Credentialing - Non-licensed, Non-employee Individuals - Oversight Expectations
What are The Joint Commission's expectations regarding non-licensed, non-employee individuals in health care organizations, including health care industry representatives (HCIRs)?
Any examples are for illustrative purposes only
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). 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. For non-employees brought into the organization by licensed practitioners, there are two additional requirements regarding qualifications (HR.01.01.01) and competence (HR.01.06.01) for these individuals.
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). 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. For non-employees brought into the organization by licensed practitioners, there are two additional requirements regarding qualifications (HR.01.01.01) and competence (HR.01.06.01) for these individuals.
Manual:
Nursing Care Center
Chapter:
Human Resources HR
First published date: April 11, 2016
This Standards FAQ was first published on this date.
This page was last updated on November 23, 2022
with update notes of: Editorial changes only
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