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Thursday 10:19 CST, April 17, 2014

Standards FAQ Details


Human Resources (CAMH / Hospitals)

Non-licensed, Non-employee Individuals
New | April 25, 2012
What are The Joint Commission’s expectations regarding non-licensed, non-employee individuals in health care organizations, including health care industry representatives (HCIRs)?

The Joint Commission, similar to organization’s themselves, has expectations regarding anyone entering a health care organization.  In order to maintain patient safety, accredited health care organizations need to be aware of who is entering the organization and their purpose at the organization (EC.02.01.01, EP 7).  Accredited health care organization leaders need to also make sure they oversee operations and that responsibilities are assigned for administrative and clinical direction of programs, services, sites, and departments (LD.04.01.05, EPs 1 and 3); this includes processes for knowing who is entering the organization and their purpose.

There are additional expectations for non-licensed, non-employees that have a direct impact on patient care.  Some examples of these individuals are HCIRs in procedure rooms/operating rooms providing guidance to the surgeon, HCIRs providing training to staff on equipment use, and surgical assistants brought in by surgeons.  Additional requirements related to these individuals include:

  • Taking steps to ensure that patient rights are respected, including communication, dignity,  personal privacy (RI.01.01.01, EPs 4, 5, and 7), and privacy of health information (IM.02.01.01, EPs 1 and 2)
  • Obtaining informed consent in accordance with organization policy (RI.01.03.01, EPs 1, 2, and 13)
  • Implementation of infection control precautions (IC.01.01.01, EP 1)
  • Implementation of the patient safety program (LD.04.04.05, EP 1)
  • For non-employees brought into the organization by licensed independent practitioners, there are two additional requirements regarding qualifications and competence of these individuals (HR.01.02.05, EP 7 and HR.01.07.01, EP 5)

***This requirement does not apply to health care industry representatives as they are not under the direction of a licensed independent practitioner

Please note that The Joint Commission requirements cited above are the minimum standards organizations should address for non-licensed, non-employee individuals.  Accredited health care organizations may choose to apply other Joint Commission standards and/or more stringent requirements for these individuals as they see fit.

Note: The Joint Commission has received many questions relating to credentialing requirements for HCIRs.  While The Joint Commission does not require credentialing of these individuals, some professional organizations are recommending specific credentialing requirements for HCIRs.  For more information on what the industry is recommending as it relates to credentialing of HCIRs, you may want to contact AdvaMed whose website is


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