Hidden Compliance Risks in the OR-SPD Workflow and how to fix them

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1. Under Accreditation 360, what best describes what happened to Joint Commission standards?*

a. Many standards were eliminated to reduce the burden on healthcare facilities.

b. Standards were relaxed in low-risk areas such as sterile processing.

c. Standards were reorganized into 14 National Performance Goals.

d. Standards were made optional based on facility size and accreditation type.

2. How has the Joint Commission’s survey methodology most significantly changed under Accreditation 360?*

a. Surveyors now focus primarily on reviewing written policies and binder documentation.

b. Surveys are conducted only when a complaint has been filed.

c. Surveyors observe real workflows and interview frontline staff directly.

d. Accreditation decisions are now based solely on outcome metrics from the prior year.

3. A surveyor asks two staff members the same question about tray handling and receives different answers. What is the PRIMARY compliance concern this raises?*

a. It indicates the facility does not have a written tray handling policy.

b. It suggests inconsistency in process understanding, which can trigger deeper review.

c. It demonstrates a staffing shortage in the sterile processing department.

d. It shows that the two departments are not accredited under the same standards.

4. Which of the following BEST describes a recommended approach for testing staff competency under Accreditation 360?*

a. Annual written exams administered to all clinical staff.

b. Real-time demonstration checks using tasks like fire safety (RACE & PASS) or point-of-use care.

c. Peer-to-peer observation forms submitted quarterly to department managers.

d. Online modules with automated scoring and certificate issuance.

5. When a surveyor asks a frontline staff member “Show me how this works,” what is the surveyor primarily evaluating?*

a. Whether the staff member can recite the relevant policy from memory.

b. Whether management has communicated expectations through the chain of command.

c. Whether the staff member can independently demonstrate the correct process with consistency.

d. Whether the facility’s documentation is organized and accessible.

6. What are the three core components of a well-defined workflow as described in the presentation?*

a. Written policy, documented training records, and annual audit results.

b. A defined series of actions in order, clear role ownership, and defined communication at each handoff.

c. Leadership oversight, departmental checklists, and real-time monitoring software.

d. Staff-to-patient ratio compliance, equipment maintenance logs, and infection control audits.

7. According to the presentation, what is the PRIMARY risk created by inconsistency between OR and SPD staff when answering process questions?*

a. Staff may be disciplined individually for incorrect answers during surveys.

b. The facility’s written policies may be invalidated retroactively.

c. Inconsistent answers raise doubt about whether processes are understood and followed, which can trigger deeper review.

d. Staff may lose their individual professional certifications.

8. How is the use of scenario-based questions (“What would you do if…?”) recommended in the context of staff readiness?*

a. As a replacement for written competency exams during orientation.

b. Only in cases where staff have received prior survey citations.

c. As a regular practice to build confidence and align decision-making across roles.

d. As a one-time assessment tool administered at the start of survey season.

9. What is the purpose of the SAFEST program introduced under Accreditation 360?*

a. To create a national database of facilities that have received survey citations.

b. To allow the Joint Commission to identify high-performing processes and spread those insights across the industry.

c. To replace existing accreditation requirements with a points-based scoring system.

d. To provide facilities with a self-assessment tool for annual internal audits.

10. What is the recommended frequency for huddles as part of an ongoing compliance monitoring approach?*

a. Monthly, aligned with department quality meetings.

b. Weekly, to review the prior week’s performance data.

c. Daily, to surface issues from the previous day and make corrections before the next shift begins.

d. Quarterly, as part of a formal performance improvement cycle.

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