JCI - SQE Staff Qualification & Education (2021)

Edition 7 - 2021

Welcome to International Standards of Human Resources Management by JCI under SQE 

HRM - Human Resources Management   

SQE - Staff Qualification & Education

JCI - Joint Commission International

 

JCI – SQE Standards

The following is a list of all Standards for this function. They are presented here for your convenience without their intent statements or measurable elements.

 For more information about these standards, please see the next section in this chapter, Standards, and Measurable Elements.

 *  Planning

SQE.1 Leaders of hospital departments and services define the desired education, skills, knowledge, and other requirements of all staff members.

SQE.1.1 Each staff member’s responsibilities are defined in a current job description. 

SQE.2 Leaders of hospital departments and services develop and implement processes for recruiting, evaluating, and appointing staff as well as other related procedures identified by the hospital.

SQE.3 The hospital uses a defined process to ensure that clinical staff knowledge and skills are consistent with patient needs.

SQE.4 The hospital uses a defined process to ensure that nonclinical staff knowledge and skills are consistent with hospital needs and the requirements of the position.

SQE.5 There is documented personnel information for each staff member. 

SQE.6 A staffing strategy for the hospital, developed by the leaders of hospital departments and services, identifies the number, types, and desired qualifications of staff.

SQE.6.1 The staffing strategy is reviewed on an ongoing basis and updated as necessary.

SQE.7 All clinical and non-clinical staff members are oriented to the hospital, the department or unit to which they are assigned, and to their specific job responsibilities at the appointment to the staff.

SQE.8 Each staff member receives ongoing in-service and other education and training to maintain or to advance his or her skills and knowledge.

SQE.8.1 Staff members who provide patient care are trained and demonstrate competence in the resuscitative techniques specific to the level of training identified.

SQE.8.1.1 Other staff identified by the hospital are trained and can demonstrate appropriate competence in resuscitative techniques. 

* Staff Health and Safety

SQE.8.2 The hospital provides a staff health and safety program that addresses staff physical and mental health and safe working conditions. 

SQE.8.3 The hospital identifies staff who are at risk for exposure to and possible transmission of vaccine-preventable diseases and implements a staff vaccination and immunization program. 

* Determining Medical Staff Membership

SQE.9 The hospital has a uniform process for gathering the credentials of those medical staff members permitted to provide patient care without supervision. 

SQE.9.1 Medical staff members’ education, licensure/registration, and other credentials required by law or regulation and the hospital are verified and kept current. 

SQE.9.2 There is a uniform, transparent decision process for the initial appointment of medical staff members. 

* The Assignment of Medical Staff Clinical Privileges

SQE.10 The hospital has a standardized, objective, evidence-based procedure to authorize medical staff members to admit and to treat patients and/or to provide other clinical services consistent with their qualifications. 

* Ongoing Professional Practice Evaluation of Medical Staff Members

SQE.11 The hospital uses an ongoing standardized process to evaluate the quality and safety of the patient care provided by each medical staff member. 

* Medical Staff Reappointment and Renewal of Clinical Privileges

SQE.12 At least every three years, the hospital determines, from the ongoing professional practice evaluation of each medical staff member, if medical staff membership and clinical privileges are to continue with or without modification. 

* Nursing Staff

SQE.13 The hospital has a uniform process to gather, to verify, and to evaluate the nursing staff’s credentials (license, education, training, and experience). 

SQE.14 The hospital has a standardized process to identify job responsibilities and to make clinical work assignments based on the nursing staff member’s credentials and any regulatory requirements.

SQE.14.1 The hospital has a standardized process for nursing staff participation in the hospital’s quality improvement activities, including evaluating individual performance when indicated.

* Other Health Care Practitioners

SQE.15 The hospital has a uniform process to gather, to verify, and to evaluate other healthcare practitioners’ credentials (license, education, training, and experience).

SQE.16 The hospital has a uniform process to identify job responsibilities and to make clinical work assignments based on other health care practitioners’ credentials and any regulatory requirements.

SQE.16.1 The hospital has a uniform process for other healthcare practitioners’ participation in the hospital’s quality improvement activities. 

* 16 Standards of SQE - HRM Chapter of JCI are covered for Learning & Practicing HR 

Conclusion: Incorporating advanced HR technologies enables healthcare organizations to streamline HR processes in alignment with international standards such as NABH and JCI, fostering improved compliance and enhanced employee satisfaction.