Transcript Document

Human Resources
Standards
September 2008
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Management of Human Resources
Chapter
The goal of the HR Chapter is to ensure that the organization:
Provides an adequate number of staff
Provides competent staff
Orients, trains and educates staff
Assesses, maintains and improves staff competence
There are 8 HR Standards
Three under Planning
Three under Orientation, Training & education
Two under Competence Assessment
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2005 HR Standards
HR.1.10 --The organization provides an adequate number
and mix of staff consistent with the organization's staffing
plan.
Do you have an up-to-date staffing plan?
Are staff familiar with the staffing plan for the department?
What do you use for benchmarking methods?
Do you use data from similar hospitals to put your staffing plan together?
What do you flex for?
Acuity, volume, patient needs, number of appointments, number of patients.
Do you have enough staff?
Per Diem pool is used when necessary, Overtime, Registry, etc.
How do you cover when a number of people are out?
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Every department has a staffing plan.
Staffing plans are based on approved budget & scope of services
Staffing Plan Template is on the HR website
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2005 HR Standards
HR.1.20 -- The organization has a process to ensure that a person’s
qualifications are consistent with his or her job responsibilities.
Every employee must have a current Job Description (JD)
A signed copy of the latest JD must be on-file
Ensure that you use latest format
Well defined Job Descriptions
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Five JD/PE templates have been created on the website:
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Administrative; Unlicensed Clinical; Licensed Clinical; RN; Management
Age specific requirements must be listed, assessed and evaluated yearly
 Simplify the JDs & PEs as much as possible; Ensure that only requirements are listed.
Any changes must be updated timely on the JD
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Did you receive a copy of your JD? Is it up-to-date?
Every employee receives a copy of their JD during department orientation.
During the Performance Evaluation review, the job description is reviewed again
If the employee’s duties have changed, the job description is updated. Input from both the
employee and supervisor is taken into consideration.
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2005 HR Standards
HR.1.30 --The organization uses data and clinical/service
screening indicators and human resources screening indicators
to assess and continuously improve staffing effectiveness.
o Human Resources Indicators:
RN Hours per Patient Day
o Clinical/Service Indicator: Number of Patient Falls
o Human Resources is working with Nursing staff to gather data and information on
patient falls. Further drill downs will be conducted in Nursing Units where falls occur.
o Human Resources Indicators:
FTE/AOB
o Clinical/Service Indicator: Overall Satisfaction with Care question on NRC Patient
Satisfaction Survey
o Human Resources is working with Nursing Units to do some drill downs in areas where
there is a significant increase or decrease in the patient satisfaction scores from one
quarter to the next.
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2005 HR Standards
HR.2.10 -- Orientation provides initial job training and information.
All employees, including contract staff, must complete the following within 30 days of their hire date:
General Orientation Session
HIPAA Security Module
HIPAA Confidentiality Module
Corporate Compliance Module
Department/Job Specific Orientation – FORM must be completed by the supervisor or preceptor
and employee within 30 days -- Environment Care part must be completed on the first day
TEMPLATE should be expanded to include items unique to your area
Review Patient Safety standards
Environment of Care items
Cultural Diversity & Sensitivity
Departmental policies
Volunteers should always be directed to the Volunteer Office for orientation and training.
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2005 HR Standards
HR.2.20 -- Staff members, licensed independent practitioners, students and
volunteers can describe or demonstrate their roles and responsibilities based on
specific job duties or responsibilities relative to safety.
Make sure you document on the Department/Job Specific Orientation form that
staff were oriented and trained on the following:
Potential risks within your area
Actions to eliminate, minimize or report risks
Procedures to follow in the case of an event
Processes for reporting common problems, failures and user errors
How do you report any patient safety issues, near misses and errors?
There is a chain of command within each area. Make sure ALL staff are familiar with it
Encourage all staff to report any unsafe process and unsafe physical conditions
Documentation is critical. If no one knows about it, things may not be fixed
The link to the Event Reporting System can be found on the MedNet homepage
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2005 HR Standards
HR.2.30 -- Ongoing education, including in-services, training
and other activities, maintains and improves competence.
Document all education (one-time or on-going)
Encourage staff to attend trainings
Trainings offered:
House-wide annual education
On-going unit/department in-services
Patient safety training
Environment of Care classes
Management Training Course
House-wide Training Needs Assessment Survey – every 2 years
Classes offered through: HR, CHR, Nursing Research & Education,
MCCS
Performance Evaluation - “future plans and goals”
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HR Standards
What type of management training is offered in the
organization?
Directors and Managers should review the following
Leadership Orientation Manual (available on-line)
Management Training Courses (see schedule on HR website)
Campus HR training schedule
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2005 HR Standards
HR.3.10 Competence to perform job responsibilities is assessed,
demonstrated, and maintained.
Initially, ALL employees must have competencies completed
All major skills of job are assessed.
Age Specific Training Module & Post Test must be reviewed by patient
care and patient care support staff (as appropriate).
Initial Competency Assessment form must be completed for all new hires
and transfers into new positions within six months of the hire date
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2005 HR Standards
Annually, only these skills must be reviewed:
high risk, low frequency;
high risk, high frequency (as appropriate);
problem prone;
required by regulatory agencies, i.e., blood administration and accuchek
patient safety related;
new competencies;
not routine, daily tasks
Annual Age Specific Competencies-documented in PE
An Annual Competency Assessment form must be completed for staff working in:
In patient care positions
Patient care support positions
Other positions that meet the requirements shown above
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2005 HR Standards
HR.3.20 The organization periodically conducts performance
evaluations.
Performance Evaluation Policy
According to Hospital Policy, all employees must be evaluated every 12 months
There is a two month grace period for signature and review
When an employee transfers to another unit/department before the 12 month period, an
initial competency assessment & a Department Specific/Job Specific Orientation are
completed in the NEW department and a new performance evaluation period starts on the
day of the transfer
The evaluation period must cover 12 months or less
PE compliance must be at 98% during a Joint Commission visit
The next visit will be unannounced so, we have to be at 98% at all times
The last 18 months prior to a visit are also looked at
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Back Up Documentation
Back- up documentation MUST be available for the surveyors to review.
Back-Up Documentation must always accompany initial and annual competency assessment summary
sheets for all competencies listed.
The back-up documentation binder must include the following:
Each competency listed on the summary sheet must have a back-up document listing steps of
competency.
The back-up documentation must match up with each competency listed on the summary sheet.
What did you observe the employee do to deem them competent?
i. Have a checklist listing all the steps.
ii.
Include the checklist the preceptor works from to ensure that nothing was missing during the assessment process.
What different steps did the employee take for the different age groups?
i.
Have a checklist for each age group, if applicable.
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Back Up Documentation
Policies and protocols used.
i. What policies and procedures do you follow?
ii. Put copies of them inside your binder.
Tests used. Not Applicable for Inpatient Nursing Dept.(Self Study Guide test only)
i. What tests do you use to ensure that the employee is competent?
ii. Put copies of the tests in the binder.
iii. Put a statement that clarifies the passing score for each test.
Include any other material used to ensure that the employee is competent and ready to work
independently.
The back-up documentation should also be sorted by age groups if applicable.
Binders should be separated by title, if the competencies required are different for each title.
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HR Policies
Performance Evaluation Policy
Staff Rights Policy
Employees may request not to participate in care or treatment of a patient
based on cultural, religious or ethical beliefs
departments must document request ahead of time
patient care may not be interrupted at any time
What do you do if you don’t want to take care of a patient?
Talk to your supervisor
Complete request form as soon as possible, so that supervisor is aware for
staffing purposes
Forensics Policy
When a prisoner is admitted to the hospital, forensic staff is educated by security on our
emergency procedures and codes.
When a prisoner comes to Med Plaza for an appointment, department must notify
UCPD to alert them.
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HR Forms
To access the most up-to-date HR Forms
Please go to http://hr.healthcare.ucla.edu/
Click on the
Employee
section
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HR Forms
Click on
All HR
Forms
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HR Forms
Click on
Regular
Staff
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HR Forms
Click on
Regular
Staff
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HR Tracking System
Do you have access to the HR Tracking System?
Call Maria Olegario at x48622 to get your access
Review your own compliance regularly, prior to
reports being sent out.
Ensure compliance for all your accounts
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HR Tracking System
Click on
More
Services
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HR Tracking System
Click on
HR
Web
Applications
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HR Tracking System
Click on
Competency
Tracking
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HR Contacts
Kety Duron at 40500
Debby Brown at 40500
Salpy Akaragian at 46903
Maria Olegario at 48622 (for access to the HR
tracking system)
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