I recently learned that The Joint Commission has a Certification Program for Health Care Staffing Services.  The program evaluates the staffing service's ability to provide qualified and competent clinical staff.  To be eligible for this certification a staffing firm must be responsible for placement of clinical staff in other organizations that oversee or provide direct patient care; or placement of clinical staff under the direct supervision of another organization's personnel and have placed at least 10 clinical staff at the time of the evaluation. 

The program also evaluates the staffing service's processes for verifying the credentials and competencies of the clinical staff.  The Health Care Staffing Services Certification Manual standards cover leadership, human resources management, performance measurement and improvement, and information management. 

Two external groups helped The Joint Commission establish the certification program.  One was an Advisory Council comprised of representatives from health care staffing firms and associations and the other was a Standards Task Force composed of industry recipients, providers and other stakeholders.  A Certification of Distinction is awarded to the health care staffing firm that meets the requirements for certification. 

The next time a hospital or ambulatory clinic needs temporary coverage (locum tenens), it might be worth the effort to ask about Health Care Staffing Services certification. 

Carole  La Pine, MSA, CPMSM, CPCS

With the new numbering of The Joint Commission standards, the controversial MS.1.20 is now MS.01.01.01.  However, it is still too early to look at the renumbered EPs (elements of performance) in this specific standard because the Task Force on MS.1.20 has not completed it work to clarify the issues which have been a major cause for concern expressed by many MSPs and their facilities. 

On preliminary review of the new 2009 format, it appears that the efforts for improvement have been successful to some extent.  As an example:  MS.1.40, EP 6 now becomes MS.02.01.01 EP 8.  This change actually establishes a more logical flow when describing the Medical Executive Committee. 

It will be well worth the time to carefully review the Cross Walk of 2008 to 2009 standards.  We have been assured by TJC that there are no changes in the standards nor EPs; rather the new format is merely renumbering and a more logical flow. 

Carole La Pine, MSA, CPMSM, CPCS

What will The Joint Commissions be looking for on your next survey? 

I had the opportunity to attend the Alaska Association of Medical Service Professionals 10^th Anniversary Conference held in Soldotna, AK on June 11-13.  One of the speakers was a physician surveyor for The Joint Commission and he shared with us what surveyors will be reviewing the next time around. 

At this point in time we are still uncertain of the impact MS.1.20 will have on our medical staff offices as to the Elements of Performance that may affect our medical staff bylaws.  MSPs hope that we will not be required to include the details of the credentialing and privileging procedures in the bylaws but be allowed to house those in appropriate policies and procedures. 

One thing is certain; there will be a totally new numbering system for all the standards.  I’m considering myself fortunate that I did not memorize all the current numbers or I’d be on brain-overload by December 2009.  The 2009 standards will be available on-line at TJC’s web site by September 2008.  I have been assured that there are NO new standards only a more logical flow in the new format. 

Here are some of the key elements that surveyors will be looking for on the next survey: 

1. Privileges

If your facility is using “core” privileges, there must be a listing of what is included in that grouping.  Those physicians who wish to delete a core privilege must be allowed the opportunity to do so by crossing it out. 

2. Health Statement

Applicants will still make a statement regarding health status and any problems that could affect his/her ability to perform a specific privilege BUT that must be confirmed (each facility will determine how this will be implemented). 

3.  Focused Professional Practice Evaluation

Is there a clear description of the process for FPPE for new privileges, both for initial requests and for new privileges?   Is the trigger criteria clearly defined?  Is the proctor plan in place with appropriate documentation? 

4. Focused Professional Practice Evaluation

Is there a clear description of the process for FPPE for new privileges, both for initial requests and for new privileges?   Is the trigger criteria clearly defined?  Is the proctor plan in place with appropriate documentation? 

Those are the highlights from my notes.  The more I hear about these standards, the more I start to understand it.  And that makes me just a little nervous … am I really getting this? 

I shared this information with my Chair of our Credentials Committee and his response was, “Well, that’s one surveyor’s viewpoint”. 

I wish us all the best on our next surveys and I’m keeping my fingers crossed that I won’t be the first! 

Carole  La Pine, MSA, CPMSM, CPCS

Coming Soon from The Joint Commission: New format, new numbering system, and more logical layout.

The Joint Commission’s (TJC) Standard Improvement Initiative (SII) will be bringing a new, logical structure to the manual chapters.  The manual will also have a new numbering format designed to allow electronic sorting and make possible the addition of new requirements within the outline.  TJC reported that all of the standards and the National Patient Safety Goals (NPSG) will be in sync with the chapter outline.  Each standard and NPSG will be assigned a 6-digit number.  For example, the 2008 Infection Control (IC) Chapter IC.4.15 will be appear as IC.02.04.01.  This number represents:

• 02 – the standard is in the implementation section (II)
• 04 – the standard pertains to Influenza Vaccinations (D)
• 01 – the first standard in the section

The 2009 standards will be reorganized and will include new chapters (example:  NPSG) all arranged in alphabetical order by title.  Changes to the standards have been made to clarify the language as well as to delete duplicative requirements.

Check The Joint Commission website in July to review the revised 2009 standards for ambulatory, critical access hospital, home care, hospital and office-based surgery programs.  To help with the transition to the new numbering system, TJC will provide an extensive, historical crosswalk.

These documents will be on the website until the printed manuals are published in September 2008.

Carole  La Pine, MSA, CPMSM, CPCS