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The Joint Commission Accreditation Manual’s chapter (2023) on human resources (HR) outlines the requirements for performance that healthcare companies must satisfy in order to provide efficient HR management. The chapter is crucial because it makes sure that the organization’s HR policies are in line with its goal, vision, and values and that the personnel who perform patient care and support tasks are suitably qualified, competent, and motivated.
The standards are HR 01.01.01, 01.02.01, and 01.02.07.
Ten Elements of Performance:
- The hospital defines the qualifications required for each job category.
- The hospital verifies each staff member’s identity and qualifications prior to employment.
- The hospital ensures that all staff members receive orientation and ongoing education and training.
- The hospital conducts an annual performance evaluation for each staff member.
- The hospital maintains personnel records for each staff member.
- The hospital establishes policies and procedures for managing staff complaints and grievances.
- The hospital has a process for managing staff conflicts of interest.
- The hospital maintains a safe and healthy work environment.
- The hospital provides support for staff well-being and work-life balance.
- The hospital has a process for managing staff disciplinary actions and terminations.
Team Members:
- Human Resources Manager
- Education and Training Coordinator
- Employee Health Nurse
- Employee Relations Specialist
- Compliance Officer
Work Division: The team’s work will be under the direction of the human resources manager, who will also collaborate with other departments as needed to coordinate. The planning and execution of orientation and training programs will be overseen by the education and training coordinator. The Employee Health Nurse will be in charge of keeping track of employee health and safety records. The employee relations specialist is in charge of handling employees’ concerns and complaints. All policies and procedures must be in accordance with accreditation standards, according to the
Team Deliverables:
- A report detailing the qualifications required for each job category and how these qualifications are verified.
- A documented orientation and training program for each job category.
- A record-keeping system for employee health and safety.
- A process for managing staff complaints and grievances.
- A process for managing staff conflicts of interest.
- A documented plan for maintaining a safe and healthy work environment.
- A plan for supporting staff well-being and work-life balance.
- A documented process for managing staff disciplinary actions and terminations.
The organization will require a team of people with specific functional titles, including HR experts, nurse leaders, physician leaders, and representatives from the organization’s executive team, to ensure compliance with the HR chapter. Based on each team member’s areas of knowledge and interest, the team will split the task by designating specific performance criteria for each team member. The team will collaborate to create and put into practice policies and processes that guarantee adherence to the chapter’s standards. A thorough report outlining the organization’s adherence to the standards and performance components of the HR chapter will be one of the deliverables the team presents to the organization’s lead team. Evidence of the organization’s compliance, such as policies, processes, training records, and other documents, will be included in the report.
The team will show that the organization has a thorough process for confirming staff qualifications and ensuring that staff members have the necessary skills and knowledge to carry out their assigned responsibilities in order to satisfy the element of performance related to staff qualifications and competence. The team will create and put into practice rules and procedures to confirm staff credentials, offer education and training to maintain and boost staff proficiency, and track staff performance to pinpoint areas that need work.
Reference
The Joint Commission. (2023). Comprehensive Accreditation Manual for Hospitals. Web.
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