All hospitals have to comply with a wide variety of government regulations and requirements by accrediting agencies. For hospitals to receive certain types of accreditation and to be compliant with industry standards, employees must receive training in particular areas and be able to demonstrate their knowledge.The training and development requirements to meet some key standards are:

National Accreditation Board for Hospitals and Healthcare Providers

National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India, set up to establish and operate accreditation programme for healthcare organizations. The board has been structured to cater to much desired needs of the consumers and to set benchmarks for progress of health industry in India.

The standards require a documented training and development policy for the staff which shall cover following aspects:

  • Proper induction of the staff which covers orientation of the staff to the services and the service standards being delivered by the organization.
  • The staff shall be well acquainted to the policies and procedures of the institution and of the respective departments.
  • Inductive and ongoing training programmes in critical areas such as infection control, disaster management, drug safety, patient safety, employee/patients rights and responsibilities
  • Ongoing programme for professional training and development of the staff.
  • Maintenance of training and development records in the employee portfolio,
  • Monitoring and evaluation of the training programme including objective evaluation of the training outcome.
Joint Commission for Accreditation of Healthcare Organizations (JCAHO)

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is an independent, not-for-profit organization that evaluates the quality and safety of more than 16,000 health care organizations in the United States. Orientation and Training forms one of the priority focus areas of the JCAHO standards. Priority focus areas in JCAHO are those processes, systems, or structures in a health care organization that significantly impact the quality and safety of care.

The JCAHO puts stress on following aspects related to training and development:

  • The hospital provides initial orientation.
  • Staff and licensed independent practitioners, as appropriate, can describe or demonstrate their roles and responsibilities relative to safety.
  • Ongoing education, including in-services training, and other activities, maintains and improves staff competence.
  • Staff training occurs when job responsibilities or duties change.
  • Ongoing in-services, training, or other staff activities emphasize specific job-related aspects of safety and infection prevention and control.
  • Staff competence to perform job responsibilities is assessed, demonstrated, and maintained.
  • The hospital periodically conducts performance evaluations.
  • The hospitals are required to assess staff development needs on hospital wide, departmental and individual levels.
  • Ongoing in-services, training, or other staff education incorporate methods of team training, when appropriate.
  • Ongoing in-services, training, or other staff education reinforce the need and ways to report unanticipated adverse events.
American Association of Blood Banks (AABB)

AABB requires a quality assessment and improvement program to ensure personnel are knowledgeable and skilled in their assigned duties. The Association demands a quality management program that includes periodic evaluation and documentation of competence of personnel to perform assigned duties. At least annually, the employees must demonstrate their abilities to carry out every test or procedure they may be called upon to perform. The AABB standards suggest use of proficiency testing, written and oral exams, and observance of daily work. Corrective action to improve substandard performance must be documented.

College of American Pathologists (CAP)

CAP requires a sufficient work force with adequate documented training and experience to meet the needs of the laboratory. Periodic evaluations are required.

Clinical Laboratory Improvement Act of 1988 (CLIA '88)

CLIA '88 requires a mechanism for periodically evaluating the effectiveness of policies and procedures to ensure employee competence. The procedures for evaluating competency must include those listed in the box. The laboratory director must employ competent personnel to perform and report tests, and the technical supervisor is responsible for evaluating competency. The technical supervisor also is responsible for conducting performance evaluations semiannually for new employees during their first year in the lab and annually thereafter. The technical supervisor may delegate these periodic evaluations to the general supervisor. Corrective action to improve performance must be documented.
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