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There is a standard tucked into the TJC Human Resources chapter that seems innocuous at first reading but frequently causes challenges on surveys. The standard is HR.01.06.01 Element of Performance # 3 in both the Behavioral Health and Hospital manuals:

“Staff with the educational background, experience, or knowledge related to the skills being reviewed assess competence.”

Here’s how this standard is typically reviewed by surveyors: During the Human Resources interview, they will ask for the file of a specialty or “one of a kind” practitioner such as an occupational therapist, a dietician, or a rehab therapist. Then, the surveyor will review the HR file to see if that practitioner has had input to their clinical competence assessment from someone in the same discipline. The concept is that the individual conducting the competency assessment must have the appropriate background and training to assess the clinical competence of the practitioner being evaluated.

So, where do problems arise?

The following are examples from actual surveys:

  • The organization had only one dietician and her performance evaluation had been conducted by an administrator with no input from another dietician.
  • The nurses who worked in a community based program had been evaluated by the program director who was not a nurse.
  • The contract occupational therapist had never had any type of competence assessment.
  • The activity therapists were being reviewed by the Director of Nursing.

Thus, it’s important to have a mechanism in place to ensure that these types of practitioners get input from a peer in the same discipline. What are the options? First, identify if there is a clinical peer within your own organization. This can either be someone in a supervisory position or a colleague working in the same position. If there is no clinical peer within your organization, is there a “sister facility” within your system that has the same type of practitioner who can provide a peer review? If neither of these is an option, TJC allows for obtaining a peer recommendation from an individual outside of the organization; for example, from a peer at another agency where the practitioner works.

What about the scenario in which there is no peer within the organization and the practitioner does not work at another agency where they can get a peer recommendation? In this case, the best approach is to retain (i.e. pay for) a peer from outside the organization to conduct some type of clinical review on your practitioner.


A few points of clarification on this issue:

  • The individual who is the administrative supervisor for the practitioner should complete the non-clinically related portions of the practitioner’s performance evaluation. Input from a clinical peer is only required for the clinical responsibilities.
  • The peer input should include some type of hands-on review of the practitioner’s work: e.g. evaluation of clinical documentation; observation of work; case presentations, etc. This is, of course, easier to structure if the peer is within your organization because you can define the process and the format for documenting the peer review. However, if peer input is being obtained from a practitioner at another agency, you do not have as much control over the process. In this case, the peer review actually becomes more of a peer recommendation. However, this recommendation can still be structured (by you) such that you ask the peer reviewer to comment on specific aspects of the practitioner’s work including the quality of their assessments and their plans of care. (See the sample at the end of this article for some generic peer review indicators that can be adapted to your setting and services.)
  • The working definition of a peer that we have seen accepted by TJC is the following:
    • The peer is a practitioner in the same discipline; e.g. nurse to nurse. OR
    • The two practitioners are peers because they are both working under the same job description. For example, the Outpatient Therapist job description allows for the position to be filled by a social worker, a licensed mental health counselor, or a marriage and family therapist. In this case, these individuals are considered peers.


[tblock title=”SAMPLE: Generic Peer Review Indicators” tag=”h4″ position=”text-center”/]

Clinical Responsibilities Always Frequently Sometimes Rarely
Assessments are thorough in evaluating clients’ needs and making recommendations for treatment.
Diagnostic and therapeutic decisions are made based on client/ family information and preferences, scientific evidence, and clinical judgment.
Documentation is completed within the required timeframes.
Documentation reflects the standards for quality established by the organization.
Practitioner collaborates with other members of the clinical team for coordination and management of ongoing care.
Practitioner fulfills assigned clinical responsibilities, (i.e. is reliable and available).