Transcript HR Chap Mock Survey Findings 2-2016

Human Resources Chapter
The Joint Commission
Mock Survey Results
February 2016
Personnel Files Requested
21 Files were requested from the following departments /units:
• Inpatient Nursing: L&D; 6 East; 4 ICU; 7 North; 7 East
• Other Areas: Bowyer Pharmacy; Bowyer Treatment; Cath Lab; 200 Med
Plaza SPD; Central Sterile; EVS; Hyperbarics; Wound Care; JSEI Pre/Post Op;
Nuclear Medicine; Surgery Center
Job Titles that were requested:
• Inpatient Nursing: Unit Manager; CCP (2); CN III (3)
• Other Areas: Pharm Tech II; CN II (2); CN III; Sterile Processing Tech I, II,
and III; Surgical Coordinator; Sr. Custodian (2) ; Hyperbarics Tech; RN (2);
Manager; Traveler RN
Topics Reviewed During HR Interview
• License/Certification
• Competency Process
• Unit Specific or Position Specific Competencies
• Evaluations
• Orientation
• Job Descriptions
• Floaters
• Skills Fair
• Promotions/Management Training
3
Unit Specific Competencies
Insure these competencies are reviewed each year:
• POCT;
Fire Safety; Rapid Response Teams; Surgical Site Infections
(annual refresher on prevention and program specs)
Skills Fair:
•Include
basic nursing skills, but also unit specific items for each area
•Include
Contract Personnel in the Skills Day, such as Hyperbarics and
Wound Care
Interpreter Competencies:
•
Staff who interpret MUST be certified to work as an interpreter on the unit
•
Insure staff are aware of the policy
•
Differentiate between interpreting basic needs vs. health care discussion
•
Review staff’s role if they don’t have certification.
4
Moderate Sedation
• Unit Specific Competencies:
Moderate Sedation: Questions from the surveyor:
•Is
it a competency requirement? Do they have to be a nurse? What
is the orientation/training time? How is this competency documented?
After they pass a test, who verifies their capability to perform? How
many cases would a nurse need to be observed doing? How many
return demonstrations until competent?
•Sedation
competency MUST stand alone as a line item
•Found
tests in the file that were not scored and did not have any
pass/fail parameters noted on test. Could not tell if person passed or
failed or whether test was reviewed. (applied to other tests in files
as well)
•This
•Be
must be annual competency
able to articulate these answers in a survey
5
Pharmacy Competencies
Reviewed Aseptic Compounding Competency
• Some
documentation for competencies are tests
• Must
also include details that offer evidence of each step that
was observed, assessed/scored and signed off
• Demonstrate/document
how employee learned to do their
competencies in addition to tests. Tests don’t stand alone.
• Bring
back up docs of competency information to interview
6
Contract Departments
• Unit Specific Competencies:
Contract Departments
Hyperbaric: Reviewed a tech in hyperbaric area who would
have responsibility of cleaning a machine
•
Need competency to be specific on each component of how to
clean the machine and its components
•
Competency has to stand alone
•
May be different procedures for cleaning different bodily fluids
– need to document each cleaning procedure
•
Include area in Skills Day
7
Contract Departments
• Unit Specific Competencies:
Contract Departments
Wound Care:
•
Make sure this department is included in Skills Day
•
Insure they assess same annual competencies, in addition to
specific ones for their area only
•
Treat them the same as a UCLA Department
•
POCT testing should be annual competency
•
Tests need to have legends to indicate pass/fail rate
8
Unit level Orientation/
Department Specific Orientation
•
Where are the environmental orientation topics documented?
(i.e. fire extinguishers)
-Day One
-Orientation and Annual Education Guide
-Dept./Unit Specific Orientation
-Fire Drills
-EC Rounds
•
How are contract employees oriented?
-Invited to Day One / Process has been set up with CORE Training
-Orientation and Annual Education Module
•
Are the orientation materials ever reviewed again after new hire?
-Articulate to surveyor where topics are covered
9
Floaters
•
All Floaters must be oriented to every unit they float to, including
RNs, Assts., RTs, EVS, etc…
•
Need to review key critical components
•
It doesn’t have to be full unit orientation, use abbreviated version
•
Key components:
-Emergency practices
-Infection prevention practices, i.e. transplant units vs.
med surg units
-Fire safety plan variations – emergency routes are
different
•
Orient/train with people from the areas they float to
•
Surveyor would like to see documentation in file as to where they
are trained/oriented if they float
10
Promotions
What are the steps to promote staff within the unit?
Scenario example – CN III to Charge Nurse
•
Bring documentation to HR interview of classes taken as evidence
of training/preparation and supporting material of content
•
Leadership training? Preceptor workshops? Where was she/he
taught those new skills?
•
Looking for conflict mgmt., critical conversations, interview skills
•
Bring course education content and not just a checklist of classes.
Interested in content of class
•
Assess key competencies for managers/charge nurses/ new
leaders who are promoting and assuming leadership role
New Leadership Orientation program started in Feb. 2016/monthly
11
Job Descriptions
•
On the JD page with the requirements/qualifications, please be
clear on what is checked off and identified.
•
Make sure this section is completed
•
If specialty certifications are required, be sure to include them on
JD in the requirements section. If section is blank, can raise
questions when it is a clinical position.
•
Be clear on whether requirement is preferred or required. Be
consistent across JDs.
•
Be consistent on baseline education / knowledge required for
anyone entering that job
•
Be consistent on experience required
•
If a manager, be consistent with managerial experience
requirements
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Findings Received During Mock Survey
Human Resources Chapter
Unit Specific (HR 01.04.01)
The hospital provides orientation to staff.
• Float staff do not receive unit specific orientation
Competencies (HR 01.06.01)
Staff are competent to perform their responsibilities.
•
No competencies for CNA doing translation
•
No specific sedation competencies in Cath Lab
•
Registry CSD and CSD had no competencies
•
Peds infusion nurse did not have chemo competencies up to date
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Continued Preparation
•The Human Resources Chapter is about people management throughout the
organization.
•The Human Resources Dept. is your gatekeeper of files and can identify and explain
the requirements needed for all departments.
•Meeting the standards in that chapter comes the contributions of every department
and how the staff are oriented, trained, assessed and evaluated by their managers
and educators and how that is all documented and articulated.
•Competency and Education binders / Back-up docs must be brought to HR Interview
to support forms/summary sheets in file.
•Depts. need to get completed paperwork to HR in a timely fashion for filing so we
are not asking for docs the night before the HR Interview. Let’s eliminate that stress.
•Primary Source Verification remains priority!
•HR team is doing rounds to review personnel files with dept. reps and their
supervisors/managers.
•Invite HR to departments meetings; huddles; inservices; file review sessions