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.
What are The Joint Commission's expectations regarding non-licensed, non-employee individuals in healthcare organizations, including healthcare industry representatives?
Sign up for our FREE E-Weekly for more coverage like this sent to your inbox!
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:
Coastal Eye Surgery Center Receives Joint Commission Accreditation
Study Finds Accreditation Improves Safety Culture at Nursing Homes
4 Recent Changes to Joint Commission's Comprehensive Accreditation Manual for Ambulatory Care