Jcaho Documentation Requirements

The Joint Commission, formerly known as the JCAHO (Joint Commission on Accreditation of Healthcare Organizations), is a nonprofit organization tasked with accreditation of hospitals and other health care organizations. It sets standards for accreditation and certification, and tracks patient safety and other performance measurements. Among other standards, it sets documentation requirements for certification of health care staffing.

Leadership Standards and Documentation

• The Joint Commission requires a code of business ethics, contracts showing the services provided to customers, a description of the complaint process by which customer complaints can be resolved, and an emergency management plan. It also recommends that the health care organization in question have an organization chart and personnel records to document its leadership roles. It recommends written policies and procedures to document its code of business ethics, its conflict of interest policy, its customer service and customer accessibility, and its safety and risk management policies. The Joint Commission also recommends employee handouts in the areas of business ethics, customer accessibility, and risk and emergency management. It recommends having written marketing materials regarding business ethics, conflicts of interest, and customer accessibility. It recommends documentation of all laws and regulations applicable to the organization. In addition, the Joint Commission recommends maintenance of customer and contractor lists, blind copies of complaints and their resolution, occupational safety and near miss reports, and hazard vulnerability analyses.

Human Resources Management Standards and Documentation

• Documentation required by the Joint Commission in the area of human resources includes health information records to ascertain employee qualifications. The Joint Commission requires personnel records to document employee qualifications, orientation, competence, and ongoing employment. It also requires a written policy regarding employee qualification, and performance evaluation records. Documentation recommended by the Joint Commission in this area includes a list of current staff, policies and procedures regarding orientation and assessment, job descriptions, orientation materials, assessment materials, formal educational activities, performance measurement data, and analysis of negative trends.

Information Management Standards and Documentation

• The Joint Commission requires documentation of health information records and personnel records on all staff. It also requires a written policy regarding security and confidentiality of information. The Joint Commission also recommends written policies and procedures regarding information management needs, health and personnel records, confidentiality of information, and continuity of information. Other documentation recommended but not required in the area of information management standards includes a list of active customers, customer and staff handouts regarding information confidentiality, and a business continuity plan.

Performance Measurement and Improvement Standards and Documentation

• The Joint Commission does not require any documentation regarding performance measurement and improvement standards. However, it does recommend performance improvement plans and reports, performance measurement data reports, policies and procedures regarding collection of data, a current and past customers list, and data analysis tools.