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Are you qualified? Stay on top of HR.1.20

Staff Development Weekly: Insight on Evidence-Based Practice in Education, December 15, 2005

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The JCAHO's standard HR.1.20 stipulates that hospitals must have a process in place to ensure that a staff member's qualifications are consistent with his or her job responsibilities. This requirement pertains to staff, students, and volunteers who work in the same capacity as staff who provide care, treatment, and services, and includes contract staff.

It seems simple enough, doesn't it? Say Steve Doe applies to be an ED staff RN. Representatives from the Human Resources department compare what Steve Doe put on his application to the RN job description for an ED staff nurse to determine whether he meets the qualifications for the position. If the criteria on the job description states, "Licensed RN in the state of Texas. Minimum of two years recent clinical experience in an ED required. Current card in basic life support (BLS) for healthcare providers, advanced cardiac life support (ACLS) and pediatric advanced life support (PALS) required. Certified emergency nurse preferred," Steve Doe will have to meet the requirements.

The process for verifying these credentials is of utmost importance to the safety of your patients. Your organization needs a system to ensure that staff members are who they say they are and have the experience and documentation to back it up. At survey time, a surveyor may ask an ED nurse (who happens to be Steve Doe), "What is required to work in this department?" The nurse tells the surveyor what was required for his position. The surveyor may then ask for an ED staff RN job description and Steve's file to determine whether the hospital did indeed verify that all the screening requirements were met and whether there is a record indicating that the requirements are still being met.

Editor's note: The above excerpt is from the online course, "Nursing CE Series: Assessing Competencies." For more information on this and other courses in our library, go to www.hcprofessor.com.

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