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Understanding HR.1.20

Credentialing Resource Center Connection, February 14, 2008

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Anne Roberts, CPMSM, CPCS, is the director of medical affairs at Children's Medical Center in Dallas, where she oversees the medical administration, graduate medical education, and medical staff services departments.

Dear credentialing colleague:

There are several categories of nonemployees that provide services for healthcare organizations. Although many are clinical students who participate in training that is governed by a contract with their training institution, there are also the following additional categories:

• Traveling nurses and temporary staff that HR departments typically process in a manner similar to employees
• Transplant teams that provide services generally covered under a contract with an organ procurement center
• Healthcare vendors who are typically cleared through a simple credentialing process or covered under a contract

The nonemployees that MSPs are the most familiar with, however, are what we generally call allied health professionals (AHPs). Over the past few years, The Joint Commission (formerly JCAHO) has increased the credentialing requirements for both employees and nonemployees who fulfill similar roles by revising standard HR.1.20.

The first change to Joint Commission standard HR.1.20, the standard, which occurred in 2006, was the requirement that organizations verify all licenses and certifications which are required by law or by job description through a primary source for all clinical employees. In many cases, MSPs stepped in to help their HR department develop processes to comply with these new employee requirements and perform primary source verification both at the time of initial hire and upon expiration of licenses and certifications.

The next revision to standard HR.1.20, which occurred in 2007, included the requirement that the qualifications and competence of a nonemployee who provides care, treatment, and services are commensurate with the qualifications and competence required if the individual were to be employed by the hospital to provide the same or similar services (EP 11). This required MSPs to review all of their AHP protocols (which some organizations alternatively referred to as AHP privileges) and ensure that the qualifications and competency for nonemployees mirrored that of employees in an equivalent role. For example, if a hospital employs psychologists, and there are also some psychologists who are not employed by the hospital, but are granted permission to provide services as a credentialed AHP, then the employees and nonemployees qualifications and competencies need to match. These qualifications should include matching degrees, licensures, certifications, and experience requirements.

Additionally, nonemployees' qualifications, performance, and competency must be evaluated at the same frequency of those that were employed in similar positions (EP12). For example, if a hospital requires initial competency assessments after 90 days of employment and an annual review for all of its psychologists, then it must also require privileged psychologists who are non-hospital employees to undergo a 90-day competency assessment and an annual review.

Although the Joint Commission standards do not specifically require that orientation procedures must also match, my facility had a surveyor ask if our orientation is the same for nonemployees versus employees.

The new requirements for this standard have forced organizations to scrutinize their processing of allied health professionals, and some have started by asking if it's worth continuing to allow nonemployees to provide services at all.

Remember, clear, effective communication is the key to success!

That's all for this week.

All the best,

Anne Roberts, CPMSM, CPCS

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