1 2010 HR Standards Management & Staff Education Health System Human Resources March 2010

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2010 HR Standards 2010 HR Standards Management & Staff EducationManagement & Staff Education

Health System Human ResourcesHealth System Human Resources

March 2010March 2010

Human Resource Standards Overview Human Resource Standards Overview

The HR Standards are the responsibility of HR but we need a strong partnership with the departments in order to meet the requirements

HR Standard Topics include -License, Certification, Registration Verification: Upon Hire and Renewal

Job Description

Orientation: House-wide and Dept./Unit Specific

Education, Experience and Clearance to Work

Annual Education and Training

Competencies: Initial and Annual

Performance Evaluation

Other Personnel: Non-Employees brought in by independent licensed practitioners/students/volunteers/temporary staff

Measurement: Competency Tracking System

Documentation

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Staff without a current TB test should not be scheduled to work.

Immediate citationRFI (Request for

Improvement) for HR

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Why is the HR Compliance important?HR Joint Commission Chapter defines the standards and expectations

The right thing to do in managing people in a Health Care environment

We must be at 100% in all areas to avoid citations

Entry must be completed timely to be reflected on the bi-weekly reports

During Joint Commission Surveys and DPH visits

There are always file reviews to ensure appropriate documentation of competency assessment, performance evaluations, training documentation

HR Joint Commission ChapterHR Joint Commission Chapter

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Job Descriptions Job Descriptions - Standard HR.01.02.01- Standard HR.01.02.01

The hospital defines staff qualifications specific to their job responsibilities.Do you have an up-to-date Job Descriptions (JDs) for each position/staff member?

JDs derived from the Scope of Service and Staffing Plans for each dept./unitEvery employee must have an up-to-date Job DescriptionJD/PE templates are on the HR Website under HR Operations/Forms

new content and language as of 1/1/09 that includes the CICARE Standards

and Workplace Conduct policy

JDs must be reviewed and signed by new hires during Dept Specific OrientationSigned JDs must be placed in the employee files

100% Compliance is required

Specific Competency – Standard HR.01.02.01

New for 2010: If blood transfusions and intravenous medications are administered by staff other than doctors, the staff members have special training for this duty.

Covered in Nursing Orientation Specific competencies are completed on the units Part of competencies in Outpatient Areas for job titles and clinics that have the particular scope as part of their practice

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License, Certification & Registration Verification License, Certification & Registration Verification –– Standard Standard HR .01.02.05HR .01.02.05

IT IS YOUR RESPONSIBILITY TO VERIFY LICENSE & CERTIFICATION AUTHENTICITY Primary Source verification is required for all licenses, certifications and registrations upon hire

and prior to expiration or at renewal time.

Copies of a licenses or certifications are no longer acceptable

A copy of the primary source verification from the Board’s website must be printed

RENEWALS: On or prior to the expiration date of the license/certification The copy is date stamped electronically / one day after the expiration date it is considered late

and hospital is cited

NEW HIRES: Prior to start date or on the employee’s first day of work.

Employees cannot work with an expired license. Please make sure that any excused delay, employee on leave, employee was suspended is

documented in the file

A HOSPITAL CAN LOSE ITS OPERATING LICENSE IF STAFF ARE PRACTICING WITH EXPIRED CREDENTIALS REQUIRED FOR THE JOB.


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Standard HR.01.02.05Elements of Performance for HR.01.02.05

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Education, Experience & Clearance to Work Education, Experience & Clearance to Work – – Standard HR.01.02.05Standard HR.01.02.05

HUMAN RESOURCES COMPLETES THESE REQUIREMENTS – AN EMPLOYEE CAN NOT START UNTIL ALL CLEARANCE IS COMPLETED Education and Experience verification -

Staffing Office has a clearinghouse to verify a degree is required by the JD and a vendor to check references.

Criminal Background Check on the applicant as required by law and regulation or hospital policy. Criminal background checks are documented. Completed in Human Resources. Never make an offer until the results of the

background checks are completed.

Pre-Employment Health Screenings as required by law and regulation or hospital policy. Completed by OHF, which is the official office of records. Health screenings must be completed prior to the start date.


Student Requirements and Oversight Student Requirements and Oversight Standard –HR. 01.02.07Standard –HR. 01.02.07 Do you have students in your area? How do you orient & train them?

Staff oversee the supervision of students when they provide patient care, treatment, and services as part of their training. Same Orientation and Education requirements and documents as staff:

1. Copy of Resume or completed Application for Assignment

2. Verification of (3) signed Abuse Reporting Statements ~ (child, domestic, elder)

3. Verification of signed Confidentiality Statement

4. Verification of completed HIPAA Training Module and Post Test

5. Evidence of Medical Criteria Clearance/TB Testing/Drug Screening completion

6. Evidence of Background Check completion

7. Verification of valid License/Certification/CPR Card (if applicable)

8. Annual Education Guide and Post Test (Fulfills Orientation)

9. Review of Restraints Competency Module (if applicable)

NOTE: Original license, certification and/or CPR card must be presented to UCLA Health System personnel

before starting any assignment. These documents must be current at all times.

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Orientation Standard -- Orientation Standard -- HR.01.04.01HR.01.04.01

NEW EMPLOYEE ORIENTATION & DEPT SPECIFIC ORIENTATION HR RESPONSIBILITY -- All staff must complete New Employee Orientation

within 30 days of hire date Covers the following:

Introduction to CICARE; Hospital-wide Policies & Procedures; Fire & Safety; Infection Control

Post test is completed in class or online. Forms placed in personnel file.

DEPARTMENT RESPONSIBILITY -- Department Unit-Specific Orientation must be completed within 7 days for the safety part and 30 days for the rest

Additional Orientation Programs include: Nursing Orientation and Ambulatory Care Orientation


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Department/Unit Specific Orientation Department/Unit Specific Orientation – – Standard HR.01.04.01Standard HR.01.04.01

Complete the Dept Specific Orientation form for every new employee/transfer

Review the Environment of Care items within the first day of employment and no later than the first week.

Review all other parts within 30 days of the date of hire Review and sign Job Description during this time Review specific job duties, including those related to infection prevention

and control and assessing and managing pain. Review sensitivity to cultural diversity based on their job duties and

responsibilities. Review patient rights, including ethical aspects of care, treatment, and

services and the process used to address ethical issues based on their job duties and responsibilities


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New Hire Requirements New Hire Requirements – Standard – Standard HR.01.04.01HR.01.04.01

HR RESPONSIBILITY

Orientation also includes NEW HIRE PROCESS: Abuse Reporting Forms (3 forms to sign – child, elder, domestic) Confidentiality Form

ON-LINE REQUIREMENTS: Must be completed within 30 days of hire Located on Mednet Home Page under Employee Required Training

Code of Conduct / Compliance Quiz (one time only) HIPAA Education & Training Program (one time only) C-ICARE Annual On-line Training (annual) UCOP Compliance Briefing (annual) – NEW REQUIREMENT as of 2/10


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Ongoing Education and Training Ongoing Education and Training – – Standard HR.01.05.03Standard HR.01.05.03

Staff participate in ongoing education and training in order to maintain or increase their competency. whenever staff responsibilities change. review the needs that are specific to the patient population served by the

hospital. enhance the skills of team communication, collaboration, and coordination of

care. includes information about the need to report unanticipated adverse events and

how to report these events. Includes participation in fall reduction activities Includes addressing the changes in a patient’s condition

What education & training do your provide to staff? What is your education plan? How do you find out the educational needs of staff? How do you document education & training?

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Annual Education – Annual Education – Online Staff Employee Online Staff Employee Handbook QuizHandbook Quiz

Staff participate in ongoing education and training. All staff meet the Annual Education requirement by completing the Annual Education Guide found on the Mednet home page under Employee Required Training.

Competency Tracking System shows who is out of compliance so that you can remind staff to complete the module online

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Standard HR.01.05.03Elements of Performance for HR.01.05.03

Annual Education

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Initial Competencies --Initial Competencies --Standard HR.01.06.01Standard HR.01.06.01INITIAL COMPETENCY ASSESSMENT – DEPT RESPONSIBILITY

Competencies are all the skills required to perform the job. As defined on the job description.

All skills must be assessed successfully prior to the employee being able to work independently on the floor. Initial Competency Assessment may take up to six months

Staff competence is initially assessed and documented as part of orientation Performed at point of hire or transfer to a new position

An individual with the educational background, experience, or knowledge related

to the skills being reviewed assesses competence. The INITIAL COMPETENCY ASSESSMENT FORM must be used and the appropriate

assessor /preceptor/educator/supervisor must initial the form as each competency is successfully completed. Signature and date is required when all competencies have been assessed.


Annual Competency Annual Competency – Standard HR.01.06.01– Standard HR.01.06.01ANNUAL COMPETENCY ASSESSMENT – DEPT RESPONSIBILITYStaff competence is assessed and documented once every three years, or more frequently as required by hospital policy or in accordance with law and regulation

Per UCLA Health System Policy - Only the following competencies should be assessed annually:

HIGH RISK/LOW FREQUENCY PROBLEM PRONE AREAS REGULATORY REQUIREMENTS, i.e. blood administration; blood glucose NEW COMPETENCIES

Routine daily tasks may not be reviewed annually unless the employee is not able to perform them

The hospital takes action when a staff member’s competence does not meet expectations

Action plans are developed with established timelines for review

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Performance Evaluation Performance Evaluation – Standard – Standard HR.01.07.01HR.01.07.01

The hospital evaluates staff performance

The hospital evaluates staff (and non employees brought in by licensed independent practitioner) based on performance expectations that reflect their job responsibilities.

The hospital evaluates staff performance once every three years, or more frequently as required by hospital policy or law. This evaluation is documented.

According to UCLA policy, the PE is completed annually by the supervisor

Use JD/PE form from the on-line templates on HR Website

Performance Evaluation process is a two-way process Allow staff to discuss their performance with the supervisor Discuss their training needs and document those so that you can follow

up on them Annual planning is also done during this time Goals and objectives for the next year should be established


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Competency Tracking SystemCompetency Tracking System

Do you have access to it?

Did you receive training on how to use it?

Contact Debby Brown or Audrey Lazaro to set up a private session at x40500

Is your department appropriately listed on the Competency Report?

If not, contact Maria Olegario at x40500

REMINDERS:

If a competency does not apply to a staff member, you need to indicate that on the tracking system, otherwise the reports will show you out of compliance.

Reports are based on the entry. Please do your entry timely & accurately. Make sure the dates on the forms match the dates in the system.

Verify licenses/certifications through primary source before start of work and prior to renewal. Print online verification for file.

DON’T HESITATE TO CALL US FOR QUESTIONS!

Survey HR Related QuestionsSurvey HR Related Questions

How do you determine your staffing levels? Scope of Service along with budgets, the following elements are included:

Availability of Service

Hours of service

How patients, etc., access their service during “regularly” scheduled periods

How patients, etc., access their services during “off-hours”

Patient care areas flex with volume and acuity

Type(s) of staff available to serve the customer. License/certification and other education requirements

Number of staff (by category, if applicable)

Availability of Staff (scheduling, coverage, on-call arrangements)

Acuity Methodology

Skill mix and number of staff required

Acuity system in place.

Benchmarking

a. What data do you collect and how do you use the data?

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What is your process for competence assessment, maintenance and improvement?Initial & Annual Competency Assessment (refer to pages 18 & 19)

How do you orient staff to your hospital, their job responsibilities and/or their clinical responsibilities?

General Orientation -- cover all topics – policies, safety, HIPAA, Inf. ControlDepartment/Unit Specific Orientation – within 30 days of the date of the hireReview Job Descriptions/Initial Competency Assessment ProcessBefore the orientation is completed employee is assigned a “buddy” for any emergency situation

DETAILS:

Throughout the year, education takes place through fire drills, EC rounds, EC surveys, EC education postersIn case of emergency before completion of Orientation in dept., new employee is paired up with another dept. employee for safety


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What on-going staff education and training do you provide? How do you promote job-related educational and advancement goals of staff members?

On-going education and training classes are offered throughout the year

Managers are trained to assess learning needs specific to individuals and their unit/dept.

It’s part of Performance Evaluation, part of goals and education planning section

It can be part of competency assessment process as well

Each department is responsible for offering on-going development courses

HHR offers leadership courses

Web site for education resources

Paid development time

Web access to information for employees

Vendor provides training for new equipment

Staff offer suggestions for topics – some staff members may present or another speaker in house

Interview staff during Skills Day and ask them what they’d like dept. to review


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What is your population competencies process?Age Specific competency training

New hires with patient contact are tested (Age Specific Module) and observed during their orientation period

No patient contact, basics are reviewed at General Orientation and annual education

Cultural Competencies

New Hire Orientation view a tape to introduce all new hires on the subject

In patient areas, more in-depth training is provided in unit specific orientation, in department orientations

Self study module with a test - optional

On-going education and training classes are offered throughout the year

Patient Population group – Consistent process on floors/units. Individualize as necessary according to patient need


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How do you Communicate changes & new topics to the staff?Chain of command/team dynamics

Huddles, Staff Meetings, HOT,

What are your vacancy and turnover rates?

Documents

1 2010 HR Standards Management & Staff Education Health System Human Resources March 2010