SDS Accreditation Update: Joint Commission targets non-licensed non-staff
Joint Commission targets non-licensed non-staff
The Joint Commission has published the answer to a frequently asked question by hospitals, ambulatory centers, and office-based surgeons related to non-licensed, non-employee individuals. The question is: What are The Joint Commission's expectations regarding non-licensed, non-employee individuals in healthcare organizations, including healthcare industry representatives (HCIRs)?
The Joint Commission says that to maintain safety, you should be aware of who is entering your facility and what their purpose is (EC.02.01.01, EP 7). Also, you need to make sure that responsibilities are assigned for administrative direction of programs, services, sites, and departments (LD.04.01.05, EPs 1 and 3). This requirement includes processes for knowing who is entering the organization and their purpose, The Joint Commission says.
For non-licensed, non-employees who have a direct impact on patient care, there are additional expectations, the agency says. Examples of these individuals are HCIRs in procedure rooms/ORs providing guidance to the surgeon, HCIRs providing training to staff on equipment use, and surgical assistants brought in by surgeons. Additional requirements for these individuals include:
- taking steps to ensure that patient rights are respected, including communication, dignity, personal privacy (RI.01.01.01, EPs 4, 5, and 7), and privacy of health information (IM.02.01.01, EPs 1 and 2);
- obtaining informed consent in accordance with organization policy (RI.01.03.01, EPs 1, 2, and 13);
- implementation of infection control precautions (IC.01.01.01, EP 1);
- implementation of the patient safety program (LD.04.04.05, EP 1);
- For non-employees brought into the organization by licensed independent practitioners, there are two additional requirements regarding qualifications and competence of these individuals (HR.01.02.05, EP 7 and HR.01.07.01, EP 5).
These Joint Commission requirements are the minimum standards organizations should address, the agency emphasizes.
The agency also notes that The Joint Commission does not require credentialing of these individuals; however, some professional organizations are recommending specific credentialing requirements for HCIRs. For more information on what the industry is recommending on credentialing of HCIRs, you may want to contact AdvaMed at website www.advamed.org.The Joint Commission has published the answer to a frequently asked question by hospitals, ambulatory centers, and office-based surgeons related to non-licensed, non-employee individuals.
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