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JCAHO Joint Commission (click to view)
An independent, not-for-profit organization, The Joint Commission accredits and certifies more than 15,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

JCAHO Frequently Asked Questions

JCAHO Standards

Question:
Does the person administering sedation have to be qualified to monitor the patient if other staff who are present are qualified? 

Answer:
Standard PC.13.20 requires a sufficient number of staff, in addition to the person performing the procedure, be present to perform the procedure, monitor and recover the patient.

JCAHO Policy

The person administering the medication must be qualified to manage the patient at whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally.
Must be able to manage one level deeper
There may be a need for additional monitoring personnel, but the person administering the sedation must be qualified to monitor the patient.

JCAHO Policy – Permission to Administer Moderate Sedation

Question:
Are specific privileges to administer moderate sedation required?

Answer:
The anesthesia care standards require that the individuals who are "permitted" to administer sedation are able to perform airway & cardiac rescue.

JCAHO Policy – Permission to Administer Moderate Sedation

Each organization is free to define how it will determine that the individuals are able to perform the required types of rescue. 
  
Acceptable examples include, but are not limited to, ACLS certification, a satisfactory score on a written examination developed in concert with the department of anesthesiology, a mock rescue exercise evaluated by an anesthesiologist.

With regard to non-Licensed Independent Providers (LIPs), such as nurses, who are permitted to administer the sedation, the permission could be found in the individual’s job description, or other documentation in their personnel file.

 

Sedation by Non-Anesthesia Personnel (click to view)