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Human ResourcesHuman ResourcesStandardsStandards

September 2008

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The goal of the HR Chapter is to ensure that the organization:

Provides an adequate number of staffProvides competent staffOrients, trains and educates staffAssesses, maintains and improves staff competence

There are 8 HR Standards Three under PlanningThree under Orientation, Training & educationTwo under Competence Assessment

Management of Human Management of Human Resources ChapterResources Chapter

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HR.1.10 --The organization provides an adequate number and mix of staff consistent with the organization's staffing plan.

Do you have an up-to-date staffing plan?Are staff familiar with the staffing plan for the department?What do you use for benchmarking methods?

Do you use data from similar hospitals to put your staffing plan together?

What do you flex for?Acuity, volume, patient needs, number of appointments, number of patients.

Do you have enough staff? Per Diem pool is used when necessary, Overtime, Registry, etc.

How do you cover when a number of people are out? Every department has a staffing plan. Staffing plans are based on approved budget & scope of services

Staffing Plan Template is on the HR website

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2005 HR Standards2005 HR StandardsHR.1.20 -- The organization has a process to ensure that a person’s qualifications are consistent with his or her job responsibilities.

Every employee must have a current Job Description (JD)

A signed copy of the latest JD must be on-fileEnsure that you use latest format

Well defined Job Descriptions Five JD/PE templates have been created on the website:

Administrative; Unlicensed Clinical; Licensed Clinical; RN; Management Age specific requirements must be listed, assessed and evaluated yearly Simplify the JDs & PEs as much as possible; Ensure that only

requirements are listed. Any changes must be updated timely on the JD

Did you receive a copy of your JD? Is it up-to-date?Every employee receives a copy of their JD during department orientation.During the Performance Evaluation review, the job description is reviewed againIf the employee’s duties have changed, the job description is updated. Input from both the employee and supervisor is taken into consideration.

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HR.1.30 --The organization uses data and clinical/service screening indicators and human resources screening indicators to assess and continuously improve staffing effectiveness.

o Human Resources Indicators: RN Hours per Patient Day

o Clinical/Service Indicator: Number of Patient Falls

o Human Resources is working with Nursing staff to gather data and information on patient falls. Further drill downs will be conducted in Nursing Units where falls occur.

o Human Resources Indicators: FTE/AOB

o Clinical/Service Indicator: Overall Satisfaction with Care question on NRC Patient Satisfaction Survey

o Human Resources is working with Nursing Units to do some drill downs in areas where there is a significant increase or decrease in the patient satisfaction scores from one quarter to the next.

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HR.2.10 -- Orientation provides initial job training and information.All employees, including contract staff, must complete the following within 30 days of their hire date:

General Orientation SessionHIPAA Security Module HIPAA Confidentiality ModuleCorporate Compliance Module

Department/Job Specific Orientation – FORM must be completed by the supervisor or preceptor and employee within 30 days -- Environment Care part must be completed on the first day

TEMPLATE should be expanded to include items unique to your areaReview Patient Safety standardsEnvironment of Care itemsCultural Diversity & SensitivityDepartmental policies

Volunteers should always be directed to the Volunteer Office for orientation and training.

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HR.2.20 -- Staff members, licensed independent practitioners, students and volunteers can describe or demonstrate their roles and responsibilities based on specific job duties or responsibilities relative to safety.

Make sure you document on the Department/Job Specific Orientation form that staff were oriented and trained on the following:

Potential risks within your areaActions to eliminate, minimize or report risksProcedures to follow in the case of an eventProcesses for reporting common problems, failures and user errors

How do you report any patient safety issues, near misses and errors?

There is a chain of command within each area. Make sure ALL staff are familiar with itEncourage all staff to report any unsafe process and unsafe physical conditionsDocumentation is critical. If no one knows about it, things may not be fixedThe link to the Event Reporting System can be found on the MedNet homepage

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2005 HR Standards2005 HR StandardsHR.2.30 -- Ongoing education, including in-services, training and other activities, maintains and improves competence.

Document all education (one-time or on-going)Encourage staff to attend trainings

Trainings offered: House-wide annual educationOn-going unit/department in-servicesPatient safety trainingEnvironment of Care classesManagement Training CourseHouse-wide Training Needs Assessment Survey – every 2 years

Classes offered through: HR, CHR, Nursing Research & Education, MCCSPerformance Evaluation - “future plans and goals”

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HR StandardsWhat type of management training is offered in the organization?

Directors and Managers should review the following

Leadership Orientation Manual (available on-line) Management Training Courses (see schedule on HR website)Campus HR training schedule

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HR.3.10 Competence to perform job responsibilities is assessed, demonstrated, and maintained.

 

Initially, ALL employees must have competencies completedAll major skills of job are assessed.

Age Specific Training Module & Post Test must be reviewed by patient care and patient care support staff (as appropriate).

Initial Competency Assessment form must be completed for all new hires and transfers into new positions within six months of the hire date

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Annually, only these skills must be reviewed: high risk, low frequency; high risk, high frequency (as appropriate);problem prone; required by regulatory agencies, i.e., blood administration and accuchekpatient safety related; new competencies;not routine, daily tasks  

Annual Age Specific Competencies-documented in PE

An Annual Competency Assessment form must be completed for staff working in:

In patient care positionsPatient care support positionsOther positions that meet the requirements shown above

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2005 HR Standards2005 HR Standards HR.3.20 The organization periodically conducts

performance evaluations. 

Performance Evaluation Policy

According to Hospital Policy, all employees must be evaluated every 12 monthsThere is a two month grace period for signature and reviewWhen an employee transfers to another unit/department before the 12 month period, an initial competency assessment & a Department Specific/Job Specific Orientation are completed in the NEW department and a new performance evaluation period starts on the day of the transferThe evaluation period must cover 12 months or less

PE compliance must be at 98% during a Joint Commission visitThe next visit will be unannounced so, we have to be at 98% at all timesThe last 18 months prior to a visit are also looked at

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Back Up DocumentationBack Up Documentation

Back- up documentation MUST be available for the surveyors to review. 

Back-Up Documentation must always accompany initial and annual competency assessment summary sheets for all competencies listed. 

The back-up documentation binder must include the following: Each competency listed on the summary sheet must have a back-up document listing steps of competency. The back-up documentation must match up with each competency listed on the summary sheet.

What did you observe the employee do to deem them competent?        i.     Have a checklist listing all the steps.

ii.     Include the checklist the preceptor works from to ensure that nothing was missing during the assessment process.

 What different steps did the employee take for the different age groups?

     i.     Have a checklist for each age group, if applicable.

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Back Up DocumentationBack Up Documentation

Policies and protocols used.            i.     What policies and procedures do you follow?            ii.     Put copies of them inside your binder. 

Tests used. Not Applicable for Inpatient Nursing Dept.(Self Study Guide test only)

            i.     What tests do you use to ensure that the employee is competent?             ii.     Put copies of the tests in the binder.             iii.     Put a statement that clarifies the passing score for each test.

Include any other material used to ensure that the employee is competent and ready to work independently.

 The back-up documentation should also be sorted by age groups if applicable.

 Binders should be separated by title, if the competencies required are different for each title.

 

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Performance Evaluation Policy

Staff Rights PolicyEmployees may request not to participate in care or treatment of a patient based on cultural, religious or ethical beliefs

departments must document request ahead of timepatient care may not be interrupted at any time

What do you do if you don’t want to take care of a patient?Talk to your supervisorComplete request form as soon as possible, so that supervisor is aware for staffing purposes

Forensics PolicyWhen a prisoner is admitted to the hospital, forensic staff is educated by security on our emergency procedures and codes.When a prisoner comes to Med Plaza for an appointment, department must notify UCPD to alert them.

HR PoliciesHR Policies

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HR FormsHR FormsTo access the most up-to-date HR FormsPlease go to http://hr.healthcare.ucla.edu/

Click on the

Employee section

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Staff

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Staff

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HR Tracking SystemHR Tracking System

Do you have access to the HR Tracking System?

Call Maria Olegario at x48622 to get your access

Review your own compliance regularly, prior to reports being sent out.

Ensure compliance for all your accounts

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HR Tracking SystemHR Tracking System

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Services

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HR Tracking SystemHR Tracking System

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Applications

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HR Tracking SystemHR Tracking System

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Tracking

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HR ContactsHR Contacts

Kety Duron at 40500Debby Brown at 40500Salpy Akaragian at 46903Maria Olegario at 48622 (for access to the HR tracking system)