JCI Staff File Tracer tool

• Conducted on

  Date

• Prepared by

• Location
  Address

• Unit

• Badge Number

• Degree/Credential

SQE.1.1 Each staff member not permitted to practice independently has a job description

• 1.1.1 Valid Job description

  Yes

  No

  N/A

• 1.1.2 Valid Addendum

  Yes

  No

  N/A

• 1.1.3 Signed Job description and addendum

  Yes

  No

  N/A

SQE. 3.1 The hospital uses a defined process to match clinical staff knowledge, skills, and competency with patient needs

• 1.1 Complete Summary Competency Checklist (signed and validated)

  Yes

  No

  N/A

• 1.2 Valid and complete competencies

  Yes

  No

  N/A

• 2. New clinical staff members are evaluated before or at the time they begin their work responsibilities ( Probationary Evaluation)

  Yes

  No

  N/A

• 3. There is at least one documented evaluation of each clinical staff defined by the hospital (Latest evaluation signed by UM)

  Yes

  No

  N/A

SQE. 5

• 1. Personnel files for each staff member are standardized and current and maintained and kept confidential according to hospital policy

  Yes

  No

  N/A

2. Personnel files contain the qualifications and the work history of the staff member

• Yes

  No

  N/A

• 2.1 BSN/Diploma/ Master Degree - 100%

• 2.2 License of Origin

  Yes

  No

  N/A

• 2.3 Previous Employment Certificate

  Yes

  No

  N/A

• 2.4 Latest Certificate of Employment

  Yes

  No

  N/A

3. Personnel files contain the job description of the staff member when applicable

• 3.1 Valid job description

  Yes

  No

  N/A

• 3.2 Valid Addendum

  Yes

  No

  N/A

• 3.3 Signed Job description and Addendum member

  Yes

  No

  N/A

4. Personnel files contain a record of orientation to the hospital and the staff member’s specific role and in-service education attended by the staff member

• 4.1 GNO/GSO

  Yes

  No

  N/A

• 4.2 In-Service education attended

  Yes

  No

  N/A

• 5. Personnel files contain the results of performance reviews ( Latest Evaluation signed by UM)

  Yes

  No

  N/A

• 6. Personnel files contain required health information (Records in Employee Health Services)

  Yes

  No

  N/A

SQE. 8.1.1 1. Staff members who provide patient care, including physicians, are trained in at least basic life support (BLS)

• 1.1 Valid BLS

  Yes

  No

  N/A

• 1.2 Valid PALS/ACLS if applicable

  Yes

  No

  N/A

• 1.3 Expired BLS/ACLS/PALS - Booking as evidence

  Yes

  No

  N/A

2. There is evidence to show if a staff member passed the training

• 2.1 Valid competencies and trainings

  Yes

  No

  N/A

• 2.2 MAHER Certificate of Completion: Simulation Based Competency Assessment and theoretical Exam

  Yes

  No

  N/A

3. The desired level of training for each individual is repeated based on the requirements and/or time frames established by a recognized training program, or every two years if a recognized training program is not used

• 3.1Valid competencies and trainings

  Yes

  No

  N/A

• 2.2 MAHER Certificate of Completion: Simulation Based Competency Assessment and theoretical Exam

  Yes

  No

  N/A

SQE. 13

• 1. The hospital has a standardized procedure to gather and document the education, certifications, and experience of each nursing staff member.

  Yes

  No

  N/A

Education, training, and certifications are verified from the original source according to parameters found in the intent of SQE.9 and are documented.

• 2.1 Primary Source Verification for Saudi only

  Yes

  No

  N/A

• 2.2 Dataflow

  Yes

  No

  N/A

3. Licensure is verified from the original source according to the parameters found in the intent of SQE.9 and is documented

• 3.1 Dataflow for License

  Yes

  No

  N/A

• 3.2 Saudi Council

  Yes

  No

  N/A

• 4. There is a record maintained of the credentials of every nursing staff member (Valid Credentialing Record)

  Yes

  No

  N/A

SQE. 14.1

• 1. Nursing staff participate in the hospital’s quality improvement activities evaluation signed by UM)

  Yes

  No

  N/A

• 2. The performance of individual nursing staff members is reviewed when indicated by the findings of quality improvement activities (latest evaluation signed by UM).

  Yes

  No

  N/A

• 3. Appropriate information from the review process is documented in the nurse’s personnel file or in a separate credential file (Valid Credentialing Record)

  Yes

  No

  N/A

Completion

• Comments/Suggestions

• Auditor Name and Signature

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