Health Care Staffing Services Certification Review Process Guide

Health Care Staffing Services

Certification

Review Process Guide

2024

Health Care

Staffing Services

Certification

Review Process Guide

2024

What’s New in 2024

Updates effective in 2024 are identified by underlined text in the activities noted below.

Changes effective January 1, 2024

No changes.

Table of Contents

Review Process Introduction ........................................................................................................ 5

Multi-Site (Corporate) Review Process Overview ......................................................................... 6

Organization Review Preparation Guidelines ............................................................................... 8

Requested Documentation for Certification Reviews .................................................................. 12

Certification Review Notification and Postponement Policies ..................................................... 14

Opening Conference and Staffing Firm Overview ...................................................................... 15

Reviewer Planning Session ........................................................................................................ 16

Orientation to the Staffing Firm and Data Use ............................................................................ 17

Multi-Site (Corporate) Review Monitoring and Oversight System Tracer ................................... 19

Contract/Formal Agreement Review ........................................................................................... 20

Competence Assessment & Credentialing Session .................................................................... 22

Personnel File Review ................................................................................................................ 23

Individual Clinical Staff Tracers ................................................................................................... 25

On-Call Contact .......................................................................................................................... 27

Multi-Site (Corporate) Review – Individual Site (Branch Office) Review..................................... 28

Issue Resolution ......................................................................................................................... 30

Reviewer Report Preparation ...................................................................................................... 31

Organization Exit Conference ..................................................................................................... 32

Intra-cycle Evaluation Process .................................................................................................... 33

Agenda Templates ...................................................................................................................... 34

Contract/Formal Agreement Review Checklist ........................................................................... 47

Personnel File Review Checklist ................................................................................................. 49

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Health Care Staffing Services Certification

Review Process Introduction

This guide is intended to prepare your organization for a review of compliance with the Health

Care Staffing Services certification standards. It is important that you read this guide and follow

the instructions, as well as access the recommended resources so that your organization is

prepared for participating in the certification review process. In this activity guide your

organization will find guidance on how to prepare for a Health Care Staffing Services

certification review.

The Certification Review Process Guide describes each activity of a Joint Commission

certification review. Organizations should become familiar with the review activities which

include:

 The purpose of the activity,

 Descriptions of what will happen during the activity

 Suggested amount of time for the activity

 Discussion topics, when applicable

 Recommended participants

 Any materials to have available for the activity

These activity descriptions can be shared organization-wide as appropriate.

Introductory Phone Call

A Joint Commission Account Executive will be in touch with your organization by phone soon

after your application is received. The purpose of this call is to:

 Conduct initial introductions

 Confirm information reported in your application for certification

 Confirm your hours of operation; if these change at any time, please call and inform your

Account Executive

 Confirm your mailing address, internet website address, if applicable

 Confirm that your organization knows how to access your secure Joint Commission

Connect extranet site to view communications and certification-related information

 Obtain the phone number for any on-call service that your firm may provide

 Answer any of your questions.

Health Care Staffing Certification Review Configurations

There are three possible configurations for a health care staffing certification review:

• One Day Review

• Multi-Day Review

• Multi-Site Review (formerly referred to as the Corporate Integration Review)

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The event scheduled for your organization is based on the information provided in your

certification e-application. The same activities take place on each of these reviews. Multi-Day

review events include more contract, personnel file reviews, and clinical staff tracers. The Multi-

Site event includes a few additional activities and is described in the following overview.

Multi-Site (Corporate) Review Process Overview

Many health care staffing firms operate multiple offices in order to meet the demands of their customers

and to have a physical presence in health care markets across a particular geographic area (e.g., city,

county, state, region, country). This review event was created to evaluate staffing firms with multiple

sites. The Multi-Site (corporate) unique review process and activity descriptions have been integrated

throughout this Health Care Staffing Services, Certification Review Process Guide. The content will be

identified as applicable to this review type by either lead-in text or within activity titles.

Multi-Site Review Process Description

Part one:

• The staffing firm main site (corporate office) will receive a 30-day notice on initial and 7-day notice on

recertification scheduled reviews.

• A Joint Commission Health Care Staffing Services (HCSS) reviewer performs a one-day review of the

main site (corporate office) of the staffing firm.

• The review focuses on leadership, corporate structure, and multi-office management and operations.

• Additional emphasis will be placed on:

 Corporate systems in place to support sites (branch offices)

 Corporate and site (branch office) responsibilities and accountabilities

 Corporate monitoring and oversight of site (branch office) operations

 Centralized and decentralized operations

 Communication between main site (corporate) and other site (branch office) management and

operations

 Reporting of data between main site (corporate) and other sites (branch offices)

 Main site (corporate) and other site (branch office) performance improvement processes

Part two:

An HCSS reviewer conducts reviews of sampled sites (branch offices). Sites (branch offices) are

selected by Joint Commission central office staff. Sites selected for review are not revealed until the

reviewer needs to interact with or requires information from the site.

Reviewers will conduct site reviews using a video meeting platform. If the site performs its own

credentialing and contracting functions and maintains its own records, the reviewer and the site (branch

office) staff will identify a sample of contracts/formal agreements and a sample of clinical staff whose

records will be reviewed. Site (branch office) staff and the reviewer will be interacting during this

scheduled review time. See

Part three:

The Final Exit Conference takes place following the conclusion of the last site (branch office) review. The

reviewer will take a short break to review the main site and other site observations and prepare the report.

The reviewer will reconnect, if necessary, with the main site (corporate office) review coordinator and

leaders for the Multi-Site Review Exit Conference to present the Summary of Review Findings Report.

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The final certification report is processed in the Joint Commission central office and is posted to the

organization’s secure extranet site within ten business days.

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Health Care Staffing Services Certification

Organization Review Preparation Guidelines

Your certification review will be conducted by a Joint Commission, Health Care Staffing

Services field representative using the video meeting platform known as Zoom for interacting

with you and your organization’s staff. Following are some important steps for you to take in

order to participate in the certification review process.

Step 1: Signing the Amendment to Permit a Virtual Survey

To proceed with scheduling a Health Care Staffing Services certification review for your

organization, The Joint Commission requires you to electronically sign the contract entitled,

“Amendment to Permit Virtual Survey.” This grants The Joint Commission permission to perform

your review off-site as opposed to onsite. This contract can be signed under the Contracts

section of your organization’s Connect site. Once logged into the Connect site please go to the

Survey Process tab and select Contracts on the far right side of the screen. You will find the

contract entitled, “Amendment to Permit Virtual Survey” there for signature.

Step 2: Review Agenda

Template agendas for the three possible configurations of Health Care Staffing Services

reviews can be found later in this guide. An agenda specific to your organization’s event will be

provided by the assigned Joint Commission reviewer soon after your certification review has

been scheduled (see Step 4).

Step 3: SharePoint Access and Document Upload

The review process continues to include document review as part of standards compliance

evaluation. A specific list of required documents for Health Care Staffing Services certification

will need to be uploaded to a secure SharePoint site at least 72 hours prior to the start of the

review. This list appears at the end of these guidelines. It is recommended that you begin

gathering and uploading these documents as soon as you receive notice of your organization’s

scheduled review date. Please use the instructions below and work with your assigned Account

Executive to gain access to a secure SharePoint portal for document uploading. Please note

that while this list includes required documents, reviewers may request additional

documentation be uploaded based on discussions with staff.

SharePoint Document Upload Instructions

Please follow the instructions below to access the SharePoint Portal:

1. The Primary Certification contact will receive a link to the SharePoint folder as you get

closer to your scheduled review. This email will come directly from

no-

[email protected]. If you cannot locate this email, please check your spam or

junk folders as this is an automated email generated once you are added to the folder by

your Account Executive.

2. You should intitally see the login page displayed below. Try first logging in as an

“organizational account’ with your e-mail address and normal password for that account.

If that does not work, go to step 3.

3. If step 2 did not work, click on “Create a Microsoft account” using that same email

address. Follow the steps below.

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LOGIN PAGE:

3a. If you need to create an account, you should specify the same email address.

3b. And then specify a Microsoft password

You will then receive an automated email to verify the new account and password. These steps

do not create a new Microsoft account, it just allows you to access the portal.

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**Please note: On subsequent visits to the site you would always select Microsoft account**

Step 4: Zoom Video Meeting Platform

The certification review is conducted utilizing the Zoom meeting platform. Please be sure to

familiarize yourself with the Zoom platform prior to the review. The links below will direct you to

numerous resources that Joint Commission customers have found beneficial in preparing for

their certification review.

Meeting Controls

Joining & Configuring Audio & Video

Sharing Your Screen

Day of Review: Accessing the Zoom Meeting Link

Once your organization has received notice of the scheduled certification event, the reviewer

provides a specific agenda for your organization and posts it in your organization’s SharePoint

folder. The agenda will include a link to the Zoom meeting beginning with

“https://Jointcommission.zoom.us.....” which will provide access to your organization’s secure

Zoom meeting event. On the scheduled review date at the appointed time, click on the link and

the Zoom meeting application will launch, and you will be placed into a waiting room until

admitted by the reviewer.

Review Activity Preparation and Participation Tips

 Group activity participants should be limited, if possible, to key individuals who can provide

insight on the topics of discussion. It is the organization’s discretion as to who will

participate.

 The reviewer will be talking with staff about the day-to-day operations of the organization.

The reviewer will rely on organization staff to find locations where video meeting discussions

can take place that allow confidentiality and privacy to be maintained and that will minimize

disruption to operations.

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 The review agendas found later in this guide offer the suggested order of activities and

timeframes for each. Discuss any need for changes to the proposed agenda with the

reviewer.

 Organizations should use this review process guide and the agendas as a planning tool for

the review by identifying key participants for various activities.

 Consider planning for how and who will participate in the Individual Clinical Staff Tracer

Activity; present the reviewer with your recommendations.

Questions about Standards

If you have a question about a standard or element of performance, please consider reviewing

the Standards Interpretation FAQs page:

https://www.jointcommission.org/standards_information/jcfaq.aspx prior to submitting a

question. To submit a question, Login to your organization’s Joint Commission extranet site,

Connect: https://customer.jointcommission.org/TJCPages/TJCHomeEmpty.aspx and click on

Resources - Standards Interpretation, to submit your question. If you do not have access to

Connect, please go to the Standards Interpretation Page:

https://www.jointcommission.org/standards_information/jcfaq.aspx to submit a question.

If you have questions about the review process, agenda, scheduling, or other subjects – Call

your Joint Commission Account Executive.

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Health Care Staffing Services Certification

Requested Documentation for Certification Reviews

Following is the list of documents that organizations are asked to upload to a secure Sharepoint

folder for review during the certification event. Documents must be uploaded at least 72 hours

prior to the scheduled event date.

If this is a Multi-Site Review, and any of the following documentation is unique to each site, the

firm is asked to provide site-specific documentation to the reviewer.

 Leadership:

 Organization chart

 NOTE: If this is a Multi-Site Review, a chart or diagram displaying the

reporting structure between the main site (corporate office) and other sites

(branch offices) if applicable

 List of current customers with approximate number of placements in the past

12 months

 NOTE: If this is a Multi-Site Review and each site (branch office) works

with a separate and unique group of customers, the firm is asked to

provide a customer list for each site (branch office) selected for review.

 List of currently placed staff organized by discipline with an indication of the

assignment setting (for example, hospital, clinic), and if traveler, an indication

of the state

 NOTE: If this is a Multi-Site Review and each site (branch office) works

with a separate and unique group of clinical staff, the firm is asked to

provide a list of clinical staff for each site selected for review.

 Business license, if applicable

 Written code of business ethics

 Conflict of interest policy with indication of annual review

 Customer contract template if one is used

 Firm’s standard contract addendum if one exists

 Written description of the complaint process for customers

 Written description of the complaint process for staff

 Emergency Management Plan, including a hazard vulnerability analysis

(HVA)

 NOTE: If this is a Multi-Site Review, the firm is asked to provide a site-

specific HVA and Emergency Management Plan for each site selected for

review.

 Emergency Management Plan annual testing record—test date and any

identified opportunities for improvement

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 NOTE: If this is a Multi-Site Review, the firm is asked to provide

Emergency Management Plan annual testing records for each site

selected for review.

 Human Resource Management:

 Credentialing policies and procedures, including competency assessment

 Written procedures for clinical professionals’ involvement in competence

assessment-related activities, including required qualifications for these

clinical professionals, description of roles and responsibilities (for example,

job description or contract language outlining performance expectations)

 Clinical staff handbook or documents given to staff upon hire

 Policy on presentation of proof of identity

 Copy of the performance evaluation tool for client feedback

 Copy of the performance evaluation tool conducted by the firm which extends

beyond customer feedback

 Information Management:

 Written policy to address privacy, confidentiality, and security of information

 Written policy to address who has access to information

 Process to follow when confidentiality or security of information is breached

 Business continuity plan, including disaster recovery for information systems

 Performance Measurement and Improvement:

 Any performance measure data displays, action plans, improvement project

plans, reports prepared for leaders’, etc.

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Health Care Staffing Services Certification

Certification Review Notification and Postponement Policies

Notice of Initial Certification Review

If this is your program’s first time through the certification process you will receive a thirty (30)

day advance notice of your review date(s). Notice will be provided via e-mail to the individuals

identified on your account as the Primary Certification Contact and CEO. Also thirty (30) days

prior to your review, the Notification of Scheduled Events section on your organization’s extranet

site, The Joint Commission Connect, is populated with the event along with a link to the

reviewer(s) name, biographical sketch and photograph.

Notice of Re-Certification Review

Your organization will receive notice from The Joint Commission seven (7) business days prior

to the first day of the scheduled review date(s) for Health Care Staffing re-certification. The

notice will be emailed to the individuals identified on your account as the Primary Certification

Contact and CEO and will include the specific review date(s) and the program(s) being

reviewed. Additionally, at 7:30 a.m. in your local time zone on the morning of the review, the

Notification of Scheduled Events section on your organization’s extranet site, The Joint

Commission Connect, is populated with the review event including a link to the reviewer(s)

name, biographical sketch and photograph.

Review Postponement Policy

The Joint Commission may not certify a staffing firm if the firm does not allow The Joint

Commission to conduct a review. In rare circumstances, it may be appropriate to request a

review postponement. An organization should direct a request for postponement to its Account

Executive. A request to postpone a review may be granted if a major, unforeseen event has

occurred that has totally or substantially disrupted operations, such as the following:

• A natural disaster or major disruption of service due to a facility failure

• The organization’s involvement in an employment strike

The Joint Commission may, at its discretion, approve a request to postpone a review for an

organization not meeting any of the criteria listed above.

Your organization’s Certification Account Executive can answer questions about these policies,

or put you in contact with other Joint Commission staff that can assist you.

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Health Care Staffing Services Certification

Opening Conference and Staffing Firm Overview

Duration

Approximately 40 minutes

Overview of Activities

The Opening Conference will include the following:

• Introduction of reviewer

• Introductions of organization review coordinator and leaders

• Reviewers will provide

o A brief overview of The Joint Commission and Certification if this is an initial review; if

this is a re-certification review, the discussion will focus on any changes or updates to

the Certification process since the last review

o Agenda review with discussion of any needed changes

 If this is a Multi-Site (corporate) review, reviewers will discuss the site review agenda

and preparations

o Brief overview or refresher on the SAFER

™

portion of the Summary of Certification

Review Findings Report

o Answer any questions about the review process

• Confirm that requested documentation will be available for the Reviewer Planning Session

During the Staffing Firm Overview, the reviewer will facilitate the discussion to:

• Learn about the firm’s organizational structure and scope of operations

• Review and discuss information provided by the organization in their certification application

and any changes since the application was submitted

• If this is a Multi-Site (corporate) Review,

 Confirm the site (branch office) information provided in the application

 Determine if each site works with a separate and unique group of customers and clinical

staff

 Determine at a high-level what activities, resources, and operations are universal across

sites, and unique to each site

The reviewer will use the information provided by the firm to plan for the remainder of review

activities.

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Health Care Staffing Services Certification

Reviewer Planning Session

Organization Participants

• Firm’s review coordinator or individual familiar with office operations

• Firm’s review coordinator, other internal staff familiar with clinical staff and

matching/placement processes and with contracts/formal agreements

Reviewer Planning (30 minutes)

The reviewer, with the assistance of internal staff, will identify the sample of clinical staff whose

personnel files they would like to examine. Clinical staff rosters will be used to guide and

facilitate this selection. The number of personnel files selected will vary based on the

characteristics of each organization. A minimum of 20 clinical staff personnel files will be

reviewed per day.

The reviewer will identify from the list of customers where clinical staff are currently placed

those customers whose contracts/formal agreements the reviewer would like to see. A

minimum of six contracts/agreements will be identified for review per day. The number

selected will vary based on the number and types of customers. Reviewers will look at these

contracts/agreements during the time designated on the agenda.

Multi-Site (Corporate) Review-Specific Planning

The reviewer will

• Inform the firm’s review coordinator of the sites (branch offices) selected to participate in

the review.

• Ask for assistance in determining the best order in which to review/engage the sites.

• Collaborate with the review coordinator to provide selected sites with information needed

to participate using the video meeting platform.

• Request site-specific (branch office) clinical staff and customer lists, if applicable, to

select the sample of personnel files and contracts/agreements for review

Please Note: It will be important that this activity conclude at the designated time, unless

otherwise negotiated. The Orientation to the Staffing Firm and Data Use activity immediately

follows.

Any activity scheduled for this session that has not been completed will be covered later in the

review at a time agreed upon by the firm and reviewer.

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Health Care Staffing Services Certification

Orientation to the Staffing Firm and Data Use

Joint Commission standards address various aspects of a staffing firm’s performance. The

Orientation session is an opportunity for the organization and reviewer to discuss some specific

topics covered in the standards, and more importantly, agreed to by the industry as key

indicators of staffing firm performance. The Data Use discussion will focus on how the staffing

firm is using data to improve the quality of services provided to health care organizations by the

clinical staff assigned by the firm.

Duration

Approximately 60-minutes

Organization Participants

• Leader(s) of the staffing firm

• Individuals who can answer questions and explain the topics being discussed

• Others at the discretion of organization leaders

Overview

The reviewer will want to explore and learn about a variety of topics from those individuals most

knowledgeable about the staffing firm’s processes and operations in these areas. The

standards-based topics cross all functions and include:

Business Functions

- Management and day-to-day operations

- On-call structure and service, if applicable

- Marketing activities (strategy and practice)

- Information management

 Cyber security and protection systems

- Code of business ethics

- Emergency management (risk assessment, planning, testing)

Customer/Client Functions

- Contracting/formal agreement processes

 MSPs and vendor management

 Subcontracting

- Conflict of interest policies

- Customer reassignment of clinical staff (floating)

- Tracking and fulfillment of customer/client staff requirements

Staffing Functions

- Recruitment, retention and competency (strategies)

- Clinical staff performance evaluation (strategies)

- Clinical staff health (strategies, customer requirements)

- Tracking law and regulation requirements for staffing

- Processes for reporting and investigating work-related illness or injuries

- Firm’s expectations regarding orientation to and knowledge of National Patient Safety Goals

Data Use

- Approach to performance improvement

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 Monitoring performance – What is being monitored (for example, customer satisfaction

and complaints, clinical staff satisfaction and complaints)

 Data collection processes

 Data quality and maintaining integrity

 Data analysis processes -- Type of analyses being conducted – approach to trending

data over time, graphical data displays, comparing data to an expected level of

performance, and looking at data in combination for potential cause and effect

relationships

 Data reporting and dissemination, when it occurs and who receives

 Strengths and weaknesses in the processes used to obtain data and meet internal and

external information needs

 Selection and prioritization of performance improvement activities

 Actions taken as a result of using data

The depth of discussion and questioning on each topic will vary. If a topic is better explained

through demonstration or a review of documentation, indicate this to the reviewer.

Multi-Site (Corporate) Review

If this is a Multi-Site (Corporate) review, all discussion topics will be explored from the

perspective of the main site (corporate)-to-site (branch office) relationship. It is important for the

reviewer to understand this relationship and the expectations before beginning the review of

sites (branch offices). For example, when talking about each of the subjects noted above, the

firm should be prepared to provide details about:

• Site direction, oversight, and reporting

• Centralized and decentralized processes

 Operations performed at main site (corporate office) for the other sites (branch

offices)

 Operations delegated to the sites (branch offices)

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Health Care Staffing Services Certification

Multi-Site (Corporate) Review Monitoring and Oversight System

Tracer

Staffing firms subject to the Multi-Site Review option will need to demonstrate that their

operations include an ongoing, rigorous process for monitoring site (branch office)

performance.

Organization Participants

• Individuals responsible for oversight of site (branch office) performance

• Individuals responsible for monitoring site performance

• Individuals responsible for day-to-day interactions with sites

Overview

The staffing firm should be prepared to provide reviewers with details of their process to

identify sites (branch offices) that may exceed or may not be performing according to

the quality expectations established by the firm. Specifically, the reviewers will want to

understand the:

 Frequency of monitoring and oversight

 Criteria and performance expectations for sites (branch offices)

 Aspects of site performance (e.g., financial, number of placements,

completeness of clinical staff data collected and analyzed) that are monitored

 Individuals responsible for ongoing monitoring and oversight

 Data gathered and used to monitor site performance

 Procedures and tools for overseeing sites

 Procedures for providing performance feedback to sites

 Requirements and time frames for site corrective action

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Health Care Staffing Certification

Contract/Formal Agreement Review

The content of contracts and agreements is clearly a considerable influence on a staffing firm’s

performance. These agreements spell out what a customer can expect in terms of staffing firm

services and may additionally outline the staffing firm’s expectations of its customers in terms of

treatment of clinical staff and feedback on clinical staff performance. Joint Commission

standards require some specific elements be contained in the staffing firm’s formal agreements,

and the purpose of this activity is to determine that the formal agreements meet standards

expectations.

Organization Participants

• Individuals responsible for establishing, fulfilling and monitoring compliance with contracts

and formal agreements

• Individuals familiar with the contracts/formal agreements who can facilitate the review

• Others at the discretion of organization

Materials Needed for this Session

The selected sample of contracts identified during the Opening Conference and Orientation to

the Organization sessions

Preparation

The reviewer will gather information from the staffing firm’s application for certification as well as

during the Staffing Firm Overview and Orientation to the Staffing Firm activities to help

determine the contracts he or she will select for review.

The reviewer will be asking about the different types of contracts the staffing firm has in place,

the types of health care entities and their size, and the type and number of staff placed per

contract. The following criteria may be considered in the reviewer’s selection of a sample of

specific contracts and formal agreements.

• Smallest health care entity

• Largest health care entity

• Contract in place for the longest duration

• Contract in place for the shortest duration

• Vendor management contracts (if applicable)

• Subcontracts with other staffing firms (if applicable)

One contract can satisfy multiple criteria. A minimum of six contracts/formal agreements will be

examined per review day. The reviewer may request more if necessary.

The reviewer will make an effort to complete his or her selection of contracts during the

Reviewer Planning Session so that the firm’s staff may pull them in advance of this activity.

However, reviewers may request additional contracts or formal agreements as the day

progresses if there is a need to validate standards compliance.

Overview

The staffing firm is requested to have an individual available who has authorized access to and

is familiar with the contracts, formal agreements, and customers. This individual should be able

to answer reviewer questions and facilitate and expedite the review.

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Reviewers will discuss the entire contracting process while they are engaged in a review of the

contracts. Specifically, they will trace the contracting process, including:

 Sales and marketing securing a customer for the firm’s staffing services

 Negotiation and establishment of a formal agreement

 Monitoring the firm’s ability to meet contractual obligations

 The firm’s customer service operations, including satisfaction, complaints, new

needs/expectations

 Renewal or termination of a contract

Reviewers will be using the Contract Review Checklist (Appendix A) to record their findings and

note any questions for follow-up. If a reviewer is unable to locate an item in the contract that is

required by the standards he or she will seek help from the firm’s staff.

Information gathered through the contract and formal agreement review will be considered in all

subsequent review activities.

At the conclusion of the designated time for this session, the reviewer will identify any

contracts/formal agreements that can be returned to file and those that still require review. The

reviewer will identify the time that contract/formal agreement review activity will be completed

and if he or she will require the assistance of firm staff.

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Health Care Staffing Services Certification

Competence Assessment & Credentialing Session

Health care staffing firms are in the business of providing human resources to health care

organizations looking for temporary staff to fulfill assignments. A crucial industry function is

checking credentials and competency of individuals recruited to fill positions.

Organization Participants

 Individual(s) responsible for the recruitment of clinical staff

 Individual(s) responsible for collecting credentials information

 Individual(s) responsible for evaluating applicant credentials and making hiring decisions

 Individual(s) responsible for evaluating clinical staff performance

 Individual(s) responsible for customer communication

 Others at the discretion of organization

Materials Needed for this Session

 Samples of competency tests or other evaluation methods

Preparation

None required

Overview

Staffing firm representatives attending this session should be prepared to explain all aspects of

the credentialing and competency assessment processes in their day-to-day operations.

Tracing the process from the internal perspective, through every step, identifying individuals

(that is, positions) that play a role from collecting, filing, and data entry to making decisions that

impact further activity, is the goal of this session. Reviewers will want to explore standards-

based topics such as:

 Application process

 Employment history checks

 Credentials verification process

 Hiring criteria

 Tracking of regulatory requirements for health care staff

 Orientation of clinical staff

 Placement criteria

 Clinical staff to customer matching process

 Clinical staff supervision

 Clinical staff performance evaluation, including use of customer feedback

 Maintaining competency of clinical staff

This session is most effectively conducted as a group discussion.

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Health Care Staffing Services Certification

Personnel File Review

The review of personnel files provides an opportunity to see how consistently the staffing firm is

complying with its own internal procedures, the requirements of its customers, and Joint

Commission standards in terms of data it collects and uses to make hiring decisions and

evaluate performance of clinical staff. While primarily a review of files, this session can reveal

areas for improvement in human resources data collection, evaluation, and use in decision-

making and reporting.

Organization Participants

• Individual(s) with authorized access to personnel files and familiarity with content and layout

who can participate for the duration of this activity

• Others at the discretion of organization

Materials Needed for this Session

The selected sample of personnel files identified during the Reviewer Planning session.

Preparation

The reviewer will gather information from the staffing firm’s application for certification as well as

during the Staffing Firm Overview and Orientation to the Staffing Firm activities to help

determine the number and types of disciplines that will be included in the selection of clinical

staff personnel files. The reviewer will be asking about the different types and sizes of health

care customers, and the type and volume of clinical staff placed at each. Selection of clinical

staff for tracer activity and file review will be based on customer information and the following

selection criteria which apply to all disciplines:

 Highly specialized health care providers (e.g., ICU, NICU, OR)

 Health care providers placed in areas not highly supervised (e.g., occupational nurse,

school nurses, community service nurses [flu shots, blood pressure checks])

 New clinical staff member

 Long term clinical staff member

 Clinical staff member with greater working frequency

 Clinical staff member who works infrequently

 Clinical staff member who crosses state lines to practice

The reviewer will:

 Select a sample of three (3) clinical staff from each discipline

 Include per diem and travel clinical staff in the sample

 If applicable, select and examine a minimum of ten (10) credentials files that cross the

specialties within the discipline of licensed independent practitioners (physicians,

podiatrists, advance practice nurses, etc.); this selection will include placements in a

variety of settings (inpatient, outpatient, emergency room, clinics)

 Complete the Personnel File Review Checklist (Appendix B) for each file reviewed

The minimum number of personnel files that will be reviewed for clinical staff is 20. There is no

maximum number of human resource files that can be reviewed. The reviewer will make every

effort to make his or her initial selections of clinical staff for whom they would like to review files

during the Reviewer Planning Session so that the firm’s staff may gather them in advance of this

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activity. However, reviewers may request additional files as the day progresses if there is a

need to validate compliance with standards.

Additionally, the reviewer will select several internal staff (supervisory staff, individuals

responsible for collecting and evaluating credentials) for whom they would like to review

personnel files. These are in addition to the clinical staff selected.

Overview

The staffing firm is requested to have available an individual(s) who has authorized access to

personnel data and who is familiar with the clinical staff and internal staff file layout and

contents. This individual should be able to both facilitate and participate in the file review

process.

Files will be reviewed using the Personnel File Review Checklist (Appendix B) that lists the

items of information required by the standards. Reviewers will look through each file identifying:

 The presence or absence of the items, and

 Any interactions the individual has had with staffing firm supervisory staff

If a reviewer is unable to locate information in a file, firm staff will be asked to locate the

material. Inform the reviewer of any information maintained in locations other than the

personnel file.

There are several blocks of time on the agenda for file review activity, both in the morning and

afternoon.

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Health Care Staffing Services Certification

Individual Clinical Staff Tracers

A tracer is a review method that is used to evaluate the staffing firm’s performance as viewed by

the individual clinical staff member and the customer at which a clinical staff member is placed.

During tracer activity the reviewer will:

• Follow a clinical staff member’s experience with the firm from the point of first contact to the

point of his or her first performance evaluation and all steps in between

• Assess the relationship of the clinical staff member with the firm and with the customer at

which he or she is placed

• Assess the relationship between the staffing firm and the customer

• Evaluate the firm’s performance of processes related to recruiting, retaining, evaluating, and

placing individual clinical staff members

Organization Participants

Staffing firm representative(s) to guide the reviewer through clinical staff member experience –

see the overview below

Preparation

None required

Overview

The reviewer will evaluate processes from the perspective of the health care professional who is

seeking clinical work assignments through the staffing firm. Tracer activity in a health care

staffing firm will follow a clinical staff member’s entire experience from the point of first contact

to the present. A clinical staff tracer will focus on hand-offs and clinical staff communication.

The reviewer will conduct the clinical staff tracer by interacting with the individuals responsible

for:

• Recruiting clinical staff

• Initial interaction with clinical staff (phone calls, interviews)

• Gathering data on potential clinical staff applicants

• Verifying credentials information on applicants

• Hiring decisions

• Orientation to the staffing firm, customers and assignments

• Developing and implementing the initial and ongoing competency assessment process

• Customer interaction

• Scheduling and placement decisions

• Receiving and responding to clinical staff questions, concerns, and complaints

• Receiving and responding to customer requests, questions, concerns, and complaints

• Clinical staff performance evaluation

The reviewer will conduct a group discussion with individuals that includes:

 Introductions

 A brief statement about how they play a role in the firm’s certification

 Asking staff members to describe: What they do, their responsibilities, and how they

interact (directly or indirectly) with clinical staff or customers

 Asking about the hand-offs or coordination points with other firm staff members

 Asking the staff member any clarifying questions or for more details

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 Asking the staff member if they have any questions about The Joint Commission

certification or the review process

 Thanking the staff members for their time

Reviewers will look to the firm’s staff members to participate in the discussion in the order that a

clinical staff member would interact with them. At the end of all the discussions with staff the

reviewer should have a clear picture of the process that a clinical staff member would

experience.

Aspects of the staffing firm’s operations and procedures that will be explored through the clinical

staff tracer activity include:

 Screening clinical staff

 Clinical staff application process

 Credentials verification process

 Hiring decision process

 Competency assessment process, initially and ongoing

 Orientation to staffing firm, customers, assignments

 Clinical staff to customer matching process

 Clinical staff feedback process (concerns/complaints)

 Clinical staff and on-call, after hours, and weekend internal staff communication

 Customer feedback process (concerns/complaints)

 Customer and on-call, after hours, and weekend internal staff communication

 Clinical staff performance evaluation process

 Clinical staff ongoing education, in-service

 Clinical staff retention

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Health Care Staffing Services Certification

On-Call Contact

When a staffing firm has committed to providing 24 hour service to customers and clinical staff,

there is an expectation that service will be available.

Organization Participants

None required

Materials Needed for this Session

The on-call phone number

Preparation

The reviewer will check the application for certification to determine if the firm provides for on-

call services. If the staffing firm provides on-call services, the reviewer will check the phone

number and hours of operation.

Overview

Reviewers will usually place a call to the on-call phone number before the certification review

begins. The call will range anywhere from 5-10 minutes. The focus will be on the challenges

presented by “outside of business hours” activity. Discussion will include:

 Introductions

 Asking the individual if they have a moment to talk

 Providing a brief statement about how he or she plays a role in the firm’s certification

 Assuring the individual that if he or she needs to take a phone call or take care of any

business he or she should feel free to interrupt the discussion

 Asking the individual to describe what he or she does, his or her responsibilities, and how

he or she interacts (directly or indirectly) with clinical staff or customers

 Asking the individual about the resources available to him or her for doing his or her job

after traditional business hours

 Asking about the challenges of his or her job and how the firm supports him or her in this

role

 Asking about the hand-offs or coordination points with other firm staff members

 Asking any clarifying questions or for more details

 Asking the staff member if he or she has any questions about Joint Commission

certification or the review process

 Thanking the individual for his or her time

Any follow-up from the phone call will take place during the course of the review.

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Health Care Staffing Services Certification

Multi-Site (Corporate) Review – Individual Site (Branch Office) Review

Staffing firms subject to the Multi-Site (corporate) Review option will have a sample of sites

(branch offices) selected to participate in the review. The site’s performance will be evaluated

by the reviewer through video meetings with the site staff and through review of clinical staff

personnel files and health records and customer contracts/agreements.

Organization Participants

• Site (branch office) manager

• Staffing coordinator(s)

• Supervisory staff

• Staff responsible for collecting/verifying application data

• Others at the discretion of the site manager

Overview

Reviewers will first conduct a 45-60 minute video meeting with site (branch office) staff.

Reviewers will want site staff to participate in a Clinical Staff Tracer which covers the

• First contact (recruitment)

• Data gathering (application process)

• Discussion related to file review

 Licensure

 Credentials

 Competency

 Continuing education

 Orientation

 Health status

• Hiring decision

• Orientation/Assignment Availability

• First placement

 How data is provided to customer

 Clinical staff to customer matching process

 Customer reassignment of clinical staff (floating)

 Registering concerns/complaints

 Performance evaluation process

During the clinical staff tracer, the reviewer will be exploring the relationship between the

site and main site (corporate office) covering such topics as:

 Site structure & place within the corporate structure

 Corporate systems to support sites

 Corporate/site responsibilities and accountabilities

 Centralized and decentralized processes

 Communication between corporate and sites

 Data reporting between corporate and sites

 Organization-wide performance improvement

At the conclusion of the site (branch office) video meeting, the reviewer may advise site staff to

have someone on stand-by during the issue resolution time frame in the event the reviewer has

questions or needs clarification based on the results of the file review.

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Following the site video meeting, the reviewer will turn their attention to the evaluation of the

clinical staff personnel files and health records selected for the site. This activity will take

approximately 45-60 minutes. It is important that these files and records be available at the

designated time of this session in order to complete the activity within the noted timeframe.

The above noted process will be repeated for each site selected to participate in the review. At

the conclusion of the site reviews for a given day, time is allotted for issue resolution and

reviewer report preparation for each of the sites. These activities will be followed by either

reviewer planning for additional site reviews or an Interim Exit Conference to report on any

findings from the site reviews.

The Interim Exit Conference will be conducted with corporate office staff. Individual site staff

are invited to participate, however, findings for all sites reviewed that day will be covered in the

same session. Reviewers will not be able to conduct separate exit conferences with each site.

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Health Care Staffing Services Certification

Issue Resolution

Issue resolution time provides an opportunity for the reviewer to follow-up on potential findings

that could not be resolved in other review activities.

Organization Participants

Will vary depending upon the issue

Materials Needed for this Session

Will vary depending upon the issue

Preparation

None required

Overview

The reviewer may have identified issues during review activities that require further exploration

or follow-up with staff. This follow-up may include a variety of activities such as:

• Review of policies and procedures

• Review of personnel files

• Review of performance improvement data

• Discussions with selected staff

The reviewer will work with the staffing firm’s review coordinator to organize and conduct all

issue resolution activity in a timely fashion.

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Health Care Staffing Services Certification

Reviewer Report Preparation

The reviewer will use this time to compile, analyze and organize the data he or she has

collected throughout the review into a report reflecting the organization’s compliance with

standards.

Organization Participants

None required

Preparation

None required

Overview

This time is reserved on the agenda for the reviewer to reflect on his or her observations and

activities and determine if there are any findings that reflect issues of standards compliance.

The reviewer will prepare a Summary of Certification Review Findings Report and plan for the

Organization Exit Conference.

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Health Care Staffing Services Certification

Organization Exit Conference

During the Organization Exit Conference the reviewer will:

• Review the Summary of Certification Review Findings report, including the new SAFER

™

matrix feature, if desired by the CEO

• Discuss any standards compliance issues that resulted in Requirements for

Improvement (RFIs)

• Allow the organization a final opportunity to discuss the review findings

• Review required follow-up actions as applicable

Organization Participants

• Chief executive officer (CEO)

• Other senior leaders identified by the CEO

• Other staff at the discretion of the CEO

Preparation

None required

Overview

This is a 30-minute activity that takes place on the last day of the review. The CEO,

organization leaders, and other organization staff as invited by the CEO will be presented with a

verbal report of the review observations. The certification review findings and report are shared

with participants ONLY with the permission of the CEO.

The reviewer will use the Summary of Certification Review Findings report as the basis for

conducting the Organization Exit Conference.

During the Organization Exit Conference, the reviewer will:

• Explain the session format and approach

• Reiterate that performance observations have been communicated and discussed

throughout the review

• Indicate that questions and comments are encouraged during this session.

• Comment on areas in which the staffing firm is performing well

• will provide a verbal report of review findings, requirements for improvement, and where

these are appearing on the SAFER

™

matrix.

• Respond to questions and comments about findings.

• Recap the Joint Commission follow-up process including the Evidence of Standards

Compliance procedures

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Health Care Staffing Services Certification

Intra-cycle Evaluation Process

All organizations participating in the certification process are required to collect, report, and

monitor their performance relative to the standardized measures on an ongoing basis. The

Certification Measure Information Process (CMIP) tool assists certified organizations with the

data collection, reporting and monitoring requirements associated with the standardized

measures. The CMIP tool is available on your organization’s secure extranet site, The Joint

Commission Connect. The Performance Measure (PM) Data Report portion of the CMIP tool is

available for all staffing organizations to perform an annual analysis of their performance relative

to each performance measure.

For all staffing organizations that participated in an initial or recertification review in 2009, a mid-

point (intra-cycle) evaluation of the performance measurement activities and standards

compliance will be conducted via conference call with a Joint Commission reviewer.

Prior to the Intra-cycle Event

Your organization will receive an automated email to the primary certification contact and the

CEO approximately 3 months in advance of the anniversary date of your last certification

review. You will have 30 days to enter any missing monthly data points for any of the three

standardized measures, complete the performance measure (PM) data report for each

measure, and review your performance improvement plan for any updates. Once everything has

been entered or updated, please use the submission checklist section of the CMIP tool to

formally submit the CMIP tool to The Joint Commission for the intra-cycle event. If the tool is not

submitted on time, your organization will receive an email reminder to submit the tool or risk

having your certification decision changed.

Intra-cycle Evaluation Logistics

The intra-cycle evaluation conference call will take place as close as possible to the one year

mid-point of the current two year certification cycle. The call will be scheduled by a Joint

Commission reviewer with the person identified in the “Intra-cycle Conference Call Contact

Information” section of the CMIP tool for a time that is convenient to both parties involved.

Participation in the intra-cycle conference call is mandatory for all staffing organizations.

Overview

During the conference call, the reviewer will discuss

• The results of your organization’s performance against the three standardized measures

(monthly data),

• Your analysis of your performance (PM Data Report),

• Your organization’s ongoing approach to performance improvement (PI Plan)

• Your questions regarding compliance with Joint Commission standards

This call is your organization’s opportunity to have an interactive discussion with the Joint

Commission reviewer to assure you are on the right track relative to performance measurement

and ongoing performance improvement and standards compliance.

There are no negative outcomes to the intra-cycle event, unless the reviewer identifies that your

organization has not actively engaged in performance measurement and improvement activities

since the time of the most recently completed initial or recertification review.

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Health Care Staffing Services Certification

Agenda Templates

One Reviewer, One Day Pages 35-37

One Reviewer, One Site, Multiple Days Pages 38-42

Multi-Site (Corporate), Multi-Day Review Pages 43-46

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Health Care Staffing Services Certification

One Reviewer for One Day – Review Agenda

Time

Activity

Organization

Participants

40 minutes

starting at 8:00

a.m.

Opening Conference

- Introductions

- Joint Commission & Certification overview

- Agenda review

Staffing Firm Overview

- Organizational structure

- Customer base

- Review and discuss information provided on certification

application

Certification review

coordinator

Leader(s)

Others at the discretion

of the organization

20 minutes

Reviewer Planning Session

Please note: The reviewer needs a list of customers where

clinical staff are currently working or have worked.

- Reviewer selection of contracts/agreements for review—

A minimum of six contracts/ agreements will be

identified

 Selected contracts/agreements need to be available

for the Contract/Formal Agreement Review activity

Please Note: The reviewer needs a roster of clinical staff that

are currently placed or available for placement, sorted by

discipline.

- Reviewer selection of clinical staff records and tracers--A

minimum of 20 clinical staff will be identified

 Files for these individuals need to be available for the

Personnel File Review activity

Certification review

coordinator (at the

reviewer’s request)

60 minutes

Orientation to Staffing Firm and Data Use

Business Functions

- Management and operations

- On-call structure, if applicable

- Marketing activities

- Emergency management

- Information management

 Cyber security and protection systems

- Code of business ethics

Customer/Client Functions

- Contracting/formal agreement processes

 MSPs and vendor management

 Subcontracting

- Conflict of interest policies

- Customer reassignment of clinical staff (floating)

Leader(s) and

individual(s) responsible

for these functions

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Time

Activity

Organization

Participants

- Tracking and fulfillment of customer/client staff

requirements

Staffing Functions

- Performance of recruitment, retention, and competency

evaluation processes

- Clinical staff performance evaluation processes

- Setting clinical staff health requirements

- Expectations regarding National Patient Safety Goals

Data Use

- Approach to performance improvement

 Data collection processes

 Data quality and maintaining integrity

 Data analysis processes

- Priorities for improvement

 Certification standardized performance measures

 Customer satisfaction data

 Clinical staff satisfaction data

 Customer complaint reporting

 Clinical staff complaints, exit interview data

30 minutes

Review of Firm’s Uploaded Documents

30 minutes

Contract/Formal Agreement Review

- Discussion of contracting/formal agreement process

- Facilitated review of a select sample of contracts and

formal agreements

Individual(s) familiar with

content and responsible

for formal agreements/

contracts

60 minutes

Competence Assessment & Credentialing

Session

- Application process

- Employment history checks

- Credentials verification process

- Hiring criteria

- Orientation

- Placement criteria

- Clinical staff to customer matching process

- Clinical staff supervision

- Clinical staff performance evaluation, including

customer feedback

- Maintaining competency of clinical staff

Individuals responsible

for managing and

performing these

processes

30 minutes

Reviewer Lunch

120 minutes

Personnel File Review

- Facilitated review of the selected sample of files begins in

this activity

- Discussion during this activity will focus on the firm’s

Individual(s) with

authorized access to

files

Individual(s) who can

facilitate the file review

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Time

Activity

Organization

Participants

internal credentials quality assurance audit process,

including

 Reporting audit results

 Compiling and analyzing the audit data for trends

 Identifying opportunities to improve the credentialing

process

 Planned improvements or changes already

implemented to the credentialing process

 Efforts to maintain and sustain improved

performance

Individual(s) that

performs credentials

audits for the firm

30 minutes

Individual Clinical Staff Tracers

- First contact (recruitment)

- Data gathering (application process)

- Discussion related to file review

 Licensure

 Credentials

 Competency

 Continuing education

 Orientation

 Health status

- Hiring decision

- Orientation/assignment availability

- First placement

 How data is provided to customer

 Clinical staff to customer matching process

 Customer reassignment of clinical staff (floating)

 Registering concerns/complaints

- Performance evaluation process

Individual(s) who can

step the reviewer

through a clinical staff

person’s experience with

the firm from point of first

contact through

recruitment, hiring,

orientation and first

placement, through

initial performance

evaluation

Should involve

individuals responsible

for the day-to-day

performance of activities

60 minutes

Issue Resolution & Reviewer Report

Preparation

Certification review

coordinator, if requested

by reviewer

30 minutes

ending at

approximately

4:30 p.m.

Organization Exit Conference

Program and clinical

leadership

Others at the discretion

of the organization

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Health Care Staffing Services Certification

Multi-Day – Review Agenda

First Day

Time

Activity

Organization

Participants

40 minutes

starting at 8:00

a.m.

Opening Conference

- Introductions

- Joint Commission & Certification overview

- Agenda review

Staffing Firm Overview

- Organizational structure

- Customer base

- Review and discuss information provided on certification

application

Certification review

coordinator

Leader(s)

Others at the discretion

of the organization

20 minutes

Reviewer Planning Session

Please note: The reviewer needs a list of customers where

clinical staff are currently working or have worked.

- Reviewer selection of contracts/agreements for review—A

minimum of six contracts/ agreements will be identified

per day for review.

 Selected contracts/agreements need to be available for

the Contract/Formal Agreement Review activity

Please Note: The reviewer needs a roster of clinical staff that

are currently placed or available for placement, sorted by

discipline.

- Reviewer selection of clinical staff records and tracers--A

minimum of 20 clinical staff will be identified per day for

review.

 Files for these individuals need to be available for the

Personnel File Review activity

Certification review

coordinator (at the

reviewer’s request)

60 minutes

Orientation to Staffing Firm and Data Use

Business Functions

- Management and operations

- On-call structure, if applicable

- Marketing activities

- Emergency management

- Information management

 Cyber security and protection systems

- Code of business ethics

Customer/Client Functions

- Contracting/formal agreement processes

 MSPs and vendor management

Leader(s)

Individual(s) responsible

for these functions

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Time

Activity

Organization

Participants

 Subcontracting

- Conflict of interest policies

- Customer reassignment of clinical staff (floating)

- Tracking and fulfillment of customer/client staff

requirements

Staffing Functions

- Performance of recruitment, retention, and competency

evaluation processes

- Clinical staff performance evaluation processes

- Setting clinical staff health requirements

- Expectations regarding National Patient Safety Goals

Data Use

- Approach to performance improvement

 Data collection processes

 Data quality and maintaining integrity

 Data analysis processes

- Priorities for improvement

 Certification standardized performance measures

 Customer satisfaction data

 Clinical staff satisfaction data

 Customer complaint reporting

 Clinical staff complaints, exit interview data

30 minutes

Review of Firm’s Uploaded Documents

30 minutes

Contract/Formal Agreement Review

- Discussion of contracting/formal agreement process

- Facilitated review of a select sample of contracts and

formal agreements

Individual(s) familiar with

content and responsible

for formal agreements/

contracts

60 minutes

Competency Assessment & Credentialing

Session

- Recruitment

- Application process

- Employment history checks

- Credentials verification process

- Hiring criteria/decision

- Orientation/assignment availability

- Health status requirements

- Placement criteria

- Clinical staff to customer matching process

- Clinical staff supervision

- Clinical staff performance evaluation, including

customer feedback

- Maintaining competency of clinical staff

Individuals responsible

for managing and

performing these

processes

30 minutes

Reviewer Lunch

120 minutes

Personnel File Review

Individual(s) with

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Time

Activity

Organization

Participants

- Facilitated review of the selected sample of files begins in

this activity

- Discussion during this activity will focus on the firm’s

internal credentials quality assurance audit process

including

 Reporting audit results

 Compiling and analyzing the audit data for trends

 Identifying opportunities to improve the credentialing

process

 Planned improvements or changes already

implemented to the credentialing process

 Efforts to maintain and sustain improved performance

authorized access to

files

Individual(s) who can

facilitate the file review

Individual(s) that

performs credentials

audits for the firm

60 minutes

Individual Clinical Staff Tracers

- First contact (recruitment)

- Data gathering (application process)

- Discussion related to file review

 Licensure

 Credentials

 Competency

 Continuing education

 Orientation

 Health status

- Hiring decision

- Orientation/assignment availability

- First placement

 How data is provided to customer

 Clinical staff to customer matching process

 Customer reassignment of clinical staff (floating)

 Registering concerns/complaints

- Performance evaluation process

Individual(s) who can

step the reviewer

through a clinical staff

person’s experience

with the firm from point

of first contact through

recruitment, hiring,

orientation and first

placement, through

initial performance

evaluation

Should involve

individuals responsible

for the day-to-day

performance of activities

30 minutes

ending at

approximately

4:30 p.m.

Reviewer Planning

Certification review

coordinator

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Last Day

Time

Activity

Organization Participants

90 minutes

starting at 8:00

a.m.

Personnel File Review

…continued

60 minutes

Contract/Formal Agreement Review

- Facilitated review of a select sample of contracts and

formal agreements

Individual(s) familiar with

content and responsible for

formal agreements/

contracts

60-120 minutes

Individual Clinical Staff Tracers

- First contact (recruitment)

- Data gathering (application process)

- Discussion related to file review

 Licensure

 Credentials

 Competency

 Continuing education

 Orientation

 Health status

- Hiring decision

- Orientation/assignment availability

- First placement

 How data is provided to customer

 Clinical staff to customer matching process

 Customer reassignment of clinical staff (floating)

 Registering concerns/complaints

- Performance evaluation process

Individual(s) who can step

the reviewer through a

clinical staff person’s

experience with the firm

from point of first contact

through recruitment, hiring,

orientation and first

placement, through initial

performance evaluation

Should involve individuals

responsible for the day-to-

day performance of

activities; if possible, a

different group of internal

staff should be accessed

30 minutes

Reviewer Lunch

120 minutes

Personnel File Review

…continued

Note: Reviewers may conduct additional Clinical Staff

Tracers if time is available.

60 minutes

Issue Resolution & Reviewer Report

Preparation

Certification review

coordinator, if requested

30 minutes ending

at approximately

4:30 p.m.

Organization Exit Conference

Program and clinical

leadership

Others at the discretion of

the organization

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Multi-Day Review Agenda for all days between the First and Last

Time

Activity

Organization Participants

150 minutes (2.5

hours) starting at

8:00 a.m.

Personnel File Review

…continued

Note: Reviewers may conduct additional Clinical Staff

Tracers if time is available.

60 minutes

Contract/Formal Agreement Review

- Discussion of contracting/formal agreement process

- Facilitated review of a select sample of contracts

and formal agreements

Individual(s) familiar with

content and responsible for

formal agreements/ contracts

30 minutes

Reviewer Lunch

60 minutes

Individual Clinical Staff Tracers

- First contact (recruitment)

- Data gathering (application process)

- Discussion related to file review

 Licensure

 Credentials

 Competency

 Continuing education

 Orientation

 Health status

- Hiring decision

- Orientation/Assignment Availability

- First placement

 How data is provided to customer

 Clinical staff to customer matching process

 Customer reassignment of clinical staff

(floating)

 Registering concerns/complaints

- Performance evaluation process

Individual(s) who can step the

reviewer through a clinical

staff person’s experience with

the firm from point of first

contact through recruitment,

hiring, orientation and first

placement, through initial

performance evaluation

Should involve individuals

responsible for the day-to-day

performance of activities; of

possible, a different group of

internal staff should be

accessed each day

150 minutes (2.5

hours)

Personnel File Review

…continued

Note: Reviewers may conduct additional Clinical Staff

Tracers if time is available.

30 minutes ending at

approximately

4:30 p.m.

Reviewer Planning

As requested by the reviewer

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Health Care Staffing Services Certification

Multi-Site (Corporate) Review Agenda

Day 1

Time

Activity

Organization

Participants

45 minutes

starting at 8:00

a.m.

Opening Conference

- Introductions

- Joint Commission & Certification overview

 Slide presentation

- Agenda review

- Site selection

Multi-Site Staffing Firm Overview

- Organizational structure

- Customer base

- Review and discuss information provided on certification

application

Certification review

coordinator

Leader(s)

Others at the discretion of

the organization

30 minutes

Reviewer Planning Session

The firm is asked to have available:

1. A roster of clinical staff that is currently on assignment or

available for assignment, sorted by discipline for each of its

sites.

2. A list of customers where clinical staff is currently working or

has worked in the past 12 months. NOTE: If each site works

with a separate and unique group of customers, the firm is

asked to have a customer list available for each of its sites.

Certification review

coordinator

Staff familiar with sites

and that can orient the

reviewer to the roster or

list(s)

Staff familiar with

customers and contracts

that can orient the

reviewer to the list(s)

60 minutes

Orientation to Staffing Firm and Data Use

Business Functions

- Management and operations

 Centralized and decentralized systems and processes

- On-call structure, if applicable

- Marketing activities

- Emergency management

- Information management

 Cyber security and protection systems

- Code of business ethics

Customer/Client Functions

- Contracting/formal agreement processes

 MSPs and vendor management

 Subcontracting

- Conflict of interest policies

- Customer reassignment of clinical staff (floating)

- Tracking and fulfillment of customer/client staff requirements

Leader(s)

Staff responsible for

these functions

Others at the discretion of

the organization

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Time

Activity

Organization

Participants

Staffing Functions

- Performance of recruitment, retention, and competency

evaluation processes

- Clinical staff performance evaluation processes

- Setting clinical staff health requirements

- Expectations regarding National Patient Safety Goals

Data Use

- Approach to performance improvement

- Centralized or decentralized

 Data collection processes

 Data quality and maintaining integrity

 Data analysis processes

- Priorities for improvement

- Organization-wide and/or site-specific

 Certification standardized performance measures

 Customer satisfaction data

 Clinical staff satisfaction data

 Customer complaint reporting

 Clinical staff complaints, exit interview data

45 minutes

Multi-Site Monitoring and Oversight System Tracer

Review systems for monitoring and oversight including:

 Frequency of monitoring and oversight

 Criteria and performance expectations for sites

 Individuals responsible for monitoring and oversight

 Data gathered and used to monitor site performance

 Procedures and tools for overseeing sites

 Procedures for providing performance feedback to sites

 Requirements and timeframes for site corrective action

Staff responsible for site

monitoring and oversight

Leader(s)

Others at the discretion of

the organization

30 minutes

Review of Firm’s Uploaded Documents

30 minutes

Reviewer Lunch

60 minutes

Contract/Formal Agreement Process

 Centralized or decentralized

 Review of contracting or formal agreement process

 Facilitated review of a select sample of contracts and

formal agreements

Individual(s) familiar with

content and responsible

for formal agreements/

contracts

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Time

Activity

Organization

Participants

60 minutes

Competence Assessment & Credentialing Process

 Centralized or decentralized processes

 Recruitment

 Application process

 Employment history checks

 Credentials verification process

 Hiring criteria/decision

 Orientation/assignment availability

 Health status requirements

 Placement criteria

 Clinical staff to customer matching process

 Clinical staff supervision

 Customer reassignment of clinical staff (floating)

 Clinical staff performance evaluation, including customer

feedback

 Maintaining competency of clinical staff

Individuals responsible

for designing, managing,

and overseeing the

performance of these

processes at sites

60 minutes

Issue Resolution and Reviewer Report Preparation

Individual coordinating

review activity

30 minutes

Reviewer Planning for Site Review Activity

Individual coordinating

review activity

30 minutes,

ending at

approximately

4:30 p.m.

Multi-Site Review Interim Exit Conference

Leader(s)and others at

the discretion of the

organization

Copyright: 2024 The Joint Commission Health Care Staffing Services Review Process Guide Page 46 of 52

Agenda for Multi-Site (Corporate) Review Days beyond Day 1

Time

Activity

Organization

Participants

180 minutes (3 hours)

starting at 8:00 a.m.

Site (Branch Office) Review

(times are approximate)

Video meeting with site staff (45-60 minutes) includes:

Clinical Staff Tracer

- First contact (recruitment)

- Data gathering (application process)

- Discussion related to file review

 Licensure

 Credentials

 Competency

 Continuing education

 Orientation

 Health status

- Hiring decision

- Orientation/assignment availability

- First placement

 How data is provided to customer

 Clinical staff to customer matching process

 Customer reassignment of clinical staff (floating)

 Registering concerns/complaints

 Performance evaluation process

Site Support System Tracer

 Site leadership structure

 Site placement within multi-site organization structure

 Systems to support sites

 Site responsibilities and accountabilities

 Centralized and decentralized processes

 Communication between corporate organization and

site

 Data reporting between corporate organization and

site

 Organization-wide performance improvement

Clinical staff personnel file review (90-120 minutes)

Site staff including

Site manager

Staffing coordinator(s)

Supervisory staff

Staff responsible for

collecting and verifying

application data

Others at the discretion

of the site manager

30 minutes

Reviewer Lunch

180 minutes (3 hours)

starting at mutually

agreed upon time

Site (Branch Office) Review

(times are approximate)

Repeat of above activity with another office

30 minutes

Issue Resolution

Certification review

coordinator, if

requested by reviewer

60 minutes

Reviewer Report Preparation

30 minutes ending at

approximately 4:30

Reviewer Planning, or Interim Exit, or Multi-Site

Review Exit Conference

Per reviewer

recommendation

The Joint Commission Health Care Staffing Services Certification

Copyright: 2024 The Joint Commission Health Care Staffing Services Review Process Guide Page 47 of 52

Contract/Formal Agreement Review Checklist

Look for the following items in staffing firm customer agreements/contracts.

• Subcontractors - The use of subcontractors

• Competency Review - Defined responsibilities for the establishment of staff competency for the assignments staff are designated for

• Floating - Reassignment (floating) of personnel

• Employees or Independent Contractors - Whether staff are employees of the firm or independent contractors working through the firm

• Incident, Error Tracking System - The firm’s system for reporting, tracking, and documenting unexpected incidents, including errors,

unanticipated deaths and other events, injuries, and safety hazards related to the care and services provided

• Requirements for Staff Specified - Were the requirements for the staff placed specified in the contract/formal agreement?

• Staff Matched Requirements - Were the contract expectations met? (Confirmed on phone calls with customers)

Customer Name

Subcontractors

Competency

Floating

Employees or

Ind. Contractors

Incident, Error,

Tracking System

Communicating

Occupational

Safety

Hazards

Orientation of

Employees

Requirements for

Staff Specified

Staff Matched

Requirements?

The Joint Commission Health Care Staffing Services Certification

Copyright: 2024 The Joint Commission Health Care Staffing Services Review Process Guide Page 48 of 52

Customer Name

Subcontractors

Competency

Floating

Employees or

Ind. Contractors

Incident, Error,

Tracking System

Communicating

Occupational

Safety

Hazards

Orientation of

Employees

Requirements for

Staff Specified

Staff Matched

Requirements?

The Joint Commission Health Care Staffing Services Certification

Copyright: 2024 The Joint Commission Health Care Staffing Services Review Process Guide Page 49 of 52

Personnel File Review Checklist

Standards and Elements of Performance

Organization Requirements

Name

B. Discipline

C. Licensure Certification

D. Advance Practice

Verifications

E. Education Training

F. Experience

G. Competency Eval

H. Performance Evaluation

I. Criminal Background

J. Orientation

L. CPR

M. TB Test or

Questionnaire

N. MMR

O. Flu Immunization or

Declination

P. Health Statement

Q. Hep B

R. Drug Screen

Notes

1

Date of Hire

2

Date of Hire

3

Date of Hire

4

Date of Hire

5

Date of Hire

6

Date of Hire

7

Date of Hire

8

Date of Hire

9

Date of Hire

10

Date of Hire

The Joint Commission Health Care Staffing Services Certification

Copyright: 2024 The Joint Commission Health Care Staffing Services Review Process Guide Page 50 of 52

Standards and Elements of Performance

Organization Requirements

Name

B. Discipline

C. Licensure Certification

D. Advance Practice

Verifications

E. Education Training

F. Experience

G. Competency Eval

H. Performance Evaluation

I. Criminal Background

J. Orientation

L. CPR

M. TB Test or

Questionnaire

N. MMR

O. Flu Immunization or

Declination

P. Health Statement

Q. Hep B

R. Drug Screen

Notes

11

Date of Hire

12

Date of Hire

13

Date of Hire

14

Date of Hire

15

Date of Hire

16

Date of Hire

17

Date of Hire

18

Date of Hire

19

Date of Hire

20

Date of Hire

21

Date of Hire

The Joint Commission Health Care Staffing Services Certification

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Standards and Elements of Performance

Organization Requirements

Name

B. Discipline

C. Licensure Certification

D. Advance Practice

Verifications

E. Education Training

F. Experience

G. Competency Eval

H. Performance Evaluation

I. Criminal Background

J. Orientation

L. CPR

M. TB Test or

Questionnaire

N. MMR

O. Flu Immunization or

Declination

P. Health Statement

Q. Hep B

R. Drug Screen

Notes

22

Date of Hire

23

Date of Hire

24

Date of Hire

25

Date of Hire

26

Date of Hire

27

Date of Hire

28

Date of Hire

29

Date of Hire

30

Date of Hire

Column Key

C. Current licensure, certification, or registration required by the state, the firm, or customer from primary sources

D. MD and Advanced Practitioners - includes NPDB, DEA, NPI, relinquishment of license, privilege termination and professional liability actions from primary

sources

E. Education and training associated with residency or advanced practice, experience, and competency appropriate for assigned responsibilities

F. Clinical work history/references

G. Initial and ongoing evaluation of competency

The Joint Commission Health Care Staffing Services Certification

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H. Performance evaluation according to organization requirements

I. Information on criminal background according to law, regulation, and customer requirements

J. Documentation that the clinical staff person has received orientation from the organization

L. CPR according to organization requirements

M, N, O, P and Q. Compliance with applicable health screening and immunization requirements established by the firm or customer

R. Drug screen according to organization or customer requirements