STANDARD 7: Staffing Management

7.1 Licensure, Registration and Certification 

1. The healthcare organization shall have a policy and practice for outlining and verifying that each staff member possesses a valid and current license, registration, or certification. This written policy shall be strictly enforced, and compliance data reported to Top management oversight. 

  7.2 Professional Scope 

1. All staff, including contract staff, students and volunteers shall function within the limits of their current license, registration, or certification. Variations shall be reported to top management oversight. 

  7.3 Determining and Modifying Staffing 

1. The method for determining and modifying staffing shall be validated through periodic reporting of variance from core staffing, outlining justification and linking that justification with patient and process outcomes, including any untoward patient events or process failures. 

2. This validation shall be done and reported to Top management oversight, when indicated. 

3. Changes to staffing as a result of the above process shall be documented and retained as necessary. 

 7.4 Job Description 

1. All staff, whether clinical or supportive, including contract staff, students and volunteers shall have a current job description (or job responsibilities) available that contains the experience, educational, physical requirements, supervision (as indicated) and performance expectations for that position. 

 7.5 Orientation 

1. All staff, whether clinical or supportive, including contract staff, students and volunteers shall receive an orientation to specific job duties and responsibilities, and their work environment. The orientation shall take place prior to the individual functioning independently in their job. 

2. Members of staff shall receive an orientation developed and approved by the healthcare organization. These shall include general safety practices, emergency procedures, infection control, especially hand-washing requirements, and use of PPE. Additionally, the orientation shall include the following topics relative to the healthcare organization scope of service: 

a) organizational structure; 

b) patient rights including confidentiality and ethics;  

c) document control, retrieval and verification (specific to policies, procedures, and work 

instructions/protocols); 

d) internal reporting requirements for adverse patient events; 

e) patient safety; 

f) operation of equipment, including medical devices, in a safe manner; 

g) risk management; 

h) other issues as required by the healthcare organization and regulatory requirements. 

NOTE 1 Orientation to specific job duties may be addressed within the department or service where the employee is assigned but completed prior to the employee working independently. 

7.6 Staff Competence 

1. The healthcare organization shall ensure that the staff is competent on the basis of appropriate performance, education, training and experience. 

2. The healthcare organization shall take actions to achieve the necessary level of staff performance within the scope and job description of all personnel. 

3. The healthcare organization shall retain appropriate documented information as evidence of competence. 

7.7 Awareness and Education 

1. The healthcare organization shall ensure that persons doing work under the organization’s control are aware of: 

a) mission, vision and the quality policy; 

b) relevant quality objectives; 

c) their contribution to the effectiveness of the healthcare organization management system, including the benefits of improved performance and patient satisfaction; 

d) the implications of not conforming with the healthcare organization management system requirements; 

e) the healthcare organizations provision of integrated care; 

f) the need for patient safety; 

g) patient's rights and complaints; 

h) the need for appropriate communication with all patients; 

i) needed respect for varying cultural beliefs. 

2. The healthcare organization shall ensure that persons doing work under the organization’s control are educated in and aware of all of the requirements stated in STANDARD 11 as they may apply to 

the person's duties, area of service, interaction, and integration with patients and other service providers. 

7.8 Staff Evaluations 

1. The performance/competency evaluation shall contain indicators that shall objectively measure the ability of staff to perform all job duties as outlined in the job description. Relevant indicators may be selected from the list of indicators for measurement as outlined below. 

2. All staff including Licensed independent practitioners (LIP) both internal and external, contract staff, and volunteers shall be evaluated initially and on an on-going basis with respect to indicators that measure issues and opportunities for improvement within their scope of duties. The measures selected may include but are not limited to: 

a) variation of outcomes while performing high-risk, low volume procedures; 

b) performance involving new technology/equipment/processes; 

c) customer/patient satisfaction feedback; 

d) improvement as a result of scheduled training session outcomes; 

e) staff learning needs identified through performance measurement and feedback-including input from the medical staff; 

f) requirements of national and local legislation and regulations as applicable; 

g) other indicators as determined by the healthcare organization. 

3. The healthcare organization shall aggregate objective performance data from sources that may include individual evaluations, incident reports, risk management, staff, and patient feedback, and/or data analysis to identify variations that may indicate the need for further training, coaching, and mentoring. 

4. Staff intervention or discipline required as a result of the above process shall be based on objective data. The outcomes of this aggregated data shall be reported to Top management oversight as needed to monitor staff performance improvement. 

5. The healthcare organization shall share results of individual performance evaluations and competence assessments with staff members allowing their feedback at regular intervals not to exceed one calendar year. 

6. The healthcare organization shall require all staff, both internal and external, to participate in continuing education as required by individual licensing, certification, professional association, or national requirements. Compliance with this standard shall be reported to top management oversight. 

 7.9 Health Promotion 

1. The healthcare organization shall have policies and procedures that address individual health maintenance, disease prevention, and workload monitoring within the staff. These shall include but are not limited to: 

a) intervention and/or rehabilitation relating to substance abuse including tobacco, alcohol and other addictive substances; 

b) wellness to include diet, exercise, acute illness, stress management, and other psycho-social needs. Pathways for assistance shall be readily available and confidential; 

c) injuries on or off the job.