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JCAHO’s Requirement on Employee Qualifications

Accreditation Monthly, December 13, 2004

Dear Colleague,

This month I would like to discuss the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) August 2004 update to the Comprehensive Accreditation Manual for Hospitals. In particular, I want to focus on HR.1.20, which requires hospitals to have a process to ensue that an individual's qualifications are commensurate with his or her job responsibilities.

Prior to the August 2004 update, Elements of Performance 3-6 required hospitals to verify the following according to law, regulation, and hospital policy:

• Current licensure, certification, or registration
• Education, experience, and competency appropriate for assigned responsibilities
• Information on criminal background
• Compliance with applicable health screening requirements established by the organization.

In August 2004 the JCAHO changed HR.1.20 elements of performance 3-6 to the hospital verifies the following:

• Current licensure, certification, or registration
• Education, experience, and competency appropriate for assigned responsibilities
• Information on criminal background
• Compliance with applicable health screening requirements established by the organization

Although the change may seem insignificant on the surface, the current requirement is that hospitals must verify the above elements.

The most challenging component of this seemingly small change is that many hospitals currently do not verify education or criminal background information on hospital staff.

I hope you continue to find this information valuable 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 & Regulatory Compliance
The Greeley Company

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