Question of the Week

April 25, 2012

Question: Did The Joint Commission issue a new FAQ regarding the use of non-licensed, non-employee individuals in a hospital, including health care industry representatives?

Yes.  The Joint Commission (“TJC”) issued the new FAQ yesterday.  The FAQ states that TJC has expectations regarding anyone entering a health care organization, and that to maintain patient safety, organizations need to be aware of who is entering, and their purpose.

The FAQ then states that there are additional expectations for non-licensed, non-employees that have a “direct impact on patient care” and uses as examples, health care industry representatives in operating rooms giving guidance to a surgeon, or training staff on equipment use, and surgical assistants brought in by surgeons, then lists these requirements and the Standards and Elements of Performance:

  • Taking steps to ensure that patient rights are respected, including communication, dignity, personal privacy (RI.01.01.01, EPs 4, 5, and 7), and privacy of health information (IM.02.01.01, EPs 1 and 2);
  • Obtaining informed consent in accordance with organization policy (RI.01.03.01, EPs 1, 2, and 13);
  • Implementation of infection control precautions (IC.01.01.01, EP 1);
  • Implementation of the patient safety program (LD.04.04.05, EP 1); and
  • For non-employees brought into the organization by licensed independent practitioners, there are two additional requirements regarding qualifications and competence of these individuals (HR.01.02.05, EP 7 and HR.01.07.01, EP 5).  (This requirement does not apply to health care industry representatives as they are not under the direction of a licensed independent practitioner.)

The FAQ then notes that these are the minimum Standards, and that an organization may choose to apply other Standards, and/or more stringent requirements.  It concludes by stating that while TJC has received many questions regarding credentialing health care industry representatives, it does not require credentialing of these individuals, but that some professional organizations do recommend specific credentialing requirements for these individuals, and to check www.advamed.org for more information.