Health Information Compliance Alert

Published on Mon Jan 28, 2008 PDF

3 tips for continual readiness.

With standard HR.1.20, The Joint Commission requires that you verify the credentials of your healthcare workers and other staff both at the time of hire and when those credentials expire. And a large staff with many credentials that all expire at different dates can be quite a challenge to keep on top of.

The answer? Concentrate on "continual readiness" and quality-control activities related to personnel and privileging files, advises Jo Wyatt, BSN, MPH, a consultant and owner of Alternatives, a Mesa, AZ-based company that specializes in behavioral health consultation, training and development. Wyatt recommends three ways to address these concerns.

1. Establish a "tickler system" -- either electronic or manual -- to keep files current, suggests Wyatt. A manual system could consist of a series of file folders representing the days and months ahead, into which you put notes to remind you of expiration dates or due dates. In addition to expiration dates of licenses and certifications, Wyatt recommends that your tickler system should, at a minimum, include these other elements:

2. Develop an audit process similar to what clinical departments do for chart documentation to keep personnel files up to date. With this system, a certain number of files would be audited each quarter against required elements, with corrective action as needed to maintain quality controls.

"This constitutes a great teaching/orientation tool for new HR staff and helps help them understand the entire filing requirements," Wyatt says.

3. Develop a cover page for each personnel file. This measure specifically addresses The Joint Commission's primary source verification (PSV) requirement, notes Wyatt. HR staff document all primary source verification activities concerning that employee on this cover page.

Advantage: "The nice thing about such a tool is that one can tell at a glance if all verification has been completed and also if there are any issues or red flags as a result of the verification process," Wyatt says.

"Whether completed by hiring staff, which is how it is done in some smaller agencies, or by HR personnel, it goes at the very front of the personnel or privileging file for quick reference," Wyatt says. "This tool could be electronic or manual; electronic allows for easier updating of elements that have to be verified periodically. Regardless, a current copy should be maintained at the front of the file."