JCAHO Standards for Hospital Staffs

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) certifies hospitals, hospital staff, and other health care organizations, holding them to industry standards. This non-profit corporation surveys hospitals and staff to assure ongoing compliance with specific performance criteria.

Monitoring the Hospitals

• Once a hospital has applied for and been granted accreditation, hospital nursing and medical staff provide their internal data to JCAHO on a yearly basis. JCAHO reviews that data, and will, at least once every 39 months, make an unannounced site visit. The site visitors review more closely the on-site compliance with the elements of performance.

Scope of Staff Standards

• The hospital standards address several aspects of hospital staff organizational processes, including the staff bylaws, self-governance and accountability. Hospital staff must meet benchmarks for clinical performance and safety. Staff policies and procedures ideally address disciplinary issues and outline methods for resolving staff conflicts.

Outside Staffing Certification

• The Joint Commission's Health Care Staffing Services program also surveys and certifies an outside staffing firm's commitment to a high standard for the health care staff that they provide to hospitals. Certification of staffing firms increases their credibility and provides external feedback on sound practices. Standardized data analysis measures look at clinical, professional, and personnel competencies.