Editor's note: Each installment of Joint Commission Standards will review a chapter of the Comprehensive Accreditation Manual for Hospitals and may be distributed to staff as a teaching tool. Joint Commission Standards will be updated monthly online and appear regularly in print.

The goal of the Management of Human Resources (HR) chapter is to ensure hospitals provide a sufficient number of qualified, competent staff to meet patients' needs. The standards require hospitals determine staffing based on their mission; patient population; and scope of care, treatment and services provided. The process to achieve this goal, based on the HR standards, includes planning; orientation, training and education of staff; assessing, maintaining and improving staff competence; and providing an environment that promotes self-development.

Challenges in HR Standards

HR.1.20 Staff qualifications are consistent with his or her job responsibilities.

Element of Performance (EP) 3 requires primary source verification of licensure, certification or registration required by law and regulation to practice a profession occur at time of hire for individuals hired Jan. 1, 2006, or later. For those hired prior to this time, primary source verification must occur at time of renewal of the license, certification or registration. Going forward, primary source verification for this category of staff must occur at time of hire and at time of credential expiration.

Verification with the primary source via secure electronic communication or telephone, if documented, is acceptable.

A primary source of information may designate another agency to communicate credentials information.

An external organization that meets Joint Commission criteria may be used to collect credentials information.

EP 7, effective Jan. 1, 2007, requires information usually obtained as part of the prehire screening process be used in making decisions regarding staff responsibilities.

EP 11 and 12, also effective Jan. 1, 2007, apply to nonemployed staff other than physician assistants (PAs) and advanced practice registered nurses (APRNs) brought into the hospital by a licensed independent practitioner to give care or perform service or treatment. The EPs require their qualifications and competencies are comparable to employed staff who performs the same or similar duties, and their qualifications, competency and performance review occur at the same frequency as employed staff.

EP 13 notes all PAs and APRNs who work in the hospital are to be credentialed and privileged through the medical staff process or its equivalent. The process must include evaluation of credentials, evaluation of current competence, peer recommendations, and communication and input from other individuals and committees.

HR.1.25 Organization may assign disaster responsibilities to volunteer practitioners.

The eight EPs associated with this standard deal with the following items:

Volunteer practitioners can be used only when an emergency management plan has been activated and the hospital is unable to meet immediate patient needs.

Written protocols describe individuals responsible for assigning disaster responsibilities, process to oversee professional performance of volunteers and mechanism by which volunteers are identified.

Volunteer identification requirements include a valid government photo ID issued by state or federal agency, plus one of the following:

• current hospital picture ID with professional designation;
• current license, certification or registration;
• primary source verification of the above;
• member ID from a recognized federal or state disaster medical assistance team;
• ID noting the individual is granted authority to render care in a disaster event;
• or identification by a person within the organization who has personal knowledge of the volunteer's qualifications.

Within 72 hours, primary source identification is completed and a decision made as to whether to continue disaster responsibilities originally assigned.

HR.2.10 The hospital provides initial orientation.

Two new EPs have been added to this standard. EP 1 and 2 require the organization determines the key elements of orientation and orients staff to these elements before they begin providing care, services or treatment. The remaining six EPs indicate required orientation content.

HR.3.10 Staff competence to perform job responsibilities is assessed, demonstrated and maintained.

The 10 EPs identify competence assessment as an ongoing process. Once deemed competent to practice independently, assessment and reassessment continue at defined times. A needs assessment is based on:

• patient population demands;
• age, epidemiological factors, length of stay;
• field of knowledge;
• diagnosis-related skills and knowledge needs related to high-volume, low-volume/high-risk or problem-prone tasks or duties, standards of care, trends identified through performance improvement/quality assurance, risk and infection control data analysis, and advances in technology;
• individual staff needs;
• legislative demands;
• OSHA, state and federal emergency preparedness, as well as state and local fire regulation;
• institutional requirements;
• licensing and accrediting agencies' standards; and
• professional associations' recommendations.
  

The Joint Commission frequency requirement for competency assessment and performance review (HR.3.20) is at least once every 3 years, but most state regulations are more stringent requiring annual evaluation.

Jean Kalemba was previously director of performance improvement at Mountainside Hospital, Montclair, NJ.