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The standard requiring staff members to "fulfill expectations of their job descriptions" is most likely to result in an ambulatory care provider receiving a Type I recommendation during an accreditation survey, according to a recent report from the Joint Commission.
Larry Poniatowski, RN, associate director of the Standards Interpretation Group, recently released the list after analyzing Type I recommendations issued for ambulatory care in 2001. These are the most common issues:
• Management of Human Resources/Competence Assessment — H.R.5 — Staff members’ abilities to fulfill expectations of their job descriptions are assessed.
• Management of Human Resources/ Credentialing — HR.7.1 — Credentialing criteria are uniformly applied to licensed independent practitioners applying to provide patient care services for the organization.
• Management of Human Resources/Credentialing — HR.7.2.1 — Clinical privileges are granted based on the practitioner’s qualifications and the care provided by the organization.
• Surveillance, Prevention, and Control of Infection — IC.4 — The organization takes action to prevent or reduce the risk of nosocomial infections in patients, employees and visitors.
• Leadership — LD 1.10.3 — Leaders evaluate the outcomes related to use of clinical practice guidelines and determine indicated refinements to improve pertinent processes.
• Management of Human Resources/Competence Assessment — HR.4.2 — Ongoing data collection about staff competence patterns and trends is used to respond to staff learning needs.
• Care of Patients/Medication Use — TX.3.4 — Preparing and dispensing medication(s) adhere to law, regulation, licensure, and professional standards of practice.
• Leadership — LD 1.9 — The leaders are responsible for making initial appointments and reappointments, and granting or curtailing the delineated clinical privileges of licensed independent practitioners.
• Patient Rights and Organization Ethics — RI.1.2.6 — Patients receive assistance in formulating advance directives.
• Care of Patients/Medication Use — TX.3.9 — The organization has emergency medication systems.