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Defining "staff" in your organization

Credentialing Resource Center Connection, May 8, 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:

As MSPs’ roles continue to expand, I am frequently asked to clarify the requirements for non-employees versus employees that provide services or participate in training at an organization.

Let’s first start with The Joint Commission’s (formerly JCAHO) definition of “staff.” In the Comprehensive Accreditation Manual for Hospitals (CAMH), The Joint Commission defines staff in the following way: “As appropriate to their roles and responsibilities, all people who provide care, treatment, and services in the hospital, including those receiving pay (e.g., permanent, temporary, and part-time personnel, as well as contract employees), volunteers and health profession students. The definition of staff does not include licensed independent practitioners (LIPs) who are not paid staff or who are not contract employees.”

In determining what is required for non-LIPs that provide care, treatment, and services, The Joint Commission outlines in LD.3.70 that the organizations’ leaders define the required qualifications and competence of staff and recommend a sufficient number of qualified and competent staff to provide care, treatment, and services. The determination of competence and qualifications of “staff” is based on the following:

• The hospital’s mission
• The hospital’s care, treatment, and services
• The complexity of care, treatment, and services needed by patients
• The technology used
• The health status of staff as required by law and regulation

In HR.1.20 the Joint Commission requires that “staff” qualifications are consistent with the individual’s job responsibilities. This standard indicates that hospitals must perform primary source verification for current licensure, certification, or registration when required by law or regulation to practice a profession. This standard also requires that organizations perform criminal background checks and verify compliance with applicable health screening requirements if these elements are required by law and regulation or established by the hospital.

Non-employees who perform services similar to those performed by individuals employed by the hospital must have qualifications and competency requirements that are commensurate with their hospital-employed counterparts. Additionally, non-employees are required to have their qualifications and competency reviewed with the same frequency as those employed by the hospital.

For non-employed “staff” who may not be participating in care (such as temporary secretarial staff, external billing staff, consultants, etc.) most organizations still implement the same requirements as far as background checks, health screening, and some level of orientation to the facility. Even if an individual does not provide patient care, it is important for him or her to have some type of “ticket” to be in your facility. How that ticket is obtained can vary. For example, residents and fellows may be governed under an affiliation agreement with the medical school., However, the hospital is still responsible for ensuring that the hospital requirements are met, e.g., the supervision policies for your facility are current and accurate, and all hospital requirements are either verified internally or covered in the affiliation agreement.

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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