey at Slidell, LA-based Ochsner Health.

TJC surveyors asked to see job descriptions, competencies, orientation checklists, certifications or licensures relevant to positions, and performance evaluations. This request underscored the importance of revenue staff going above and beyond to prepare for surveys, according to Tanya Powell, CHAM, patient access director for Ochsner’s North Shore Region.

“A great patient access leader strives to stay ahead of following the proper protocols,” she says. Registrars already followed patient privacy regulations to the letter. They confirmed the patient’s identity routinely to be sure the correct medical record was selected. Registrars also made sure to obtain all the proper consents. Registrars expected TJC surveyors to scrutinize such tasks. “However, there is another important basic [task],” Powell notes. “The competencies of our own staff, that [we] demonstrate we can perform the functions we are tasked with.”

After the survey, the department set out to revamp its competencies, job descriptions, department onboarding checklists, system checklists, employee signatures on key policies, and proof of emergency code training. Powell asked staff, “What constitutes a healthy HR chart?” For the revenue cycle, it means the application, résumé, background check, drug screen clearance, reference checks, Social Security card, and letter of offer all exist in the department’s “onboarding” file.

“The introduction of employment starts with the discussion of the job description and the initial review of the competencies,” Powell notes.

Competencies and orientation checklists also are important pieces of documentation once the employee begins training and a supervisor evaluates performance.

In Powell’s department, staff created separate competencies for the roles of registration and scheduling. “We found this was a good guide for the new employees to understand the measurement of their progress,” Powell explains.

Key employment policies are signed annually. These include policies on time and attendance, emergency preparedness teams, and uniforms.

“Our leadership team also created a subfolder to house medical information relative to their employment,” Powell adds.