Human Resources Chapter The Joint Commission Mock Survey Results February 2016

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 Personnel Files Requested

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 must be annual competency Be 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 12

Findings Received During Mock Survey Human Resources Chapter Unit Specific (HR ) The hospital provides orientation to staff. Float staff do not receive unit specific orientation Competencies (HR ) 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 13

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 ___ ___.3 Continued Preparation