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)?

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), and privacy of health information (IM.02.01.01) Obtaining informed consent in accordance with organization policy (RI.01.03.01)
  • Implementation of infection control precautions (IC.02.01.01)
  • Implementation of the patient safety program (LD.04.04.05)
  • For non-employees brought into the organization by licensed independent practitioners, organizations must also address qualifications (HR.01.0.01) competency (HR.01.06.01) and performance (HR.01.07.01 EP 5 of these individuals.
Last updated on January 16, 2019
Manual: Laboratory
Chapter: Human Resources HR

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