Guide to JCAHO Human Resource Standard 2.20

© 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 2.20

Human Resources standard 2.20: Staff members, licensed independent practitioners (LIP), students and volunteers as appropriate, can describe or demonstrate their roles and responsibilities based on specific job duties or responsibilities relative to safety.

Element of Performance 1:  Can describe risks within the hospital's environment

This page provides a set of criteria for evaluating the staff's and others' understanding of risks that they may encounter in the facility.

See also Elements of Performance 2, 3, and 4, below.
= Compliance
= Environmental Improvement
= Tools and Resources

 
Each job description details training requirements related to safety and environmental management issues including:
  • hazardous materials identification

   

 

Hazardous waste operations: 29 CFR 1910.120

Hazard identification (OSHA): 29 CFR 1910.120 (c)

  • personal protection

   

Implementation: EC3.10.3

Competence: HR2.10.9

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

  • infectious waste and bloodborne pathogens

   

 

HERC:  Managing Hazardous (RCRA) Wastes

Bloodborne pathogens: 29 CFR 1910.1030

  • spill response

   

 

Emergency coordinator responsibilities: 40 CFR 262.34 (d)(5)(C)(iv)

  • hazardous waste determination and management

   

 

HERC: Hazardous Waste Determination

HERC: Managing Hazardous (RCRA) Wastes

Training records indicate employees trained, dates, agenda covering environmental risk areas such as indoor air quality, hazardous materials and waste and infectious materials and waste.

   

Documentation: EC3.10.7

Competence: HR2.10.9

 

Employee performance records indicate employee compliance with responsibilities related to environmental management and safety.
Employees can demonstrate familiarity with emergency procedures such as spill clean up and reporting.
Employees can demonstrate knowledge of hazardous materials and waste.
Records are available for ongoing, periodic competence assessment.

   

Documentation: EC3.10.7

Competence: HR2.10.9

 

Training records indicate training on pollution prevention and waste reduction concepts.
Staff can describe pollution prevention and waste reduction activities occurring in the facility.
Staff can describe how safety risks might be minimized thorough the use of pollution prevention, e.g. use of less toxic cleaners.

Human Resources standard 2.20: Staff members, licensed independent practitioners (LIP), students and volunteers as appropriate, can describe or demonstrate their roles and responsibilities based on specific job duties or responsibilities relative to safety.

Element of Performance 2:  Can describe actions to eliminate, minimize or report risks.

 
 
Employees demonstrate competence in handling hazardous and infectious materials.
Employees demonstrate competence in handling hazardous and universal waste.

   

Implementation: EC3.10.3

Competence: HR2.10.9

HERC:  Managing Hazardous (RCRA) Wastes

Universal waste training (SQG): 40 CFR 273.16

Universal waste training (LQG): 40 CFR 273.36

Employees operate in such a manner as to minimize spill risks.
Employees can apply both engineering and work practice controls to help minimize or eliminate exposures to harmful chemical or physical agents.
Employees can locate, and are familiar with, spill response kits and equipment.
Employees are familiar with spill response procedures.

   

Impl. (HazWaste): EC3.10.3

Emerg. (HazWaste): EC3.10.6

Emerg. (RMW): EC3.10.6

Roles (Incident): HR2.20.3

Emergency response plan (OSHA): 29 CFR 1910.120 (l)(1)

Emergency procedures (SQG): 40 CFR 262.34 (d)(5)

Contingency plan (emergency procedures): 40 CFR 265.56

Staff members, LIP, students and volunteers can describe how safety risks might be minimized through the use of pollution prevention, e.g. use of less toxic cleaners.
Purchasing policies and procedures are in place that minimize the quantity of hazardous materials entering the facility, or that eliminate the use of some hazardous materials entirely.

   

Plan: EC3.10.1

Inventory:  EC 3.10.2

Implementation: EC3.10.3

Impl. (Univ. Waste): EC3.10.3

 

Human Resources standard 2.20: Staff members, licensed independent practitioners (LIP), students and volunteers as appropriate, can describe or demonstrate their roles and responsibilities based on specific job duties or responsibilities relative to safety.

Element of Performance 3:  Can describe procedures to follow in the event of an incident.

 
 
Staff members, LIP, students and volunteers can demonstrate competency in procedures to follow in the event of a release, spill, or fire.

   

Impl. (HazMat): EC3.10.3

Impl. (HazWaste): EC3.10.3

Emerg. (HazWaste): EC3.10.6

Emerg. (RMW): EC3.10.6

Emergency response training (OSHA): 29 CFR 1910.120 (e)(7)

Emergency procedures (SQG): 40 CFR 262.34 (d)(5)

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

Contingency plan (emergency procedures): 40 CFR 265.56

Staff members, LIP, students and volunteers are knowledgeable regarding the location of resources to address environmental incidents e.g., spill response plan, spill kit, emergency response coordinator, material safety data sheets, protective equipment.
 

Human Resources standard 2.20: Staff members, licensed independent practitioners (LIP), students and volunteers as appropriate, can describe or demonstrate their roles and responsibilities based on specific job duties or responsibilities relative to safety.

Element of Performance 4:  Can describe reporting processes for common problems, failures and user errors.

 
 
Procedures are in place and documented for reporting environmental and safety incidents such as exposures and illnesses, spills, leaks, compromised containers, etc.
Employees can demonstrate knowledge of reporting processes.
Employee, patient and visitor incident/accident reports are being used and data available for trending. Reports of problems and errors are submitted to Safety/Risk management/Infection Control committees.
Number of incidents relating to spills and releases decreases over time.
Number of employee exposure and illness related incidents decrease over time.