Action Alerts

JCAHO Releases Hospital CAMH Leadership Standard LD.3.70 Clarification
June 2006

On June 2, 2005, JCAHO released the following statement on the subject standard:

In the May 2005 issue of JCAHOnline, an article introduced revisions to Leadership standard LD.3.70. The standard, effective January 1, 2006, addresses an organization's responsibilities for individuals not employed by the organization who are providing services in the organization under the direct responsibility of a licensed independent practitioner. 

While the article listed a number of recommendations that clearly reflect best practice endeavors for any facility that allows non-employee individuals to provide care, treatment or services, these recommendations were beyond the actual requirement of the revised standard. 

The new LD.3.70 elements of performance (EPs) only require organizations to evaluate the qualifications and current competence of these individuals. Therefore, of the nine recommendations listed, only the first two (appropriately credentialed and competent) are actually required.

As for criminal background checks on these individuals, some states may require those and some health care facilities may have adopted policies requiring them. However, this potential is not mandated through this JCAHO Standard.

This timely information was brought to you by your partners in healthcare improvement, QMCG. Questions? Please call us at 614/227-4848 for fast and confidential assistance.