Annual Education - UCLA Health

2010 HR Standards Management & Staff Education

Health System Human Resources March 2010

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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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Immediate citation RFI (Request for Improvement) for HR

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

HR Joint Commission Chapter  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

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Job Descriptions - 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./unit Every employee must have an up-to-date Job Description JD/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 Orientation Signed JDs must be placed in the employee files

100% Compliance is required

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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

100% Compliance is required

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License, Certification & Registration Verification – Standard HR .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.

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Copies of a licenses or certifications are no longer acceptable

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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

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

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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.

100% Compliance is required 7

Standard HR.01.02.05

Elements of Performance for HR.01.02.05

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Education, Experience & Clearance to Work – Standard 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.

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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.

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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. 100% Compliance is required 10

Student Requirements and Oversight Standard –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

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

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Verification of signed Confidentiality Statement

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Verification of completed HIPAA Training Module and Post Test

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

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Evidence of Background Check completion

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

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Annual Education Guide and Post Test (Fulfills Orientation)

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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. 11

Orientation Standard -- HR.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

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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

100% Compliance is required

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Department/Unit Specific Orientation – Standard 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

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Review specific job duties, including those related to infection prevention and control and assessing and managing pain.

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Review sensitivity to cultural diversity based on their job duties and responsibilities.

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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 100% Compliance is required

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New Hire Requirements – Standard HR.01.04.01 HR RESPONSIBILITY Orientation also includes NEW HIRE PROCESS:  

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Abuse Reporting Forms (3 forms to sign – child, elder, domestic) Confidentiality Form

ON-LINE REQUIREMENTS: 

Must be completed within 30 days of hire

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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 2/10 100% Compliance is required

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Ongoing Education and Training – Standard HR.01.05.03  Staff participate in ongoing education and training in order to 

maintain or increase their competency.

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whenever staff responsibilities change.

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review the needs that are specific to the patient population served by the hospital.

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

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

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Includes participation in fall reduction activities

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Includes addressing the changes in a patient’s condition

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What education & training do your provide to staff?

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What is your education plan?

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How do you find out the educational needs of staff?

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How do you document education & training?

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Annual Education – Online Staff Employee Handbook 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.01.05.03

Elements of Performance for HR.01.05.03

Annual Education

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

Competencies are all the skills required to perform the job. 

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All skills must be assessed successfully prior to the employee being able to work independently on the floor. 

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Initial Competency Assessment may take up to six months

Staff competence is initially assessed and documented as part of orientation 

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As defined on the job description.

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.

100% Compliance is required 18

Annual Competency – Standard HR.01.06.01 ANNUAL COMPETENCY ASSESSMENT – DEPT RESPONSIBILITY Staff 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 100% Compliance is required

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Performance Evaluation – Standard HR.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.

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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

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

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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 100% Compliance is required

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Competency 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!

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Survey 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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Survey HR Related Questions  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. Control Department/Unit Specific Orientation – within 30 days of the date of the hire Review Job Descriptions/Initial Competency Assessment Process Before 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 posters In case of emergency before completion of Orientation in dept., new employee is paired up with another dept. employee for safety 

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Survey HR Related Questions What on-going staff education and training do you provide? How do you promote jobrelated 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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Survey HR Related Questions  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 25

Survey HR Related Questions  How do you Communicate changes & new topics to the staff? Chain of command/team dynamics Huddles, Staff Meetings, HOT,

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What are your vacancy and turnover rates?

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