IRO Core 3.0

IRO CORE 32 - Senior Clinical Staff Responsibilities

Submited by: Tom Goddard

The Basics

The senior clinician whose qualifications are set forth in Core 31 must, according to this standard, provide guidance and be responsible for all of the clinical aspects of the organization's program being accredited. In addition, the senior clinician must have periodic consultation with individuals in the field or licensed to deliver healthcare services without supervision, i.e. practitioners. Finally, he/she must be responsible for your organization's program to assure that all clinicians accountable to your organization for decisions that affect consumers are qualified.

Management Tips

Again, management personnel should make sure that the senior clinician's job description and resume are in order and in compliance with the standard. In addition, the organization's program description or policy and procedures that describe the clinician's role in accountabilities should be reviewed to make sure it complies with the standard.

Accreditation Tips

Desktop Review
The only documentation you need to submit for this standard is either a job description of the senior clinician, if employed, or, if he/she is a consultant, the consulting agreement. If that agreement does not address all the requirements of this standard, in addition to the contract, you should submit a program description of policy that does fully address the responsibilities described in this standard.
Validation Review
The reviewer will interview the senior clinician regarding each of the responsibilities described in this standard.
Document Review
The reviewer will examine the senior clinician's personnel file.

  • Core 4.0 / 06.20.2018

    C-RM 1-2: Policy Addressing Reporting of Violations

    This standard requires your organization’s compliance policies to:Protect individuals reporting violations of ethical, regulatory, or legal requirements;Address the consequences of failing to report violations; andProtect the confidentiality of anyone reporting violations.

  • Core 4.0 / 06.18.2018

    C-RM 1-1: Regulatory Compliance and Internal Controls

    This standard, which bears a strong resemblance to Core 4 in the previous versions of Core, describes the fundamental aspects of an effective compliance program:Tracking applicable laws and regulations. This is an ongoing process of tracking existing laws and regulations and keeping up with changes in those laws and regulations. So, you need to identify -- in a clear and specific policy and proced...

  • Core 4.0 / 06.18.2018

    C-CPE 2-3: Monitoring and Oversight of Ethical Healthcare Practices

    Once an organization has defined ethical practices, as required by the previous standard, it must implement mechanisms to monitor for violations of its ethical standards and address those violations. Such mechanisms must spell out how it:Identifies appropriate authorities to remediate particular situations involving ethical transgressions;Will take action in the event of ethical issues; andWill re...