Joint Commission
Management of Human
Resources
Leadership Meeting
September 22, 2010
About the Chapter
 Hospital must:
establish and verify staff qualifications
 orient staff
 provide on-going training
 assess staff competence and performance.
(i.e., employees, students, volunteers, contractors
or temporary agency personnel)
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HR.01.01.01
 The hospital has the necessary staff to
support the care, treatment and services it
provides.
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Methods used to determine staffing
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Staffing Plans
Budget Formulation
HR.01.02.01
 The hospital defines staff qualifications
specific to their job responsibility.
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Job descriptions
Competencies
Regulatory Requirements
HR.01.02.05
 The hospital verifies staff qualifications.
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Licensure Verification - Primary Source
Background Checks
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References
CORI Checks
Health Screening
Non-employees same process
HR.01.02.07
 The hospital determines how staff function
within the organization.
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Job descriptions
Current licensure/certification/registration
Practice within scope of L/C/R
Staff supervises students
HR.01.04.01
 The hospital provides orientation to staff.
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Hospital orientation
Department orientation
Students, Volunteers, External Law
Enforcement personnel
Other Non-Staff
HR.01.04.01 (cont.)
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Covered areas include: key safety content,
environment of care & infection control
PRIOR TO PROVIDING CARE
Documentation
HR.01.05.03
 Staff participate in ongoing education and
training.
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Training when duties change
To increase knowledge
Appropriate to populations served
Reporting unanticipated adverse events
Documentation
HR.01.06.01
 Staff are competent to perform their
responsibilities.
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Use assessment methods (direct observation,
demonstration, simulation, etc.)
Qualified individuals assess staff
Initial assessment as part of orientation
Competence assessed at least once every 3
year (does not need to done same time as
evaluation)
HR.01.06.01 (CONT.)
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Corrective action if no improvement
Based on populations served
Applies to non-employees
Documentation
HR.01.07.01
 The hospital evaluates staff performance.
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Annually within 90 days of due date
Based on performance expectations described
in job description
Applies to non-employees
Survey Prep Checklist
 Current Job Description – Review & Update
 License/certification/registration (prior to
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expiration)
Orientation - hospital/department (Ees/non-Ees)
Life safety for new hires before attending monthly
hospital orientation
Initial competency assessment as part of
orientation
Annual education fair
On-going Education – documentation
Checklist cont.
 Competencies (including age specific every 3
yrs)
 Performance Evaluation (timely <90 days)
 Contract personnel – same requirements as
existing staff
 Keep file on temps
Competence Assessment Session
 Methods used to determine staffing
adequacy; frequency of measurement
 Competency Validation at Hire
 Competency Validation at Orientation
 On Going Competence
 Competency assessment for contracted
staff
 Other topics discovered during tracer
activity