Transcript 2010 HR Standards Competency Tracking System

2010 HR Standards
Competency Tracking System
Health System Human Resources
November 2009
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Standard HR.01.02.01
Elements of Performance for HR.01.02.01
The hospital defines staff qualifications ~ Job Descriptions
 EP: The hospital defines staff qualifications specific to their job
responsibilities.
 Every employee must have an up-to-date Job Description
 JD/PE Templates are on the HR Website under HR Operations/Forms
http://hr.healthcare.ucla.edu/06_header_emp_forms.html
 new content and language as of 1/1/09
 JDs must be reviewed and signed by new hires during Dept Specific
Orientation
Signed JDs must be placed in the employee files
We must be at 100% in JD compliance at all times
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Standard HR.01.02.01
Elements of Performance for HR.01.02.01
New for 2010:
 EP: 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
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Standard HR.01.02.05
Elements of Performance for HR.01.02.05

The organization verifies staff qualifications.
 LICENSE, CERTIFICATION & REGISTRATION VERIFICATION
 EP: Hospital verifies all licenses, certifications and registrations with the Primary
Source and documents this verification upon hire and at time of renewal.

You must print the electronic copy of the verification form from the Board’s website or
document the date and number you called on the telephone verification form.

Electronic verification is preferred.

MUST be completed prior to start date or at the latest on the employee’s first day of
work. Renewal verification must be done prior to the expiration date. Otherwise,
employee cannot work.

A hospital can lose its operating license if staff are practicing with expired credentials
required for the job
 100% COMPLIANCE IS REQUIRED AT ALL TIMES!
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Standard HR.01.02.05
Elements of Performance for HR.01.02.05
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Standard HR.01.02.05
Elements of Performance for HR.01.02.05
 EP: The hospital verifies and documents that the applicant has the
education and experience required by the job responsibilities

If the education is a prerequisite for a license, certification or registration, the
Board will verify before granting the credential

Staffing Office has a clearinghouse to verify a degree and a vendor to check
references
 EP: The hospital obtains a 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.
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Standard HR.01.02.05
Elements of Performance for HR.01.02.05
 EP: Staff comply with applicable health screening as required by
law and regulation or hospital policy. Health screening compliance
is documented.
 Completed by OHF, which is the official office of records. Health
screenings must be completed prior to the start date.
SUMMARY:
The hospital uses the following information to make decisions about staff
job responsibilities:
 - Required licensure, certification, or registration verification
 - Required credentials verification
 - Education and experience verification
 - Criminal background check
 - Applicable health screenings
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Standard HR.01.02.05
Elements of Performance for HR.01.02.05
 EP: Before providing care, treatment, and services, the hospital
confirms that non-employees who are brought into the hospital by
a licensed independent practitioner to provide care, treatment, or
services have the same qualifications and competencies required
of employed individuals performing the same or similar services at
the hospital.
 EP: Physician assistants and advanced practice registered nurses
who practice within the hospital are credentialed, privileged, and
re-privileged through the medical staff process or an equivalent
process.
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Standard HR.01.02.07
Elements of Performance for HR.01.02.07
 The hospital determines how staff function within the
organization.
 EP: All staff who provide patient care, treatment, and services
possess a current license, certification, or registration as required
by law and regulation.
 EP: Staff who provide patient care, treatment, and services
practice within the scope of their license, certification, or
registration and as required by law and regulation.
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Standard HR.01.02.07
Elements of Performance for HR.01.02.07
 EP: Staff oversee the supervision of students when they provide patient care,
treatment, and services as part of their training.

Orientation and Education requirements and documents:
1.
Copy of Resume or completed Application for Assignment
2.
Verification of (3) signed Abuse Reporting Statements ~ (child, domestic, elder)
3.
Verification of signed Confidentiality Statement
4.
Verification of completed HIPAA Training Module and Post Test
5.
Evidence of Medical Criteria Clearance/TB Testing/Drug Screening completion
6.
Evidence of Background Check completion
7.
Verification of valid License/Certification/CPR Card (if applicable)
8.
Annual Education Guide and Post Test
9.
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.
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Standard HR.01.04.01
Elements of Performance for HR.01.04.01
 The hospital provides Orientation to staff
All staff must complete New Employee Orientation within 30
days of hire date

EP: The hospital determines the key safety content of orientation provided to
staff

EP: The hospital orients its staff to the key safety content before staff
provides care treatment, and services. Completion is documented.

EP: Includes relevant hospital-wide and unit-specific polices and procedures
 Completion of Hospital Orientation and Department Specific Orientation
is documented
 Post test is completed in class or online
~ 100% Compliance is required.
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Standard HR.01.04.01
Elements of Performance for HR.01.04.01
DEPARTMENT SPECIFIC ORIENTATION

Select the Dept Specific Orientation form from the HR website
•
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
 EP: Specific job duties, including those related to infection prevention
and control and assessing and managing pain.
 EP: Sensitivity to cultural diversity based on their job duties and
responsibilities.
 EP: 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.
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Standard HR.01.04.01
Elements of Performance for HR.01.04.01
 EP: The hospital orients external law enforcement and security
personnel on the following:
- How to interact with patients
- Procedures for responding to unusual clinical events and
incidents
- The hospital’s channels of clinical, security, and administrative
communication
- Distinctions between administrative and clinical seclusion and
restraint

Policy HS 7311: Security for Prisoner/Patient Forensic Staff
Orientation Education
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Standard HR.01.04.01
Elements of Performance for HR.01.04.01
Orientation also includes NEW HIRE PROCESS:

Abuse Reporting Forms (3 forms to sign – child, elder, domestic)

Confidentiality Form
~ 100% compliance is required
 ON-LINE REQUIREMENTS:


Must be completed within 30 days of hire
Located on Mednet Home Page under Employee Required Training
 Compliance Quiz
 HIPAA Education & Training Program
 C-ICARE Annual On-line Training
~ 100% compliance is required
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Standard HR.01.05.03
Elements of Performance for HR.01.05.03
 Staff participate in ongoing education and training.
 EP: Staff participate in ongoing education and training to
maintain or increase their competency. Staff participation is
documented.
 EP: Staff participate in ongoing education and training whenever
staff responsibilities change. Staff participation is
documented.
 EP: Staff participate in education and training that is specific to the
needs of the patient population served by the hospital. Staff
participation is documented.
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Standard HR.01.05.03
Elements of Performance for HR.01.05.03
 Staff participate in ongoing education and training.
 EP: Staff participate and training that incorporates the skills of
team communication, collaboration, and coordination of care. Staff
participation is documented.
 EP: Staff participate in education and training that includes
information about the need to report unanticipated adverse
events and how to report these events. Staff participation is
documented.
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Standard HR.01.05.03
Elements of Performance for HR.01.05.03
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.
 Educational topics reviewed and documented in
departments, according to HR Standards, include:

Infection prevention and control

Assessing and managing pain

Ethical aspects of care, treatment and services

Patient population training

Team communication, collaboration and coordination
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Standard HR.01.05.03
Elements of Performance for HR.01.05.03
Annual Education
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Standard HR.01.06.01
Elements of Performance for HR.01.06.01

Staff are competent to perform their responsibilities

INITIAL COMPETENCY ASSESSMENT

EP: The hospital defines the competencies it requires of its staff who provide
patient care, treatment or services


Competencies are all the skills required to perform the job. These are
found on the Job Description.
EP: The hospital uses assessment methods to determine the individual’s
competence in the skills being assessed. This may include test taking, return
demonstration, or the use of simulation.
 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.
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Standard HR.01.06.01
Elements of Performance for HR.01.06.01

EP: 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
assessor must initial the form as each competency is successfully
completed. Signature and date is required when all competencies
have been assessed.
 EP: Staff competence is initially assessed and documented as part of
orientation
100% Compliance is required
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Standard HR.01.06.01
Elements of Performance for HR.01.06.01
ANNUAL COMPETENCY ASSESSMENT
 EP: 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
 EP: The hospital takes action when a staff member’s competence does not meet
expectations
100% Compliance is required
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Standard HR.01.06.01
Elements of Performance for HR.01.06.01
ANNUAL COMPETENCY ASSESSMENT
 If you are in an area where your competencies are not required to be reviewed
ANNUALLY for some or all of your staff members, please confirm with Human Resources and
then indicate that in the HR Tracking System.
 You need to mark the tracking system appropriately to reflect that there is no need for
annual competency assessment, OR THE SYSTEM WILL INDICATE THAT THE DEPARTMENT IS
OUT OF COMPLIANCE
 Change annual competency field from Y to N if not required.
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Standard HR.01.07.01
Elements of Performance for HR.01.07.01


The hospital evaluates staff performance
EP: The hospital evaluates staff (and non employees brought in by licensed independent
practitioner) based on performance expectations that reflect their job responsibilities.

EP: 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 AT ALL TIMES!
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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
 Reminder: 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.
 Reminder: 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.
 DON’T HESITATE TO CALL US FOR QUESTIONS
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COMPETENCY TRACKING SYSTEM
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