HCA375: Continuous Quality Monitoring & Accreditation-Joint Commission Standards and Processes

Program: Hospital
Chapter: Human Resources
Standard: HR.01.02.01: The hospital defines staff qualifications.
Rationale: (None)
EPs:
1 The hospital defines staff qualifications specific to their job responsibilities. (See also IC.01.01.01, EP 3; RI.01.01.03, EP 2)
Note 1: Qualifications for infection control may be met through ongoing education, training, experience, and/or certification (such as that offered by the Certification Board for Infection Control).
Note 2: Qualifications for laboratory personnel are described in the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88), under Subpart M: “Personnel for Nonwaived Testing” §493.1351-§493.1495. A complete description of the requirement is located at http://wwwn.cdc.gov/clia/Regulatory.
Note 3: For hospitals that use Joint Commission accreditation for deemed status purposes: Qualified physical therapists, physical therapist assistants, occupational therapists, occupational therapy assistants, speech-language pathologists, or audiologists (as defined in 42 CFR 484.4) provide physical therapy, occupational therapy, speech-language pathology, or audiology services, if these services are provided by the hospital. The provision of care and staff qualifications are in accordance with national acceptable standards of practice and also meet the requirements of 409.17. See Appendix A for 409.17 requirements.
Note 4: Qualifications for language interpreters and translators may be met through language proficiency assessment, education, training, and experience. The use of qualified interpreters and translators is supported by the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973, and Title VI of the Civil Rights Act of 1964.
12 For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The activities program is directed by a professional who meets one of the following criteria:
- Is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered, if applicable, by the state in which he or she practices and is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990
- Has two years of experience in a social or recreational program within the last five years, one year of which was full time in a patient activities program in a health care setting
- Is a qualified occupational therapist or occupational therapy assistant
- Has completed a training course approved by the state
13 For hospitals that use Joint Commission accreditation for deemed status purposes and have swing beds: The facility does not employ individuals who have been found guilty by a court of law of abusing, neglecting, or mistreating residents or who have had a finding entered into the state nurse aide registry concerning abuse, neglect, or mistreatment of residents or of misappropriation of their property.

Program: Hospital
Chapter: Human Resources
Standard: HR.01.02.05: The hospital verifies staff qualifications.
Rationale: (None)
EPs:
1 When law or regulation requires care providers to be currently licensed, certified, or registered to practice their professions, the hospital both verifies these credentials with the primary source and documents this verification when a provider is hired and when his or her credentials are renewed. (See also HR.01.02.07, EP 2)
Note 1: It is acceptable to verify current licensure, certification, or registration with the primary source via a secure electronic communication or by telephone, if this verification is documented.
Note 2: A primary verification source may designate another agency to communicate credentials information. The designated agency can then be used as a primary source.
Note 3: An external organization (for example, a credentials verification organization [CVO]) may be used to verify credentials information. A CVO must meet the CVO guidelines identified in the Glossary.
2 When the hospital requires licensure, registration, or certification not required by law and regulation, the hospital both verifies these credentials and documents this verification at time of hire and when credentials are renewed. (See also HR.01.02.07, EP 2)
3 The hospital verifies and documents that the applicant has the education and experience required by the job responsibilities.
4 The hospital obtains a criminal background check on the applicant as required by law and regulation or hospital policy. Criminal background checks are documented.
5 Staff comply with applicable health screening as required by law and regulation or hospital policy. Health screening compliance is documented.
7 Before providing care, treatment, and services, the hospital confirms that nonemployees who are brought into the hospital by a licensed independent practitioner to provide care, treatment, or services have the same qualifications and competencies required of employed individuals performing the same or similar services at the hospital.
Note 1: This confirmation can be accomplished either through the hospital's regular process or with the licensed independent practitioner who brought in the individual.
Note 2: When the care, treatment, and services provided by the nonemployee are not currently performed by anyone employed by the hospital, leadership consults the appropriate professional hospital guidelines for the required credentials and competencies.
10 Physician assistants and advanced practice registered nurses who practice within the hospital are credentialed, privileged, and re-privileged through the medical staff process or an equivalent process.
Note: Advanced practice registered nurses who are licensed independent practitioners are credentialed and privileged only through the medical staff credentialing and privileging process. (See the "Medical Staff" [MS] chapter)
11 The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital is approved by the governing body.
12 The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: An evaluation of the applicant’s credentials. The evaluation is documented.
13 The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: An evaluation of the applicant’s current competence. The evaluation is documented.
14 The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: Peer recommendations. The peer recommendations are documented.
15 The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: Input from individuals and committees, including the medical staff executive committee, in order to make an informed decision regarding requests for privileges.
16 For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The director of psychiatric nursing is a registered nurse who has a master’s degree in psychiatric or mental health nursing, or its equivalent, from a school of nursing accredited by the National League for Nursing, or is qualified by education and experience in the care of the mentally ill. The director of psychiatric nursing demonstrates competence to participate in interdisciplinary formulation of individual treatment plans; to give skilled nursing care and therapy; and to direct, monitor, and evaluate the nursing care furnished.
18 For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The director of the social work department or service has a master’s degree from an accredited school of social work or is qualified by education and experience in the social services needs of the mentally ill.
Note: If the director does not hold a master’s degree in social work, at least one staff member has this qualification.
19 Technologists who perform diagnostic computed tomography (CT) exams have advanced-level certification by the American Registry of Radiologic Technologists (ARRT) or the Nuclear Medicine Technology Certification Board (NMTCB) in computed tomography or have one of the following qualifications:
- State licensure that permits them to perform diagnostic CT exams and documented training on the provision of diagnostic CT exams or
- Registration and certification in radiography by ARRT and documented training on the provision of diagnostic CT exams or
- Certification in nuclear medicine technology by ARRT or NMTCB and documented training on the provision of diagnostic CT exams
(See also HR.01.02.01, EP 1; HR.01.02.05, EPs 1–3; HR.01.02.07, EPs 1 and 2)
Note 1: This element of performance does not apply to CT exams performed for therapeutic radiation treatment planning or delivery, or for calculating attenuation coefficients for nuclear medicine studies.
Note 2: This element of performance does not apply to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions.
20 The hospital verifies and documents that diagnostic medical physicists who support computed tomography (CT) services have board certification in diagnostic radiologic physics or radiologic physics by the American Board of Radiology, or in Diagnostic Imaging Physics by the American Board of Medical Physics, or in Diagnostic Radiological Physics by the Canadian College of Physicists in Medicine, or meet all of the following requirements:
- A graduate degree in physics, medical physics, biophysics, radiologic physics, medical health physics, or a closely related science or engineering discipline from an accredited college or university
- College coursework in the biological sciences with at least one course in biology or radiation biology and one course in anatomy, physiology, or a similar topic related to the practice of medical physics
- Documented experience in a clinical CT environment conducting at least 10 CT performance evaluations under the direct supervision of a board-certified medical physicist
Note: This element of performance does not apply to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions.

Program: Hospital
Chapter: Human Resources
Standard: HR.01.02.07: The hospital determines how staff function within the organization.
Rationale: (None)
EPs:
1 All staff who provide patient care, treatment, and services possess a current license, certification, or registration, in accordance with law and regulation.
2 Staff who provide patient care, treatment, and services practice within the scope of their license, certification, or registration and as required by law and regulation. (See also HR.01.02.05, EPs 1 and 2)
5 Staff oversee the supervision of students when they provide patient care, treatment, and services as part of their training.

Program: Hospital
Chapter: Human Resources
Standard: HR.01.04.01: The hospital provides orientation to staff.
Rationale: (None)
EPs:
1 The hospital determines the key safety content of orientation provided to staff. (See also EC.03.01.01, EPs 1–3)
Note: Key safety content may include specific processes and procedures related to the provision of care, treatment, and services; the environment of care; and infection control.
2 The hospital orients its staff to the key safety content before staff provides care, treatment, and services. Completion of this orientation is documented. (See also EC.02.03.01, EP 10; IC.01.05.01, EP 6)
3 The hospital orients staff on the following: Relevant hospital wide and unit-specific policies and procedures. Completion of this orientation is documented.
4 The hospital orients staff on the following: Their specific job duties, including those related to infection prevention and control and assessing and managing pain. Completion of this orientation is documented. (See also IC.01.05.01, EP 6; IC.02.01.01, EP 7; IC.02.04.01, EP 2; RI.01.01.01, EP 8)
5 The hospital orients staff on the following: Sensitivity to cultural diversity based on their job duties and responsibilities. Completion of this orientation is documented.
6 The hospital orients staff on the following: Patient rights, including ethical aspects of care, treatment, and services and the process used to address ethical issues based on their job duties and responsibilities. Completion of this orientation is documented.

Program: Hospital
Chapter: Human Resources
Standard: HR.01.05.03: Staff participate in ongoing education and training.
Rationale: (None)
EPs:
1 Staff participate in ongoing education and training to maintain or increase their competency. Staff participation is documented.
4 Staff participate in ongoing education and training whenever staff responsibilities change. Staff participation is documented.
14 The hospital verifies and documents that technologists who perform diagnostic computed tomography (CT) examinations participate in ongoing education that includes annual training on the following:
- Radiation dose optimization techniques and tools for pediatric and adult patients addressed in the Image Gently® and Image Wisely® campaigns
- Safe procedures for operation of the types of CT equipment they will use
Note 1: Information on the Image Gently and Image Wisely initiatives can be found online at http://www.imagegently.org and http://www.imagewisely.org, respectively.
Note 2: This element of performance does not apply to CT systems used for therapeutic radiation treatment planning or delivery, or for calculating attenuation coefficients for nuclear medicine studies.
Note 3: This element of performance does not apply to dental cone beam CT radiographic imaging studies performed for diagnosis of conditions affecting the maxillofacial region or to obtain guidance for the treatment of such conditions.
25 The hospital verifies and documents that technologists who perform magnetic resonance imaging (MRI) examinations participate in ongoing education that includes annual training on safe MRI practices in the MRI environment, including the following:
- Patient screening criteria that address ferromagnetic items, electrically conductive items, medical implants and devices, and risk for nephrogenic systemic fibrosis (NSF)
- Proper patient and equipment positioning activities to avoid thermal injuries
- Equipment and supplies that have been determined to be acceptable for use in the MRI environment (MR safe or MR conditional) *
- MRI safety response procedures for patients who require urgent or emergent medical care
- MRI system emergency shutdown procedures, such as MRI system quench and cryogen safety procedures
- Patient hearing protection
- Management of patients with claustrophobia, anxiety, or emotional distress
Footnote *: Terminology for defining the safety of items in the magnetic resonance environment is provided in ASTM F2503 Standard Practice for Marking Medical Devices and Other Items for Safety in the Magnetic Resonance Environment (http://www.astm.org).

Program: Hospital
Chapter: Human Resources
Standard: HR.01.06.01: Staff are competent to perform their responsibilities.
Rationale: (None)
EPs:
1 The hospital defines the competencies it requires of its staff who provide patient care, treatment, or services. (See also NPSG.03.06.01, EP 3)
3 An individual with the educational background, experience, or knowledge related to the skills being reviewed assesses competence.
Note: When a suitable individual cannot be found to assess staff competence, the hospital can utilize an outside individual for this task. If a suitable individual inside or outside the hospital cannot be found, the hospital may consult the competency guidelines from an appropriate professional organization to make its assessment.
5 Staff competence is initially assessed and documented as part of orientation.
6 Staff competence is assessed and documented once every three years, or more frequently as required by hospital policy or in accordance with law and regulation.

Program: Hospital
Chapter: Human Resources
Standard: HR.01.07.01: The hospital evaluates staff performance.
Rationale: (None)
EPs:
1 The hospital evaluates staff based on performance expectations that reflect their job responsibilities.
2 The hospital evaluates staff performance once every three years, or more frequently as required by hospital policy or in accordance with law and regulation. This evaluation is documented.
5 When a licensed independent practitioner brings a nonemployee individual into the hospital to provide care, treatment, and services, the hospital reviews the individual’s competencies and performance at the same frequency as individuals employed by the hospital.
Note: This review can be accomplished either through the hospital's regular process or with the licensed independent practitioner who brought staff into the hospital.