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At the TJC Annual Behavioral Health Conference in Chicago last week, a key presentation focused on the revisions to the Human Resources chapter in the Behavioral Health Manual that go into effect on January 1, 2015. So, what are the changes and what do you need to do to ensure compliance with the revised standards?

Here are the highlights:

  • The name of the chapter has been changed to the Human Resources Management chapter.
  • The standards have been reduced from 17 to 12 and have been re-numbered.
  • The previous standard HR.02.01.03 that dealt with the credentialing and assigning of clinical responsibilities for licensed independent practitioners (LIPs) has been eliminated. The requirements for verifying credentials and assigning job duties/responsibilities for these practitioners have now been folded into the other standards. In addition, the process has been simplified.
  • The terminology “staff” that is used throughout the chapter includes staff, LIPs, and contractors.
  • There are essentially only two new requirements in the revised standards:
    • Written job descriptions (HRM.01.01.01): Each position must have a written job description. This was not explicitly required in the previous standards. The job description must contain the following three elements:
      • Minimum qualifications
      • Minimum competencies
      • Duties and responsibilities
      • Note: For contractors, a written contract may replace a job description.
    • Verification of identity (HRM.01.02.01): The identity of all job applicants must be verified by viewing a valid picture ID issued by a state of federal agency (e.g. driver’s license or passport.) Previously, this was required only for LIPs.

So, a bit more about simplifying the process for LIPs:The terms “LIPs” and “assigning clinical responsibilities” are not used in the revised standards. As noted above, LIPs are now included under the term “staff.” The requirements for verifying credentials and assigning job duties/responsibilities foralltypes of practitioners are now included under one standard (HRM.01.02.01.) In addition, there is no longer a requirement for the governing body to grant clinical responsibilities nor a requirement to assign clinical responsibilities every two years. Once again, these clinical responsibilities can be defined in the job description (or contract.)

For those interested in a bit of TJC standards “history”: The existing BH standard for credentialing and assigning clinical responsibilities for LIPs (HR.02.01.03) was modeled after the credentialing and privileging standards in the Medical Staff chapter of the Hospital manual. Thus, the requirements in the BH manual have been very similar to those in the Hospital manual. However, in the BH manual the term “privileging” (which has a medical model connotation) was replaced with the term “assigning clinical responsibilities.” The simplified process in the 2015 revised standards is a better fit for many BH organizations in terms of how they hire and use LIPs within their organizations.

A few additional clarifications emphasized at the conference:

  • Education needs to be verified from the primary source for college degree and above. For high school diploma, a copy is sufficient.
  • If you confirm that your state licensing authority already does verification of education in order to issue the license, you do not need to re-verify the education.
  • Remember that if you are using contractors to provide care, treatment or services, the evaluation of those contracted services must also comply with the Leadership standard LD.04.03.09. (Take note: This standard is being closely scrutinized during surveys.)
  • If your BH program is part of a hospital that is surveyed under the Hospital standards, you would continue to conduct credentialing and privileging according to the requirements of the Medical Staff chapter in the Hospital manual.

So, a few tips to ensure full compliance with the revised standards:

  • Make a decision as to whether you will move to the simplified process for LIPs or retain your current process for credentialing and assigning clinical responsibilities.
  • Make sure your job descriptions are current and include all three elements required by standard HRM.01.01.01.
  • Put in place a process to verify identity for all newly hired staff.
  • If you sare using contractors to provide clinical services, make sure you are complying with all of the requirements of LD.04.03.09 regarding how you evaluate those contracted services. See our BH Checklist for Contract Services to assist you with this.