Human Resources Department The Joint Commission Survey Results August 2013

 Competency Interview and File Review both occurred on Day 4 of survey.  Last minute change in schedule moved file review to morning time.  Many thanks for all those who jumped in to get the files and accompanying documents over to the medical center quickly when interview time changed.  Focus for files was on performance evaluations for last three years; licenses and credentials, back-up documentation to support competencies and education and health information.  Surveyors were very detailed in what they were looking for.  Three surveyors reviewed files at the same time with 3 HR staff and appropriate managers.  Did not have all back-ups docs available when file was called for review. Provided back-up docs later in day.  Decentralized system proved to be challenging to maintain all required documents. HR Chapter The Joint Commission Survey Results

19 Files were requested from the following departments /units:  Inpatient Nursing: Float Pool; L&D; 6 East; 4 ICU; 7 North; 7 ICU  Other Areas: Spiritual Care; ED; Bone Marrow Transplant; Speech Pathology; Orthotics and Prosthetics; Pharmacy; Radiation Oncology; Rehab-NRRU Job Titles that were requested:  Inpatient Nursing: PD RN; Traveler RN; CN I, CN II; AN II; Unit Manager  Other Areas: Pediatric Chaplain; Clin Lab Manager; Dept. Manager; Emerg Trauma Tech; AN I; MSO II; MSO III; CN III; CN II; Rad Ther Tech; OT IV; Staff Pharmacist HR Chapter The Joint Commission Survey Results

O BSERVATIONS & F INDINGS  Centralized system for Nursing files resulted in positive feedback from surveyors.  All required docs found in Nursing files (3 yrs of licenses, competencies and evals).  Compliments from Surveyors on Nursing Filing System and process.  Competency and Education binders made available to support forms in file.  Asked for three years of performance evaluations in every file.  Back-ups docs were not all readily available to support summary sheets in file.  Need to get completed paperwork to HR from departments in more timely fashion for filing. Will be implementing guidelines with timeframes.  Important for departments to stay on top of health information to insure entry.  Primary Source Verification remains priority! * Two weeks after survey, the HR finding for performance evaluations was overturned when HR provided evidence of overall organizational compliance. TJC changed score from noncompliant to compliant. HR Chapter The Joint Commission Survey Results

Observations and Findings: Steps Going Forward Back-Ups Docs  It’s very important that every competency summary sheet has material readily available to support task.  Departments must have process/binder/system to share information used to support competency during file review sessions. Primary Source Verification  We will be sending out a request for every area to identify the job titles in their department that have credentials required and share the renewal timeframes.  Must create updated spreadsheet with every credentialed title for the organization. *Setting up new contract with outside company that will verify all licenses for health system upon hire and renewal. HR Chapter The Joint Commission Survey Results

Observations and Findings: Steps Going Forward Filing process  Due to centralized and non-centralized combination process currently set up for personnel files in medical center for non- inpatient nursing files, we must have guidelines for submitting paperwork in timely and reliable fashion.  If we can’t accomplish this, we will move to centralizing all files throughout organization in HR. Personnel Files  Converting to Nursing file format. HR Chapter The Joint Commission Survey Results

Competency Interview Topics Discussed:  Recruiting, Interviewing and Hiring Process  Nursing Turnover  Competency Process  Orientation Programs  Education Opportunities  Thirty managers, supervisors and educators participated.  Shared department processes. Collaborative effort.  Competency binders and materials were shared. Impressive interview. 7

Upcoming VAD Survey  VAD Survey is August 12 th and 13 th.  There will be a file review and competency interview.  Those areas who work with any VAD patients, please verify documents are up to date in file and any paperwork that needs to get to HR is delivered by Monday, Aug. 12th.  Must have all license verifications, evaluations, competencies and education docs in personnel file.  Managers/Educators must bring supporting docs to interview to back-up summary sheets in file. 8

Additional Information CPR Cards  Handwritten cards are now allowed again as long as they are legible.  AHA removed the requirement for computer generated or typed cards only. Flu Survey  A flu survey will be announced by OHF in Sept/Oct. HR Tracking Field has 8/31/13 expiration date for organization. i. No survey available now. ii. Wait for announcement. iii. Then have your staff complete survey. 9