Guide to JCAHO Human Resources Standard 2.10.1,2,9

© 2005 Joint Commission on Accreditation of Healthcare Organizations. Any use of any or all of the Joint Commission standards and elements of performance beyond this particular tool is strictly forbidden without the written permission of the Joint Commission. Citations from JCAHO standards are ©2005 Joint Commission on Accreditation of Healthcare Organizations. Any use of any or all of the Joint Commission standards and elements of performance beyond this particular tool is strictly forbidden without the written permission of the Joint Commission. These pages do not reflect any changes in the standards made after 2005.  

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Introduction        Table of Contents       Checklist for 2.10.1,2,9

Human Resources standard 2.10:  Staff members, students and volunteers are oriented to their jobs as appropriate and the work environment before providing care, treatment and services.

As appropriate, each staff member, student and volunteer is oriented to the following:

  • Element of Performance 1:  The hospital's mission and goals
  • Element of Performance 2:  Hospital-wide policies and procedures (including safety and infectious control) and relevant unit, setting or program-specific policies and procedures

Element of Performance 9:  The hospital assesses and documents each person's ability to carry out assigned responsibilities safely, competently and in a timely manner upon completion of orientation.

This page provides a set of criteria for evaluating the staff's exposure to and acceptance of the facility's environmental, health and safety goals.

 
= Compliance
= Environmental Improvement
= Tools and Resources

Orientation policies dictate and hospital records indicate appropriate training on:

   

Documentation: EC3.10.7

Roles (Risks): HR2.20.1

 

  • blood borne pathogens

   

Emergency (RMW): EC3.10.6

HERC:  Managing Regulated Medical Waste

Bloodborne pathogens: 29 CFR 1910.1030

  • hazardous chemicals

   

Implementation: EC3.10.3

Emergency: EC3.10.6

Haz. waste operations (HAZWOPER) training: 29 CFR 1910.120 (e)

HazMat training (DOT): 49 CFR 172.704

  • hazardous waste management

Emerg. (HazWaste): EC3.10.6

Roles (Risk Min.): HR2.20.2

Roles (Incident): HR2.20.3

HERC:  Managing Hazardous (RCRA) Wastes

Haz. waste operations (HAZWOPER) training: 29 CFR 1910.120 (e)

Employees familiar with HazWaste handling: 40 CFR 262.34 (d)(5)(C)(iii)

HazMat training (DOT): 49 CFR 172.704

  • universal waste management

   

Plan: EC3.10.1

Implementation: EC3.10.3

Emergency: EC3.10.6

Roles (Risk Min.): HR2.20.2

Universal waste training (SQG): 40 CFR 273.16

Universal waste training (LQG): 40 CFR 273.36

  • medical (infectious) waste segregation

   

Safety plan: EC1.10.1

HERC:  Managing Regulated Medical Waste

HERC: OSHA Standards for Bloodborne Pathogens

Bloodborne pathogens: 29 CFR 1910.1030

  • solid waste segregation (to support hospital recycling programs)

  • DOT hazardous materials shipping requirements

   

HazMat training (DOT): 49 CFR 172.704

Orientation records document training on any personal protective equipment that might be required on the job, e.g.:

   

Implementation: EC3.10.3

Roles  (Risks): HR2.20.1

Personal protective equipment selection: 29 CFR 1910.120 (g)(3)

  • gloves

  • gowns

   

Personal Protective Equipment (general): 29 CFR 1910.132

  • safety glasses

  • face shields

  • chemical splash goggles

   

Personal Protective Equipment (eye, face): 29 CFR 1910.133

  • respirators

   

Personal Protective Equipment (respiratory): 29 CFR 1910.134

  • hard hats

   

Personal Protective Equipment (head): 29 CFR 1910.135

  • shoes, boots

   

Personal Protective Equipment (foot): 29 CFR 1910.136

Respirator training and fit testing has been completed for all new employees requiring respirator training (e.g. N95 respirators for any staff potentially exposed to blood or body fluids)
Orientation records document additional training on environmental hazards specific to the job classification/duties of the employee. These would include but are not limited to:
  • Hazardous chemical spill response and cleanup for any staff designated for spill response, at either awareness level or response level as appropriate.
  • Proper collection/packaging/labeling of hazardous and universal wastes

   

Labeling (HazWaste): EC3.10.9

Labeling (Univ.): EC3.10.9

HERC: Managing Hazardous (RCRA) Wastes

  • Asbestos awareness training to any staff likely to disturb asbestos containing building materials

   

Implementation: EC3.10.3

Emergency: EC3.10.6

Labeling: EC3.10.9

Occupational exposure, asbestos: 29 CFR 1910.1001

  • Chemical specific training such as Ethylene Oxide, Formaldehyde, Glutaraldehyde, etc. when mandated by law or when employee exposure is likely.

   

Emergency: EC3.10.6

Occupational exposure, ethylene oxide: 29 CFR 1910.1047

Occupational exposure, formaldehyde: 29 CFR 1910.1048

Competence testing records from orientation indicate competence on above requirements.
Orientation records document staff knowledge of hospital-wide environmental health & safety policies and any unit or program specific safety/environmental policies
Community health component of facility mission; each staff member, student and volunteer is oriented to how reducing pollution from facility operation reduces risk of damage to public health and the environment.
Orientation records indicate training and competency testing on pollution prevention concepts and their application to organization's community health mission.
Orientation records indicate review of organization's environmental policy.
  • OSHA training requirements
  • Sample employee safety orientation checklist
  • Sample new employee orientation training programs
  • Sample staff competency quality assurance program