Accreditation Tip: Joint Commission's Expectations for Non-Licensed, Non-Employee Individuals in Healthcare
The Joint Commission has issued clarification on its expectations for non-licensed, non-employees.
What are The Joint Commission's expectations regarding non-licensed, non-employee individuals in healthcare organizations, including healthcare industry representatives?
The Joint Commission, similar to organizations themselves, has expectations regarding anyone entering a healthcare organization. In order to maintain patient safety, accredited healthcare organizations need to be aware of who is entering the organization and their purpose at the organization (EC.02.01.01, EP 7). Accredited healthcare organization leaders need to also make sure they oversee operations and that responsibilities are assigned for administrative and clinical direction of programs, services, sites and departments (LD.04.01.05, EPs 1 and 3); this includes processes for knowing who is entering the organization and their purpose.
There are additional expectations for non-licensed, non-employees that have a direct impact on patient care. Some examples of these individuals are HCIRs in procedure rooms/operating rooms providing guidance to the surgeon, HCIRs providing training to staff on equipment use and surgical assistants brought in by surgeons. Additional requirements related to 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)
Note: This requirement does not apply to healthcare industry representatives as they are not under the direction of a licensed independent practitioner.
Related Articles on The Joint Commission:
© Copyright ASC COMMUNICATIONS 2012. Interested in LINKING to or REPRINTING this content? View our policies by clicking here.
- Senate Introduces Companion Medicare RAC Reform Bill
- Drs. Brian Cole, Anthony Romeo of Midwest Orthopaedics at Rush Among Top Orthopedic Surgeons Contributing to Orthopedic Literature
- Spinal Elements Upgrades to 40,000-Square-Foot Headquarters
- UnitedHealth, Aetna, Cigna to Sit Out of California's Health Insurance Exchange
- Rhode Island Nixes "Confidential" Prices Between Payors, Providers