Department: Regulatory Readiness
The Joint Commission defines staff as all people who provide care, treatment, and services in the hospital, including those receiving pay (such as permanent, temporary, and part-time personnel and contract employees), volunteers, and health profession students. License verification, orientation and training, and evaluation processes must be in place and evidenced for all agency and contract staff. This becomes a pitfall for many organizations.
Examining the pitfalls
The Joint Commission Management of Human Resources chapter addresses qualifications and competencies of staff.
- Pitfall 1: Primary source license verification (HR.01.02.05). The hospital is required to verify licensure with the primary source at the time of hire. This necessitates that the license be verified before the nurse or other licensed professional provides patient care. Is this the agency's responsibility? Yes. Does it alleviate the organization of ensuring the nurses caring for your patients are licensed? No. For many states, the Board of Nursing website allows you to verify whether a nurse is appropriately licensed. When you print that verification, the document includes a footer indicating the date you printed it. During a Joint Commission survey, surveyors may take note of the print date. If it's after the date of the previous license expiration, they'll ask to see if the nurse worked between the license expiration date and the date the verification confirmation was printed. If the nurse worked after the license expiration date and before the license verification occurred, the organization didn't appropriately verify licensure.
- Pitfall 2: Initial orientation (HR.01.04.01). The organization is required to provide initial orientation. Do the agencies you work with provide the orientation for the RNs and other licensed professionals they send? If so, review their orientation packet and documentation to ensure alignment with the key elements provided to your hired nonagency RNs. If your department managers are responsible for providing initial orientation, verify the documentation exists and its location. Do you require the agency orientee to sign that he or she has received the information? If so, is the form signed? What about contract staff such as dialysis nurses or travelers? Who orients them? Where's the documentation housed? If you depend on the agency to manage initial orientation, spot-check by requesting copies on a random basis to ensure that what they have is what you expect. Don't assume everyone is on the same page.
- Pitfall 3: Ongoing education and training (HR.01.05.03). Ongoing education and training is required to maintain and improve staff competency. Does the agency accommodate and provide your annual training requirements? If so, have you reviewed the requirements with them? If you've added any new requirements, make sure the agency has received your updated list. If you've added a mandatory requirement for your staff, that same requirement should be in place for the agency staff.
- Pitfall 4: Performance evaluations (HR.01.07.01). The organization is required to periodically conduct performance evaluations. How do you evaluate agency staff competency? Do the agencies you work with evaluate the agency RNs? The organization is responsible for conducting performance evaluations at time frames identified by the hospital. If you do annual evaluations for your regular employed staff, it's expected that agency and contract staff are evaluated at the same frequency. There's no requirement that the evaluation tools used must be identical for hired versus agency staff. We implemented a very basic tool for managers to use for initial and annual evaluations of travelers, agency, and contract staff. (See Figure 1.)
Tactics for success
- Implement a process requiring online license verification for all licensed agency and contract staff. Clarify for managers the documentation process. The website printout or other documentation may be used, but the date of the verification must precede the individual's first worked shift.
- Implement a process for verification of license renewals for all licensed agency and contract staff. The date of the verification must precede the individual's first worked shift after the previous license expired.
- Create a recordkeeping system that documents initial orientation to the organization. This could be in HR files or in some other system. Consider having the agency/contract individual sign that the orientation information has been provided. If the agency provides the orientation, have them provide documentation of completion.
- Meet periodically with the agencies you use to review your hired staff requirements versus agency requirements. Work with the agency liaison to edit and update their orientation packets. Do they have the current versions of your required policies? Have you added a requirement to work in a specialty area? Do they have the most current job descriptions?
- Implement a process to ensure that the performance of agency and contract staff is evaluated at the same frequency as the staff in similar job categories. The evaluation tool may be significantly abbreviated. The purpose is to document that the individual is competent to perform the tasks being assigned.
Compliance with ease
Compliance with The Joint Commission Human Resource requirements for agency and contract staff ensures that your organization is making positive efforts to provide qualified, competent staff to meet your patients' needs.