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Non-licensed Non-employee Individuals - Human Resource Requirements

What are The Joint Commission’s expectations regarding non-licensed, non-employee individuals in health care organizations, including health care industry representatives (HCIRs or Vendors)?

Any examples are for illustrative purposes only.

The Joint Commission's, expectation is that the organization is aware of anyone entering the organization and their purpose in order to maintain patient safety.  Leadership is responsible to ensure that the processes are in place and implemented to ensure patient privacy and safety.

For non-licensed, non-employees that have a direct impact on patient care. e.g. HCIRs or Vendors in procedure rooms/operating rooms providing guidance to the surgeon or staff, training of staff on equipment use, surgical assistants brought in by surgeons additional requirements include:
  • Taking steps to ensure that patient rights are respected, including communication, dignity, personal privacy and privacy of health information Obtaining informed consent in accordance with organization policy and law/regulation.
  • Awareness of applicable infection control and patient safe processes/procedures.
  • For non-employees brought into the organization by licensed independent practitioners, organizations must also address qualifications,  competency and performance evaluation.
Last updated on August 07, 2020
Manual: Ambulatory
Chapter: Human Resources HR

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