2009 Joint Commission Human Resources

Ongoing education and training should occur when job responsibilities change and to remain current with the changes in the profession, technology, and equipment.

The Joint Commission Human Resources (HR) standards deal with the qualifications, orientation, training, education, competence, and performance evaluation of the hospital staff (including contracted employees) who provide care, treatment, and services. For the medical equipment management program, these standards apply to both clinical users of medical equipment and the biomedical/clinical engineering staff.

Changes in the HR Standards Chapter

Some of the 2008 HR standards have been moved to other chapters in the 2009 Hospital Accreditation standards.

The 2008 HR.2.20 standard—which required the staff to be familiar with their roles and responsibilities with regard to the environment of care—has been moved to the Environment of Care chapter under the new 2009 standard EC.03.01.01. This standard requires the staff to be familiar with the methods of reducing risks in the environment of care, actions to take in the event of an environment of care incident, and to report environment of care risks.

The 2008 HR.1.10 standard that required the hospital to provide an adequate number and mix of staff for various functions in the organization has been moved to the Leadership chapter under the new 2009 standard LD.03.06.01 EP3.

The 2008 HR.1.25 standard, which addressed the disaster responsibilities for volunteer practitioners, has been moved to the new Emergency Management chapter under the new 2009 standard EM.02.02.15.

The 2008 HR.1.30 standard requiring the hospital to use data from clinical/service and human resource screening indicators to assess and improve staff effectiveness has been moved to the Performance Improvement chapter under the new 2009 standard PI.04.01.01.

Human Resource Requirements

The staff qualifications are addressed in the HR.01.02.01, HR.01.02.05, and HR.01.02.07 standards. HR.01.02.01 requires the hospital to define the qualifications of staff specific to their job responsibilities. The Joint Commission does not specify a particular qualification or background for individuals working with medical equipment. It is left up to the hospital to define the qualifications of staff working with medical equipment.

In HR.01.02.05, the hospital is required to verify the staff qualifications including education, experience, health screening, and criminal background. It requires the hospital to verify the credentials of licensure, registration, or certification for staff as required by law and regulation. HR.01.02.07 addresses how the hospital staff function within the organization.

HR.01.04.01 requires the hospital to provide orientation to the staff about safety—hospital-wide and unit-specific polices and procedures. Orientation should include job-specific duties, infection control, and patient rights. The orientation should occur before the staff provide care, treatment, and services.

Read past CCE Prep and ICC Prep articles in the archives.

HR.01.05.03 calls for the staff to participate in ongoing education and training to maintain or raise competency. Ongoing education and training should occur when job responsibilities change and to remain current with the changes in the profession, technology, and equipment.

HR.01.06.01 says that the hospital needs to define the competencies it requires from its staff who provide care and services. It also requires initial assessment of competency.

HR.01.07.01 requires the ongoing competency assessment of staff once every 3 years, or more frequently as required by hospital policy, or in accordance with laws and regulations.

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Arif Subhan, MS, CCE, is a senior clinical engineer, Masterplan, Chatsworth, Calif; adjunct assistant professor, biomedical engineering, University of Connecticut; and a member of 24×7’s editorial advisory board. For more information, contact .