1. Joint Commission Management of Human Resources Leadership Meeting September 22, 2010

2. About the Chapter Hospital must: establish and verify staff qualifications orient staff provide on-going training assess staff competence and performance. (i.e., employees, students, volunteers, contractors or temporary agency personnel)

3. HR.01.01.01 The hospital has the necessary staff to support the care, treatment and services it provides. Methods used to determine staffing Staffing Plans Budget Formulation

4. HR.01.02.01 The hospital defines staff qualifications specific to their job responsibility. Job descriptions Competencies Regulatory Requirements

5. HR.01.02.05 The hospital verifies staff qualifications. Licensure Verification - Primary Source Background Checks References CORI Checks Health Screening Non-employees same process

6. HR.01.02.07 The hospital determines how staff function within the organization. Job descriptions Current licensure/certification/registration Practice within scope of L/C/R Staff supervises students

7. HR.01.04.01 The hospital provides orientation to staff. Hospital orientation Department orientation Students, Volunteers, External Law Enforcement personnel Other Non-Staff

8. HR.01.04.01 (cont.) Covered areas include: key safety content, environment of care & infection control PRIOR TO PROVIDING CARE Documentation

9. HR.01.05.03 Staff participate in ongoing education and training. Training when duties change To increase knowledge Appropriate to populations served Reporting unanticipated adverse events Documentation

10. HR.01.06.01 Staff are competent to perform their responsibilities. Use assessment methods (direct observation, demonstration, simulation, etc.) Qualified individuals assess staff Initial assessment as part of orientation Competence assessed at least once every 3 year (does not need to done same time as evaluation)

11. HR.01.06.01 (CONT.) Corrective action if no improvement Based on populations served Applies to non-employees Documentation

12. HR.01.07.01 The hospital evaluates staff performance. Annually within 90 days of due date Based on performance expectations described in job description Applies to non-employees

13. Survey Prep Checklist Current Job Description – Review & Update License/certification/registration (prior to expiration) Orientation - hospital/department (Ees/non-Ees) Life safety for new hires before attending monthly hospital orientation Initial competency assessment as part of orientation Annual education fair On-going Education – documentation

14. Checklist cont. Competencies (including age specific every 3 yrs) Performance Evaluation (timely <90 days) Contract personnel – same requirements as existing staff Keep file on temps

15. Competence Assessment Session Methods used to determine staffing adequacy; frequency of measurement Competency Validation at Hire Competency Validation at Orientation On Going Competence Competency assessment for contracted staff Other topics discovered during tracer activity