Department Representative Meeting

Survey PreparationTo Meet

TJC StandardsMarch 2013

1

2

Standard HR.01.02.05The Hospital Verifies Staff Qualifications

Elements of Performance:

EP 1: When law or regulation (or hospital EP 2) requires care providers to be currently licensed, certified, or registered to practice their professions, the hospital both verifies these credentials with the primary source and documents this verification when a provider is hired and when his or her credentials are renewed.

Standard HR.01.02.05The Hospital Verifies Staff Qualifications

Supportive Finding / Explanation:• It is the responsibility of the department mgr/designee (or Nursing

Admin for RN and LVNs) to ensure that all individuals employed in a position requiring a license, CPR certificate, certification and/or degree, assure that primary source verification requirements are met and are current.

•It is the responsibility of the employees in such positions to maintain appropriate licensure, CPR card, certification, and to renew their license and/or certification prior to the expiration date.

•Staff cannot work with an expired license, not even with a cancelled check and copy of renewal paperwork.

•Current Primary Source Verification Printouts must be in all applicable personnel files.

3

Licensee Name: JANE BRUINLicense Type: Registered Nurse

License Number: 123456

License Status: ACTIVE Definition

Expiration Date: February 28, 2015

Issue Date: January 01, 1983 (2/28/13 was last day to verify on time)

County: LOS ANGELES

Actions: No

BOARD OF REGISTERED NURSING

Related Licenses/Registrations/Permits

No records returned

Disciplinary Actions

No information available from this agency

This information is updated Monday through Friday - Last updated: MAR-14-2013

(late primary source verification by 2 weeks)

Disclaimer

All information provided by the Department of Consumer Affairs on this web page, and on its other web pages and internet sites, is made available to provide immediate access for the convenience of interested persons. While the Department believes the information to be reliable, human or mechanical error

remains a possibility, as does delay in the posting or updating of information. Therefore, the Department makes no guarantee as to the accuracy, completeness, timeliness, currency, or correct sequencing of the information. Neither the Department, nor any of the sources of the information, shall be

responsible for any errors or omissions, or for the use or results obtained from the use of this information. Other specific cautionary notices may be included on other web pages maintained by the Department. All access to and use of this web page and any other web page or internet site of the Department

is governed by the Disclaimers and Conditions for Access and Use as set forth at California Department of Consumer Affairs' Disclaimer Information and Use Information.

Licensee Name: JOE BRUIN

License Type: Registered Nurse

License Number: 987654

License Status: ACTIVE Definition

Expiration Date: March 31, 2015

Issue Date: March 12, 2003

County: LOS ANGELES

Actions: No

BOARD OF REGISTERED NURSING

Related Licenses/Registrations/Permits

No records returned

Disciplinary Actions

No information available from this agency

This information is updated Monday through Friday - Last updated: MAR-14-2013

(Verified ON TIME!)

Disclaimer

All information provided by the Department of Consumer Affairs on this web page, and on its other web pages and internet sites, is made available to provide immediate access for the convenience of interested persons. While the Department believes the information to be reliable, human or mechanical error

remains a possibility, as does delay in the posting or updating of information. Therefore, the Department makes no guarantee as to the accuracy, completeness, timeliness, currency, or correct sequencing of the information. Neither the Department, nor any of the sources of the information, shall be

responsible for any errors or omissions, or for the use or results obtained from the use of this information. Other specific cautionary notices may be included on other web pages maintained by the Department. All access to and use of this web page and any other web page or internet site of the Department

is governed by the Disclaimers and Conditions for Access and Use as set forth at California Department of Consumer Affairs' Disclaimer Information and Use Information.

CPR Card Update

•As of 2/1/13, the American Heart Association (AHA) revised the format of the CPR cards. •The AHA requires the appropriate course completion cards be stamped, typed, or computer printed to reduce the risk of course completion cards being altered. •A valid AHA card is the original card with all the information printed (handwritten is not acceptable except for the card holder’s signature).

Standard HR.01.02.05The Hospital Verifies Staff

Qualifications

Elements of Performance:

:EP 3: The hospital verifies and documents that the applicant has the education and experience required by the job responsibilities.

Supportive Finding/Explanation•In the case that a degree/education is a prerequisite in order to receive a license, it is not required that a copy of the degree be kept in the file. Advanced degrees require proof in the file if required on JD, but no licensure is required for the position. •Staffing Office has a clearinghouse to verify degree and a vendor to check references.

Standards related to Cultural DiversityHR.01.04.01The Hospital Provides Orientation to Staff.EP5: The hospital orients staff on the following : Sensitivity to cultural diversity based on their job duties and responsibilities

Standard HR.01.05.03 Staff Participate In Ongoing Education and Training.EP 5: Staff participate in education and training that is

specific to the needs of the patient population served by the hospital.

LGBT Education

•A new video available for all UCLA Health staff called “Anyone Can Be An Ally, Speaking Up for an LGBT Inclusive Workplace. •This video demonstrates how anyone can be an “ally” in helping to create a respectful workplace that is inclusive of gay, lesbian, bisexual and transgender co-workers. •It can help employees and managers build bridges of mutual respect and provide skills to become allies who speak up on behalf of others. It is not about changing the beliefs of others, but about changing behaviors and putting a face on the issues confronting LGBT workers.

• You can find it on the UCLA Health System Human Resources website under Training and the e-Learning Library. Click on the Anyone Can Be An Ally link to watch.

•It is not a specific requirement yet, but it is an important issue to address and this video is a valuable tool to open up the discussion in a department staff meeting or huddle.

Training & Development / E-Learning Library

Department Specific Required Training

 

· All Can Prevent A Fall

· Annual EKG Competency

· Annual Nursing Department Test    

· Annual Stroke Training

· Annual Chemotherapy Training (Chemo Verified RNs Only)

· Anyone Can Be An Ally

· Call Bell Training for Med/Surg

· Call Bell - ICU Training

· Call Bell - Response Training - Video Only Training

· Call Bell - ICU Do-Over Video

· Call Bell - Response Training Video

· Capnography Learning Module for Procedural Sedation

· Central Venous Catheter Care Training (RN's Only)  

· Clinical Care Partners - Role In Safety

· HBS - Time and Attendance System

· HIPAA Privacy and Information Security Training for New Workforce Members

· Improving Patient Experience Through Communication About Medication

· MedSled Training

· Safe Patient Handling Training

· Sepsis Training

· UCLA Bariatric Inservices

Home

Benefits

Compensation

Training & Development

Cultural Diversity & LGBT Resources

E-Learning Library

Employee Required Training

HIPAA Privacy and Information Security Training for New Workforce Members

Management Development Calendar

New Employee Orientation

New Hire Processing Calendar

Other Training Resources

UC Compliance Training

.

Standard HR.01.07.01 The Hospital Evaluates Staff Performance

Elements of Performance:

EP 1: The hospital evaluates staff based on performance expectations that reflect their job responsibilities.

EP 2: The hospital evaluates staff performance once every 3 years, or more frequently as required by hospital

policy or in accordance with law and regulation.

•UCLA Health System policy requires every employee to receive a performance evaluation once every 12 months.

11

Standard HR.01.07.01 The Hospital Evaluates Staff Performance

Supportive Finding / Explanation:•Performance Evaluations shall be completed for all employees, at every level in the organization, at least every twelve (12) months by the employee's immediate supervisor or designee.

•A grace period of 60 days is in place to allow for completion, meeting with the employee and signature gathering. Employees are evaluated on all duties described on their Job Description. The job description and the performance evaluation are a combined tool to insure all elements of the job description are reviewed and evaluated annually.

12

Must check one or both boxes

Must fill in eval period dates

Must check applicable

age groups

This content is the

most current

New PE Content Soon To Come…

•INSTITUTIONAL AND/OR PROFESSIONAL STANDARDS•Comply with HIPAA and Confidentiality Policies and Procedures as they apply to the job•Comply with Department of Public Health (DPH), The Joint Commission and other accreditation and regulatory agencies standards•Adhere to all Hospital Policies and Procedures•Knowledge and adherence to Infection Control and Environment of Care Guidelines and Procedures as described in the annual education module•Demonstrate adherence to the requirements for using the electronic medical record•Demonstrates understanding of institutional and department specific emergency management procedures/responsibilities to maintain personal, patient, and co-worker safety, maintains competencies in these areas, and participates in disaster/emergency related exercises and education.•Demonstrates understanding of institutional and department specific safe patient handling procedures/responsibilities and maintain a level of competency on the proper use of departmental lift equipment to ensure personal, co-worker and patient safety

SKA section must be completed if form being

used as a JD

Must check

required boxes!

Specify Required

or Preferred.

1. Date signed MUST be within 60

days of period of evaluation

identified on first page of form

2. HR Tracking Entry:

**date signed on eval is entered

as “date completed” in PE field

** “date expiring” is based on

end date of period of evaluation

identified on first page (month

and day) and one year later

Evaluator needs to complete this section so employee knows what goals are for

next year

Evaluator needs to complete this section for final comments

Employee needs to identify any

education changes here

Human Resources File ReviewEmployee Name: When a file is requested for survey, prior to sending it to HR, complete this form with all dates and make note of anything missing and what your dept. is doing about it. Sticky notes are very helpful to adhere to docs.

Title: File Review Date:

Hire Date: Dept.

DocumentsAppropriate

DocumentationYes / No

Comments Follow Up:

JOINT COMMISSION & DPH REQUIRED ELEMENTSAge Specific Trng (if app.)/Module & Post Test Put completion

dates Add any

noteworthy Anything missing?

Annual/Age Spec. Comp. Assessment: Year 1 In these columns for

explanations in this

Let HR know what

Annual/Age Spec. Comp. Assessment: Year 2 all requirements column your dept. is doing

Annual/Age Spec. Comp. Assessment: Year 3 (survey year)

to revise/complete

Performance Evaluation: Year 1 a req. document

Performance Evaluation: Year 2Performance Evaluation: Year 3 (survey year)Department /Job Specific OrientationCPR Write in exp. dateLicenses/Certifications/Source Verification Write in exp.

dateDPH and UCLA REQUIRED ELEMENTS

Abuse, ChildAbuse, AdultAbuse, DomesticConfidentiality AgreementAnnual Education Post Test (Cert.) HR will reprint CICARE Module and Post Test (Cert.) all online certs.Corporate Compliance Post Test (Cert.)Cultural Competency Post Test (Cert.)HIPAA Privacy & Info Security Training Post Test (Cert.)Hospital Orientation & Post TestInitial Competency AssessmentJob DescriptionEmployee Physical HR will contact OHF Office of RecordsTB Test OHF for health

formsOHF Office of Records

Form can be found

on HR website under HR

Requirements & Forms

HR File Review Form

Upcoming Surveys

CMS Transplant SurveyPatient Safety Licensing SurveyTJC Hospital Licensing Survey (by August 2013)

•All surveys in open window for a visit•No announced dates•File Review Session will be part of all surveys

Please call HR if you have any Questions