Introduction to JCI HRM

In the context of JCI (Joint Commission International), the HR chapters (Human Resources chapters) play a crucial role in ensuring that healthcare organizations implement effective personnel management practices. These chapters are part of JCI's accreditation standards and address various elements critical to maintaining high-quality patient care through efficient HR policies and practices.

Key Components of JCI HR Chapters

1. Staff Qualifications and Competencies

1. • Establishing job descriptions for all roles.

1. • Verifying credentials, licensure, and certifications.

1. • Ensuring staff competencies align with organizational needs.

2. Staff Recruitment and Retention

2. • Policies for hiring qualified personnel.

2. • Strategies to retain skilled staff members.

2. • Conducting pre-employment health screenings.

3. Orientation and Training

3. • Comprehensive orientation programs for new hires.

3. • Ongoing education and professional development opportunities.

3. • Regular training on patient safety, infection control, and emergency protocols.

4. Performance Appraisal and Monitoring

4. • Periodic performance evaluations.

4. • Providing constructive feedback for staff improvement.

4. • Developing plans for addressing underperformance.

5. Workforce Planning

5. • Aligning staffing levels with patient care demands.

5. • Addressing gaps in workforce through contingency planning.

5. • Monitoring workloads to prevent staff burnout.

6. Health and Safety of Staff

6. • Promoting staff well-being through occupational health programs.

6. • Addressing workplace hazards and ensuring a safe work environment.

6. • Providing access to mental health and stress management resources.

7. Rights and Responsibilities

7. • Ensuring staff rights are protected.

7. • Promoting a culture of mutual respect among staff.

7. • Clearly defining roles and responsibilities.

8. Ethical Considerations

8. • Upholding ethical standards in HR practices.

8. • Preventing discrimination and harassment.

8. • Encouraging transparent communication channels for grievances.

Benefits of HR Chapters in JCI

• Enhanced Patient Safety: Skilled and well-trained staff contribute to better patient outcomes.

• Improved Staff Morale: Transparent policies and supportive work environments boost staff satisfaction.

• Regulatory Compliance: Adhering to international standards helps meet local and global regulatory requirements.

• Operational Efficiency: Proper workforce planning and training reduce errors and enhance efficiency. 

Staff Qualifications and Education (SQE)

• Overview: Reinforced that credentialing licensed health care practitioners represents the first and most important opportunity for the hospital to protect patients

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• SQE.3, Intent: The added expectation that the evaluation process for hiring qualified clinical staff members includes an assessment of the staff member’s ability to operate medical equipment and clinical alarms and oversee medication management unique to the specific area

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• SQE.7

o ME 3: Split and clarified requirements on the orientation of staff who accompany independent practitioners and provide care and services

o ME 4: Combined with previous ME 3 to include volunteers in the hospital orientation program

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• SQE.8.1 o Standard: Split Standard SQE.8.1 that requires that staff competence with resuscitative techniques meets the level of training identified to focus on staff members who provide patient care (SQE.8.1) and other staff identified by the hospital (SQE.8.1.1)

o ME 1: Split previous ME 1 to distinguish Basic Life Support Training needs for all staff providing clinical care, including physicians, (SQE.8.1) and other staff who do not provide patient care (new SQE.8.1.1)

o ME 2: Clarified that level of life support training (basic or advanced) must be appropriate to roles of staff providing clinical care

o MEs 3 and 4: Retained requirements for staff who provide clinical care in SQE.8.1 and

duplicated them for staff who do not provide patient care in SQE.8.1.1 as MEs 2 and 3.

_ * _

 • SQE.8.1.1

o Standard: Split Standard SQE.8.1 that requires that staff competence with resuscitative techniques meets the level of training identified to focus on staff members who provide patient care (SQE.8.1) and other staff identified by the hospital (new SQE.8.1.1)

o ME 1: Split previous SQE.8.1, ME 1 to distinguish basic life support training needs for all staff providing clinical care (SQE.8.1) and other staff who do not provide patient care (SQE.8.1.1)

o ME 2: Duplicated previously applicable SQE.8.1, ME 3 to require evidence that nonclinical staff have passed basic life support training

o ME 3: Duplicated previously applicable SQE.8.1, ME 4 to require the identified staff to be

retrained on basic life support based on the required time frames established by the recognized

training program

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• SQE.8.2

o Intent: Removed periodical preventive immunizations and examinations from the list of critical elements a staff health and safety program must address; added content on compassion fatigue xxix Summary of Change to the annual and staff burnout of health care practitioners; extracted content applicable to previous Standard

SQE.8.2.1 and revised and expanded it as the intent of new Standard SQE.8.3

o ME 2: Given the change to the intent, revised the list of critical elements the hospital must

address in a staff health and safety program

o New ME 6: Added requirement that the hospital creates a culture of wellness to support physical and mental well-being

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 • SQE.8.3

o Standard: Renumbered previous Standard SQE.8.2.1

o Intent: Moved and expanded intent of previous Standard SQE.8.2.1

o MEs 1 and 2: Split previous SQE.8.2.1, ME 1 to focus on identifying infection risks (ME 1) and a staff vaccination and immunization program (ME 2)

o MEs 3 and 4: Renumbered previous SQE.8.2.1, MEs 2 and 3

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• SQE.11 o Intent: Changed the term ongoing monitoring and evaluation to ongoing professional practice evaluation (here and throughout the manual) and revised the definition to align with the current professional practice.

o ME 2: Combined with previous ME 3

o MEs 3 and 4: Renumbered previous MEs 4 and 5

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• SQE.13, Intent: Clarified that primary source verification is carried out for all nurses; described a time-limited exception for a JCI initial accreditation survey that refers only to the verification of credentials.

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• SQE.15, Intent: Clarified that primary source verification is carried out for all other health care practitioners; described a time-limited exception (reduced from 3 years to 12 months) for a JCI initial accreditation survey that refers only to the verification of credentials

• Made minor editorial revisions throughout the chapter

These are Major Changes as on 2021 in SQE - HRM Chapter

Standards

The following is a list of all Standards for this function. They are presented here for your convenience without their intent statements or measurable elements.

 For more information about these standards, please see the next section in this chapter, Standards, and Measurable Elements.

 *  Planning

SQE.1 Leaders of hospital departments and services define the desired education, skills, knowledge, and other requirements of all staff members.

SQE.1.1 Each staff member’s responsibilities are defined in a current job description. 𝖯

SQE.2 Leaders of hospital departments and services develop and implement processes for recruiting, evaluating, and appointing staff as well as other related procedures identified by the hospital.

SQE.3 The hospital uses a defined process to ensure that clinical staff knowledge and skills are consistent with patient needs.

SQE.4 The hospital uses a defined process to ensure that nonclinical staff knowledge and skills are consistent with hospital needs and the requirements of the position.

SQE.5 There is documented personnel information for each staff member. 𝖯

SQE.6 A staffing strategy for the hospital, developed by the leaders of hospital departments and services, identifies the number, types, and desired qualifications of staff. 𝖯

SQE.6.1 The staffing strategy is reviewed on an ongoing basis and updated as necessary.

SQE.7 All clinical and non-clinical staff members are oriented to the hospital, the department or unit to which they are assigned, and to their specific job responsibilities at the appointment to the staff.

SQE.8 Each staff member receives ongoing in-service and other education and training to maintain or to advance his or her skills and knowledge.

SQE.8.1 Staff members who provide patient care are trained and demonstrate competence in the resuscitative techniques specific to the level of training identified.

SQE.8.1.1 Other staff identified by the hospital are trained and can demonstrate appropriate competence in resuscitative techniques. 

* Staff Health and Safety

SQE.8.2 The hospital provides a staff health and safety program that addresses staff physical and mental health and safe working conditions. 𝖯

SQE.8.3 The hospital identifies staff who are at risk for exposure to and possible transmission of vaccine-preventable diseases and implements a staff vaccination and immunization program. 𝖯

* Determining Medical Staff Membership

SQE.9 The hospital has a uniform process for gathering the credentials of those medical staff members permitted to provide patient care without supervision. 𝖯

SQE.9.1 Medical staff members’ education, licensure/registration, and other credentials required by law or regulation and the hospital are verified and kept current. 𝖯

SQE.9.2 There is a uniform, transparent decision process for the initial appointment of medical staff members. 𝖯

* The Assignment of Medical Staff Clinical Privileges

SQE.10 The hospital has a standardized, objective, evidence-based procedure to authorize medical staff members to admit and to treat patients and/or to provide other clinical services consistent with their qualifications. 𝖯

* Ongoing Professional Practice Evaluation of Medical Staff Members

SQE.11 The hospital uses an ongoing standardized process to evaluate the quality and safety of the patient care provided by each medical staff member. 𝖯

* Medical Staff Reappointment and Renewal of Clinical Privileges

SQE.12 At least every three years, the hospital determines, from the ongoing professional practice evaluation of each medical staff member, if medical staff membership and clinical privileges are to continue with or without modification. 𝖯

* Nursing Staff

SQE.13 The hospital has a uniform process to gather, to verify, and to evaluate the nursing staff’s credentials (license, education, training, and experience). 𝖯

SQE.14 The hospital has a standardized process to identify job responsibilities and to make clinical work assignments based on the nursing staff member’s credentials and any regulatory requirements.

SQE.14.1 The hospital has a standardized process for nursing staff participation in the hospital’s quality improvement activities, including evaluating individual performance when indicated.

* Other Health Care Practitioners

SQE.15 The hospital has a uniform process to gather, to verify, and to evaluate other healthcare practitioners’ credentials (license, education, training, and experience). 𝖯

SQE.16 The hospital has a uniform process to identify job responsibilities and to make clinical work assignments based on other health care practitioners’ credentials and any regulatory requirements.

SQE.16.1 The hospital has a uniform process for other healthcare practitioners’ participation in the hospital’s quality improvement activities. 

* 16 Standards of SQE - HRM Chapter of JCI are covered for Learning & Practicing HR