Transcript THANK YOU! - Health human resources

Stroke Survey Review
September 2012
Findings
Reminders
Observations
Stroke Survey Review
THANK YOU for your assistance with the
personnel files during the
Comprehensive Stroke Survey!
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Nutrition;
Care Coordination;
Speech Pathology;
Radiology;
Emergency Dept.;
Rehab;
Nursing;
Patient Access Services;
Quality Mgmt;
Neurosurgery;
Stroke Team
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Docs Reviewed During
HR/Competency Interview
 License Verification Printouts
 Other Certifications, such as BLS, ACLS,
PALS, MICN
 Job Description
 Performance Evaluations for last two years
 Annual Education
 Annual Competencies
 Specific Stroke Education
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Observations For Licenses/Certifications
When Prepping Personnel Files
o Please make sure every required license and certification for a
position is listed on the employee profile in the HR Competency
Tracking System so it can be tracked and expiration dates can be
met.
o While many files did contain the required license verification printout,
the printout date was NOT ALWAYS completed prior to the last
expiration of the license.
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Observations for
Licenses/Certifications
o Some staff have multiple licenses listed on the Board website, such as
RN, NP, and Public Health Nurse. Please print them all for the files!
o The only acceptable license verification is the timely printout from the
Board website.
 Copies of licenses cannot replace the verification printout from the
Board website. They can be tampered with easily.
 Late printouts that are past the license expiration date will not pass a
surveyor’s inspection. It tells them we let someone work without
verifying if a license is valid.
o Education degrees – Documented on JDs
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Going Forward ...
Upcoming Surveys:
 Transplant Survey
 Patient Safety Licensing Survey
 WW TJC Survey
Same preparation process for all licensing visits:
 Keep HR tracking up to date
 Be aware of due dates and expiration dates
 Review documents for completeness before entry and filing
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Department-wide Responsibilities
for Licenses
 The HR Chapter of the licensing standards is not the Human Resource
Department Chapter.
 It’s a chapter about the qualifications of the people in our organization; the
“human” resources of every dept.
 Every dept./clinic is responsible for the requirements of their staff (the
“human” resources), so their areas remain successful, productive and in
compliance.
 There are over 5,000 licensed staff members. Many with multiple
credentials.
 Therefore, license verifications are completed in the department by a
designated person or people and must be a priority when it comes to
meeting the expiration deadlines.
 Your HR team and the HR Tracking System are your support network.
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