2010 HR Standards Management & Staff Education Health System Human Resources March 2010

Human Resource Standards Overview The HR Standards are the responsibility of HR but we need a strong partnership with the departments in order to meet the requirements HR Standard Topics include - License, Certification, Registration Verification: Upon Hire and Renewal Job Description Orientation: House-wide and Dept./Unit Specific Education, Experience and Clearance to Work Annual Education and Training Competencies: Initial and Annual Performance Evaluation Other Personnel: Non-Employees brought in by independent licensed practitioners/students/volunteers/temporary staff Measurement: Competency Tracking System Documentation

RFI (Request for Improvement) for HR Immediate citation RFI (Request for Improvement) for HR Staff without a current TB test should not be scheduled to work.

HR Joint Commission Chapter Why is the HR Compliance important? HR Joint Commission Chapter defines the standards and expectations The right thing to do in managing people in a Health Care environment We must be at 100% in all areas to avoid citations Entry must be completed timely to be reflected on the bi-weekly reports During Joint Commission Surveys and DPH visits There are always file reviews to ensure appropriate documentation of competency assessment, performance evaluations, training documentation

Job Descriptions - Standard HR.01.02.01 The hospital defines staff qualifications specific to their job responsibilities. Do you have an up-to-date Job Descriptions (JDs) for each position/staff member? JDs derived from the Scope of Service and Staffing Plans for each dept./unit Every employee must have an up-to-date Job Description JD/PE templates are on the HR Website under HR Operations/Forms new content and language as of 1/1/09 that includes the CICARE Standards and Workplace Conduct policy JDs must be reviewed and signed by new hires during Dept Specific Orientation Signed JDs must be placed in the employee files 100% Compliance is required

Specific Competency – Standard HR.01.02.01 New for 2010: If blood transfusions and intravenous medications are administered by staff other than doctors, the staff members have special training for this duty. Covered in Nursing Orientation Specific competencies are completed on the units Part of competencies in Outpatient Areas for job titles and clinics that have the particular scope as part of their practice 100% Compliance is required

2010 Joint Commission Priority License, Certification & Registration Verification – Standard HR .01.02.05 2010 Joint Commission Priority It is your responsibility to verify license & certification authenticity Primary Source verification is required for all licenses, certifications and registrations upon hire and prior to expiration or at renewal time. Copies of a licenses or certifications are no longer acceptable A copy of the primary source verification from the Board’s website must be printed Renewals: On or prior to the expiration date of the license/certification The copy is date stamped electronically / one day after the expiration date it is considered late and hospital is cited New Hires: Prior to start date or on the employee’s first day of work. Employees cannot work with an expired license. Please make sure that any excused delay, employee on leave, employee was suspended is documented in the file A hospital can lose its operating license if staff are practicing with expired credentials required for the job. 100% Compliance is required

Standard HR.01.02.05 Elements of Performance for HR.01.02.05

Please do periodic checks on RN licenses to ensure no midyear disciplinary actions

Education, Experience & Clearance to Work – Standard HR.01.02.05 Human Resources Completes These Requirements – An Employee Can Not Start until All Clearance Is Completed Education and Experience verification - Staffing Office has a clearinghouse to verify a degree is required by the JD and a vendor to check references. Criminal Background Check on the applicant as required by law and regulation or hospital policy. Criminal background checks are documented. Completed in Human Resources. Never make an offer until the results of the background checks are completed. Pre-Employment Health Screenings as required by law and regulation or hospital policy. Completed by OHF, which is the official office of records. Health screenings must be completed prior to the start date. 100% Compliance is required

Student Requirements and Oversight Standard –HR. 01.02.07 Do you have students in your area? How do you orient & train them? Staff oversee the supervision of students when they provide patient care, treatment, and services as part of their training. Same Orientation and Education requirements and documents as staff: Copy of Resume or completed Application for Assignment Verification of (3) signed Abuse Reporting Statements ~ (child, domestic, elder) Verification of signed Confidentiality Statement Verification of completed HIPAA Training Module and Post Test Evidence of Medical Criteria Clearance/TB Testing/Drug Screening completion Evidence of Background Check completion Verification of valid License/Certification/CPR Card (if applicable) Annual Education Guide and Post Test (Fulfills Orientation) Review of Restraints Competency Module (if applicable) NOTE: Original license, certification and/or CPR card must be presented to UCLA Health System personnel before starting any assignment. These documents must be current at all times.

Orientation Standard -- HR.01.04.01 New Employee Orientation & Dept Specific Orientation HR Responsibility -- All staff must complete New Employee Orientation within 30 days of hire date Covers the following: Introduction to CICARE; Hospital-wide Policies & Procedures; Fire & Safety; Infection Control Post test is completed in class or online. Forms placed in personnel file. Department Responsibility -- Department Unit-Specific Orientation must be completed within 7 days for the safety part and 30 days for the rest Additional Orientation Programs include: Nursing Orientation and Ambulatory Care Orientation 100% Compliance is required

Department/Unit Specific Orientation – Standard HR.01.04.01 2010 Joint Commission Priority Complete the Dept Specific Orientation form for every new employee/transfer Review the Environment of Care items within the first day of employment and no later than the first week. Review all other parts within 30 days of the date of hire Review and sign Job Description during this time Review specific job duties, including those related to infection prevention and control and assessing and managing pain. Review sensitivity to cultural diversity based on their job duties and responsibilities. Review patient rights, including ethical aspects of care, treatment, and services and the process used to address ethical issues based on their job duties and responsibilities 100% Compliance is required

New Hire Requirements – Standard HR.01.04.01 HR Responsibility Orientation also includes NEW HIRE PROCESS: Abuse Reporting Forms (3 forms to sign – child, elder, domestic) Confidentiality Form ON-LINE REQUIREMENTS: Must be completed within 30 days of hire Located on Mednet Home Page under Employee Required Training Code of Conduct / Compliance Quiz (one time only) HIPAA Education & Training Program (one time only) C-ICARE Annual On-line Training (annual) UCOP Compliance Briefing (annual) – NEW REQUIREMENT as of 2/10 100% Compliance is required

Ongoing Education and Training – Standard HR.01.05.03 Staff participate in ongoing education and training in order to maintain or increase their competency. whenever staff responsibilities change. review the needs that are specific to the patient population served by the hospital. enhance the skills of team communication, collaboration, and coordination of care. includes information about the need to report unanticipated adverse events and how to report these events. Includes participation in fall reduction activities Includes addressing the changes in a patient’s condition What education & training do your provide to staff? What is your education plan? How do you find out the educational needs of staff? How do you document education & training? 2010 Joint Commission Priority

Annual Education – Online Staff Employee Handbook Quiz Staff participate in ongoing education and training. All staff meet the Annual Education requirement by completing the Annual Education Guide found on the Mednet home page under Employee Required Training. Competency Tracking System shows who is out of compliance so that you can remind staff to complete the module online

Standard HR.01.05.03 Elements of Performance for HR.01.05.03 Annual Education

Initial Competencies --Standard HR.01.06.01 Initial Competency Assessment – Dept Responsibility Competencies are all the skills required to perform the job. As defined on the job description. All skills must be assessed successfully prior to the employee being able to work independently on the floor. Initial Competency Assessment may take up to six months Staff competence is initially assessed and documented as part of orientation Performed at point of hire or transfer to a new position An individual with the educational background, experience, or knowledge related to the skills being reviewed assesses competence. The INITIAL COMPETENCY ASSESSMENT FORM must be used and the appropriate assessor /preceptor/educator/supervisor must initial the form as each competency is successfully completed. Signature and date is required when all competencies have been assessed. 100% Compliance is required

Annual Competency – Standard HR.01.06.01 Annual Competency Assessment – Dept Responsibility Staff competence is assessed and documented once every three years, or more frequently as required by hospital policy or in accordance with law and regulation Per UCLA Health System Policy - Only the following competencies should be assessed annually: HIGH RISK/LOW FREQUENCY PROBLEM PRONE AREAS REGULATORY REQUIREMENTS, i.e. blood administration; blood glucose NEW COMPETENCIES Routine daily tasks may not be reviewed annually unless the employee is not able to perform them The hospital takes action when a staff member’s competence does not meet expectations Action plans are developed with established timelines for review 100% Compliance is required

Performance Evaluation – Standard HR.01.07.01 The hospital evaluates staff performance The hospital evaluates staff (and non employees brought in by licensed independent practitioner) based on performance expectations that reflect their job responsibilities. The hospital evaluates staff performance once every three years, or more frequently as required by hospital policy or law. This evaluation is documented. According to UCLA policy, the PE is completed annually by the supervisor Use JD/PE form from the on-line templates on HR Website Performance Evaluation process is a two-way process Allow staff to discuss their performance with the supervisor Discuss their training needs and document those so that you can follow up on them Annual planning is also done during this time Goals and objectives for the next year should be established 100% Compliance is required

Competency Tracking System Do you have access to it? Did you receive training on how to use it? Contact Debby Brown or Audrey Lazaro to set up a private session at x40500 Is your department appropriately listed on the Competency Report? If not, contact Maria Olegario at x40500 REMINDERS: If a competency does not apply to a staff member, you need to indicate that on the tracking system, otherwise the reports will show you out of compliance. Reports are based on the entry. Please do your entry timely & accurately. Make sure the dates on the forms match the dates in the system. Verify licenses/certifications through primary source before start of work and prior to renewal. Print online verification for file. DON’T HESITATE TO CALL US FOR QUESTIONS!

Survey HR Related Questions How do you determine your staffing levels? Type(s) of staff available to serve the customer. License/certification and other education requirements Number of staff (by category, if applicable) Availability of Staff (scheduling, coverage, on-call arrangements) Acuity Methodology Skill mix and number of staff required Acuity system in place. Benchmarking a. What data do you collect and how do you use the data?  Scope of Service along with budgets, the following elements are included: Availability of Service Hours of service How patients, etc., access their service during “regularly” scheduled periods How patients, etc., access their services during “off-hours” Patient care areas flex with volume and acuity

Survey HR Related Questions What is your process for competence assessment, maintenance and improvement? Initial & Annual Competency Assessment (refer to pages 18 & 19) How do you orient staff to your hospital, their job responsibilities and/or their clinical responsibilities?   General Orientation -- cover all topics – policies, safety, HIPAA, Inf. Control Department/Unit Specific Orientation – within 30 days of the date of the hire Review Job Descriptions/Initial Competency Assessment Process Before the orientation is completed employee is assigned a “buddy” for any emergency situation DETAILS: Throughout the year, education takes place through fire drills, EC rounds, EC surveys, EC education posters In case of emergency before completion of Orientation in dept., new employee is paired up with another dept. employee for safety

Survey HR Related Questions What on-going staff education and training do you provide? How do you promote job-related educational and advancement goals of staff members? On-going education and training classes are offered throughout the year Managers are trained to assess learning needs specific to individuals and their unit/dept. It’s part of Performance Evaluation, part of goals and education planning section It can be part of competency assessment process as well Each department is responsible for offering on-going development courses HHR offers leadership courses Web site for education resources Paid development time Web access to information for employees Vendor provides training for new equipment Staff offer suggestions for topics – some staff members may present or another speaker in house Interview staff during Skills Day and ask them what they’d like dept. to review

Survey HR Related Questions What is your population competencies process? Age Specific competency training New hires with patient contact are tested (Age Specific Module) and observed during their orientation period No patient contact, basics are reviewed at General Orientation and annual education Cultural Competencies New Hire Orientation view a tape to introduce all new hires on the subject In patient areas, more in-depth training is provided in unit specific orientation, in department orientations Self study module with a test - optional On-going education and training classes are offered throughout the year Patient Population group – Consistent process on floors/units. Individualize as necessary according to patient need  

Survey HR Related Questions How do you Communicate changes & new topics to the staff? Chain of command/team dynamics Huddles, Staff Meetings, HOT,  What are your vacancy and turnover rates?