Improperly Qualified Personnel

Unqualified or improperly qualified individuals who make quality control decisions pose both legal and accreditation problems. In many cases, the JCAH specifies the required training of individuals who hold administrative positions (such as requiring the head of nursing to be a nurse). The law requires that licensed professionals who are practicing their profession be supervised by licensed professionals. An administrator cannot tell a pharmacist how to mix drugs or tell a physician how to treat a patient. The administrator can set guidelines for these functions only in consultation with appropriately licensed professionals. This means that all quality control protocols that specify the way professional judgment are made must be approved by the appropriate professional staff committees.