Overview

The seventh chapter of standards in the Joint Commission on Accreditation of Healthcare Organizations' standards for Behavioral Health Programs is entitled, "Human Resources." The goal for this function is that the program determines what competencies are required to appropriately, serve its clients and to determine the number of staff required to provide care, treatment and services in an effective manner. In this chapter, the four areas of focus include: 1) provision of an adequate number of staff; 2) providing competent staff; 3) orienting, training and educating staff, and assessing, 4) maintaining and improving staff competence. This applies to staff hired by the organization or program and any licensed independent practitioners (LIPs) who are hired or contracted by the program.

Accreditation Requirement(s)

To conform to these standards, the organization must show evidence of the following:

• All staff hired by the program are competent through education and experience to provide quality care, treatment, and service to the clients
• All staff, contractors, students, and volunteers receive the appropriate orientation and initial skills training (including initial training in environmental and clinical safety) to perform their job functions competently
• All staff, students, and volunteers receive ongoing education and training that is designed to increase staff knowledge and abilities in work-related issues
• All LIPs hired or contracted by the program have initial credentials and competencies verified through a primary source or a credentials verification organization (CVO).
• All LIPs have defined assigned clinical responsibilities that are based on the competency of the LIP to provide those clinical responsibilities
• Renewal of the assigned clinical responsibilities will not exceed 2 years.
• All staff receive an annual competence assessment (i.e., performance evaluation) on an ongoing and periodic basis.

Sample P&Ps/Checklist

• Assignment of Clinical Responsibilities and Temporary Clinical Responsibilities to Licensed Independent Practitioners Policy and Procedure (DOC | HTML)
• Competence Requirements for Addictions Staff Policy and Procedure (DOC | HTML)
• Competency Assessment Policy and Procedure (DOC | HTML)
• Fair Hearing and Appeals Policy and Procedure (DOC | HTML)
• Guide for Obtaining Credentials Information From Other Than Primary Sources (DOC | HTML)
• Initial Orientation, Training, and Education Policy and Procedure (DOC | HTML)
• Competency Verification Process for LIP’s Policy and Procedure (DOC | HTML)
• LIP Competency and Credentials Checklist (DOC | HTML)
• Ongoing Education Policy and Procedure (DOC | HTML)
• Renewal of Current LIP Clinical Responsibilities Policy and Procedure (DOC | HTML)
• Staff Competency Assessment Checklist (DOC | HTML)
• Staff Planning Policy and Procedure (DOC | HTML)
• Staffing and Caseload Planning Policy and Procedure (DOC | HTML)

Implementation Tips

• Programs that have students or volunteers participating in treating clients must meet the same initial screening and orientation and ongoing orientation and training requirements as permanent staff.
  
  
• The process of initial verification of LIP credentials and competency must begin far enough in advance to be completed by the time of the anticipated hire date. In usual circumstances, this takes 3 months.
  
  
• Although temporary assignments of clinical responsibilities are permitted, JCAHO frowns on their consistent use or substitution in lieu of a completed credentials/competency verification process. The use of temporary assignments should be reserved only for those situations in which client needs must be quickly met, prior to the approval bodies' scheduled meetings.
  
  
• Documentation of the credentials and/or competency verification processes for both staff and LIPs is critical. Establish a standard form for documentation of these processes and survey periodically to assure that all areas are in compliance.
  
  
• Documentation of ongoing education and training content is also very important. Keep an annual record of all programs offered to staff, and document attendance for each. (Save those flyers announcing staff conferences, team meetings, and presentations on clinical topics!)
  
  
• Document how education and training needs are evaluated and prioritized.
  
  
• Although no longer required as a standard, a summary competency report to the program leadership and governance bodies is a good idea. Leadership standards require planning for an adequate number of competent staff, and an annual report is a great way to demonstrate evidence of that planning.