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Elements of Performance

Accreditation Monthly, January 7, 2004

Dear Colleague,

I hope you had an enjoyable holiday season, and I wish you and your family a prosperous new year.

The year 2004 has arrived and, as promised, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has implemented the Shared Visions-New PathwaysT survey process.

One of the many keys to success in 2004 and beyond is to truly understand the elements of performance and avoid the tendency to over interpret the expectation. To that extent, this month, I would like to share an example of an element of performance that has begun to be overinterpreted.

Standard HR.1.20
The hospital has a process to ensure that a person's qualifications are consistent with his or her job responsibilities.

Rationale for HR.1.20
This requirement pertains to staff and students as well as volunteers who work in the same capacity as staff who provide care, treatment, and services.

Elements of Performance for HR.1.20
1. The leaders define the required competence and qualifications of staff in each program or service.

2. The leaders define the required competence and qualifications of staff who make decisions about and implement restraint or seclusion use.

The hospital verifies the following according to law, regulation, and hospital policy (EPs 3-6):

3. Current licensure, certification, or registration

4. Education, experience, and competency appropriate for assigned responsibilities

5. Information on criminal background

6. Compliance with applicable health screening requirements established by the organization

7. Staff supervision of students when they provide patient care, treatment, and services as part of their training

8 Through 17. Not applicable

18. Individuals who do not possess a license, registration, or certification do not provide or have not provided care, treatment, and services in the hospital that would, under applicable law or regulation, require such a license, registration, or certification.

19. Individuals who do not possess a license, registration, or certification do not provide or have not provided care, treatment, and services in the hospital that would, under applicable law or regulation, require such a license, registration, or certification and that would have placed the hospital's patients at risk for a serious adverse outcome.

I have placed in bold and italics the fifth element of performance, information on criminal background. At a quick glance, it may seem that the JCAHO now requires all accredited organizations to conduct criminal background checks on organizational staff members. A closer look however at the heading prior to EP #3 states, "The hospital verifies the following according to law, regulation, and hospital policy (EPs 3-6)." What this means is that the JCAHO only requires criminal background checks if your state law or hospital policy requires criminal background checks. Thus, if not required by state law, you will be surveyed to hospital policy.

I hope you continue to find this information of value in your ongoing preparation efforts. If The Greeley Company can be of any further assistance, please do not hesitate to give us a call at 888/749-3054.

Sincerely,
Steven Bryant
Practice Director
Accreditation and Regulatory Compliance

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