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Health Care Staffing Services CertificationReviewer Arrival, Opening Conference, Orientation to theOrganization, and Reviewer Planning SessionSeveral activities will be occurring during the first hour a reviewer is present at the staffing firm.The breakdown of activities and the suggested length for each follows.Organization Participants Reviewer Arrival -- Firm’s review coordinator or individual familiar with office operations Opening Conference -- Leadership and others at the discretion of the organization Office Tour – Firm’s review coordinator or individual familiar with office operations Orientation to the Organization – Firm’s review coordinator, leadership or others at thediscretion of the organization Selection of Clinical Staff and Customer Tracers – Firm’s review coordinator, other internalstaff familiar with clinical staff and matching/placement processes and with contracts/formalagreementsMaterials Needed for this Session Roster of clinical staff who are currently placed, sorted by discipline Roster of clinical staff available for placement List of customers where clinical staff are currently working or have recently worked Organization chart or diagram of the reporting structureReviewer Arrival, Unannounced Reviews ONLY (5-15 minutes)This is time for the organization to prepare for proceeding with the certification review. It is anopportunity for the staff to gather some of the initial information the reviewer needs, tocontact/gather necessary staff to participate in review activities, and to provide the reviewer withhis or her workspace. The reviewer will use this time to get settled and answer any of theorganization’s questions.Opening Conference (15 minutes)Approximately 15-minutes in duration that includes: Introduction of reviewer Introductions of organization review coordinator and leaders (Please note: Other staff canbe introduced as the reviewer encounters them throughout the onsite visit) Overview of The Joint Commission and Certification Agenda review with discussion of any needed changes Overview of the SAFER portion of the Summary of Certification Review Findings Report Mention of the changes to the post-review Clarification process Questions and answers about the onsite review processOrientation to the Organization (20 minutes)This 20 minute session allows the reviewer to obtain some basic information about theorganization’s structure and scope of operations. The reviewer will facilitate the discussion anduse the information obtained to plan for the remainder of review activities. The reviewer willwant to confirm information reported by the organization in their application for certification suchas: Types of disciplines placed Number of per diem and travel clinical staff, as applicable Number of states in which clinical staff are currently placed, if applicableCopyright: 2021 The Joint CommissionHealth Care Staffing Services Review Process GuidePage 8 of 40

Types of customers the firm is currently providing with staffing services (e.g., hospitals,home care, school systems, ambulatory clinics)Number of contracts/formal agreements the firm currently has in placeOffice Tour, if necessary (5-10 minutes)This 10-minute session is a brief guided walk-through to orient the reviewer to the firm’soperations and office layout. The tour and the orientation can be combined if appropriate for theorganization. Additional touring with lengthier introductions to staff and discussion can beaccommodated during the Individual Clinical Staff Tracer time.Reviewer Planning (20 minutes)The reviewer, with the assistance of internal staff, will spend approximately 20 minutes: Identifying the sample of clinical staff whose personnel files the reviewer would like toexamine Identifying the sample of clinical staff with whom the reviewer would like to talk to by phoneat a designated time during the onsite visitThe number of personnel files selected and the number of clinical staff that will be contacted willvary based on the characteristics of each organization. Some minimum guidelines that will befollowed include: A minimum of 30 clinical staff personnel files will be reviewed per day Three to seven clinical staff per day will be identified to participate in a phone call with thereviewerClinical staff rosters will be used to guide and facilitate this selection.The reviewer will identify from the list of customers where clinical staff are currently placedthose customers whose contracts/formal agreements the reviewer would like to see. Aminimum of six contracts/agreements will be identified for review per day. The numberselected will vary based on the number and types of customers. Reviewers will look at thesecontracts/agreements during the time designated on the agenda unless an alternate time hasbeen negotiated.The reviewer will identify customers to contact by phone. A minimum of six customers will beidentified to participate in a brief phone call with the reviewer. The reviewer will identify thetimeframe during which he or she would like to place or take these phone calls to facilitate thefirm’s scheduling. Calls will be taken in private by the reviewer. Reviewers will be flexible inorder to accommodate a customer’s schedule.Please Note: It will be important that this activity conclude at the designated time, unlessotherwise negotiated. The Staffing Firm Overview immediately follows and internal staff hasbeen scheduled to participate in this activity and will be awaiting the reviewer.Any activity scheduled for this session that has not been completed will be covered later in thereview at a time and location agreed upon by the firm and reviewer.Copyright: 2021 The Joint CommissionHealth Care Staffing Services Review Process GuidePage 9 of 40

Health Care Staffing Services CertificationStaffing Firm OverviewJoint Commission standards address various aspects of a staffing firm’s performance. Theoverview session is an opportunity for the organization and reviewer to discuss some specifictopics covered in the standards, and more importantly, agreed to by the industry as keyindicators of staffing firm performance.Organization Participants Leader(s) of the staffing firm Individuals who can answer questions and explain the topics being discussed Others at the discretion of organization leadersMaterials Needed for this Session Organization chart Marketing materialsOverviewThe reviewer will want to explore and learn about a variety of topics from those individuals mostknowledgeable about the staffing firm’s processes and operations in these areas. Thestandards-based topics cross all functions and include: Organizational structure (reporting and accountability structure)Management and day-to-day operationsMarketing (strategy and practice)Customer base (current and goals)Recruitment, retention and competency (strategies)Clinical staff performance evaluation (strategies)Clinical staff health (strategies, customer requirements)Tracking law and regulation requirements for staffingProcesses for reporting and investigating work-related illness or injuriesContracts/Formal AgreementsConflicts of Interest (e.g., vendor management, subcontracting)Customer reassignment of clinical staff (floating)On-call structure and service, if applicableNational Patient Safety GoalsEmergency managementInformation managementPerformance improvement, use of data and improvement actions being takenHCSS standardized performance measures and what measure data is revealingCustomer and clinical staff satisfaction and complaint reportingThe depth of discussion and questioning on each topic will vary. If a topic is better explainedthrough demonstration or a review of documentation, indicate this to the reviewer andcoordinate an alternate time and forum to explore the topic.Copyright: 2021 The Joint CommissionHealth Care Staffing Services Review Process GuidePage 10 of 40

Health Care Staffing CertificationContract/Formal Agreement ReviewThe content of contracts and agreements is clearly a considerable influence on a staffing firm’sperformance. These agreements spell out what a customer can expect in terms of staffing firmperformance and may additionally outline the staffing firm’s expectations of its customers interms of treatment of clinical staff and feedback on clinical staff performance. Joint Commissionstandards require some specific elements be contained in the staffing firm’s formal agreements,and the purpose of this activity is to determine that the formal agreements meet standardsexpectations.Organization Participants Individuals responsible for establishing, fulfilling and monitoring compliance with contractsand formal agreements Individuals familiar with the contracts/formal agreements who can facilitate the review Others at the discretion of organizationMaterials Needed for this SessionThe selected sample of contracts identified during the Opening Conference and Orientation tothe Organization sessionsPreparationThe reviewer will gather information from the staffing firm’s application for certification as well asduring the Opening Conference and Orientation to the Organization activities to help determinethe contracts he or she will select for review.The reviewer will be asking about the different types of contracts the staffing firm has in place,the types of health care entities and their size, and the type and number of staff placed percontract. The following criteria may be considered in the reviewer’s selection of a sample ofspecific contracts and formal agreements. Smallest health care entity Largest health care entity Contract in place for the longest duration Contract in place for the shortest duration Vendor management contracts (if applicable) Subcontracts with other staffing firms (if applicable)One contract can satisfy multiple criteria. A minimum of six contracts/formal agreements will bereviewed per onsite day. The reviewer may request more if necessary.The reviewer will make an effort to complete his or her selection of contracts during the OpeningConference and Orientation to the Organization sessions so that the firm’s staff may pull them inadvance of this activity. However, reviewers may request additional contracts or formalagreements as the day progresses if there is a need to validate standards compliance.OverviewThe staffing firm is requested to have an individual who has authorized access to and is familiarwith the contracts, formal agreements and customers available to answer reviewer questions,and facilitate and expedite the review.Copyright: 2021 The Joint CommissionHealth Care Staffing Services Review Process GuidePage 11 of 40

Reviewers will discuss the entire contracting process while they are engaged in a review of thecontracts. Specifically, they will trace the contracting process, including: Sales and marketing securing a customer for the firm’s staffing services Negotiation and establishment of a formal agreement Monitoring the firm’s ability to meet contractual obligations The firm’s customer service operations, including satisfaction, complaints, newneeds/expectations Renewal or termination of a contractReviewers will be using the Contract Review Checklist (Appendix A) to record their findings andnote any questions for follow-up. If a reviewer is unable to locate an item in the contract that isrequired by the standards he or she will seek help from the firm’s staff.Information gathered through the contract and formal agreement review will be considered in allsubsequent review activities.At the conclusion of the designated time for this session, the reviewer will identify anycontracts/formal agreements that can be returned to file and those that still require review. Thereviewer will identify the time that contract/formal agreement review activity will be completedand if he or she will require the assistance of firm staff.Copyright: 2021 The Joint CommissionHealth Care Staffing Services Review Process GuidePage 12 of 40

Health Care Staffing Services CertificationPersonnel File ReviewThe review of personnel files provides an opportunity to see how consistently the staffing firm iscomplying with its own internal procedures, the requirements of its customers, and JointCommission standards in terms of data it collects and uses to make hiring decisions andevaluate performance of clinical staff. While primarily a review of files, this session can revealareas for improvement in human resources data collection, evaluation, and use in decisionmaking and reporting.Organization Participants Individual(s) with authorized access to personnel files and familiarity with content and layoutwho can participate for the duration of this activity Others at the discretion of organizationMaterials Needed for this SessionThe selected sample of personnel files identified during the Opening Conference andOrientation to the Organization sessionsPreparationThe reviewer will gather information from the staffing firm’s application for certification as well asduring the Opening Conference and Orientation to the Organization activities to help determinethe number and types of disciplines that will be included in his or her selection of clinical staffpersonnel files. The reviewer will be asking about the different types and sizes of health carecustomers, and the type and volume of clinical staff placed at each. Selection of clinical staff fortracer activity and file review may be based on customer information and the following selectioncriteria which apply to all disciplines: Highly specialized health care providers (e.g., ICU, NICU, OR) Health care providers placed in areas not highly supervised (e.g., occupational nurse,school nurses, community service nurses [flu shots, blood pressure checks]) New clinical staff member Long term clinical staff member Clinical staff member with greater working frequency Clinical staff member who works infrequently Clinical staff member who crosses state lines to practiceThe reviewer will: Select a sample of three (3) clinical staff from each discipline Include per diem and travel clinical staff in the sample If applicable, select and examine a minimum of ten (10) credentials files that cross thespecialties within the discipline of licensed independent practitioners (physicians,podiatrists, advance practice nurses, etc.); this selection will include placements in avariety of settings (inpatient, outpatient, emergency room, clinics) Select at least three clinical staff per discipline to speak with via phone Conduct a minimum of one (1) phone call with a clinical staff member per discipline Complete the Personnel File Review Checklist (Appendix B) for each file reviewedCopyright: 2021 The Joint CommissionHealth Care Staffing Services Review Process GuidePage 13 of 40

The minimum number of personnel files that will be reviewed for clinical staff is 30. There is nomaximum number of human resource files that can be reviewed. The reviewer will make everyeffort to make his or her initial selections of clinical staff for whom they would like to review filesduring the Opening Conference and Orientation to the Organization sessions so that the firm’sstaff may gather them in advance of this activity. However, reviewers may request additionalfiles as the day progresses if there is a need to validate compliance with standards.Additionally, the reviewer will select several internal staff (supervisory staff, individualsresponsible for collecting and evaluating credentials) for whom they would like to reviewpersonnel files. These are in addition to the clinical staff selected.OverviewThe staffing firm is requested to have available an individual(s) who has authorized access topersonnel data and who is familiar with the clinical staff and internal staff file layout andcontents. This individual should be able to both facilitate and participate in the file reviewprocess.Files will be reviewed using the Personnel File Review Checklist (Appendix B) that lists theitems of information required by the standards. Reviewers will look through each file identifying: The presence or absence of the items, and Any interactions the individual has had with staffing firm supervisory staffIf a reviewer is unable to locate information in a file, firm staff will be asked to locate thematerial. Inform the reviewer of any information maintained in locations other than thepersonnel file.There are several blocks of time on the agenda for file review activity, both in the morning andafternoon.Copy

Confirm your office address and phone number Confirm your hours of operation; if these change at any time, please call and inform your Account Executive . An organization should direct a request for postponement to its Account Executive. A request to postpone a review may be granted if a major, unforeseen event has