human resources standards-prince dudhatra-9724949948

8/7/2019 Human Resources Standards-Prince Dudhatra-9724949948

1/24

1

Human ResourcesHuman Resources

StandardsStandards

October 2005

prince dudhdtra-9724949948


2/24

2

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

Provides an adequate number of staff

Provides competent staff

Orients, trains and educates staffAssesses, maintains and improves staff competence

There are 8 HR Standards

Three under PlanningThree under Orientation, Training & education

Two under Competence Assessment

Management of Human ResourcesManagement of Human Resources

ChapterChapter



3/24

3

HR.1.10 --The organization provides an adequate number andmix 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?

PerDiem 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

2005 HR Standards2005 HR Standards



4/24

4

2005 HR Standards2005 HR StandardsHR.1.20 -- The organization has a process to ensure that a persons

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-file

Ensure that you use latest format

Well defined Job DescriptionsFive 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 again

If the employees duties have changed, the job description is updated. Input from both theemployee and supervisor is taken into consideration.



5/24

5

HR.1.30 --The organization uses data and clinical/service screeningindicators and human resources screening indicators to assess andcontinuously 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 patientfalls. Further drill downs will be conducted in Nursing Units where falls occur.

o Human Resources Indicators: FTE/AOB

o Clinical/Service Indicator: OverallSatisfaction with Care question on NRC PatientSatisfaction Survey

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




6/24

6

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 Session

HIPAA Security Module

HIPAA Confidentiality Module

Corporate 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

TEMPLATEshould be expanded to include items unique to your area

Review Patient Safety standards

Environment of Care items

CulturalDiversity & Sensitivity

Departmental policies

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




7/24

7


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

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

Potential risks within your area

Actions to eliminate, minimize or report risks

Procedures to follow in the case of an event

Processes 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 it

Encourage all staff to report any unsafe process and unsafe physical conditions

Documentation is critical. If no one knows about it, things may not be fixed

The link to the Event Reporting System can be found on the MedNet homepage



8/24

8


HR.2.30 -- Ongoing education, including in-services, trainingand other activities, maintains and improves competence.

Document all education (one-time or on-going)

Encourage staff to attend trainings

Trainings offered:

House-wide annual education

On-going unit/department in-services

Patient safety training

Environment of Care classes

Management Training Course

House-wide Training Needs Assessment Survey every 2 years

Classes offered through: HR, CHR, Nursing Research &Education,MCCS

PerformanceEvaluation - future plans and goals



9/24

9

HR Standards

What 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



10/24

10

HR.3.10 Competence to perform job responsibilities is

assessed, demonstrated, and maintained.

Initially, ALL employees must have competencies completed

All 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




11/24

11


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 accuchek

patient 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 positions

Patient care support positions

Other positions that meet the requirements shown above



12/24

12


HR.3.20 The organization periodically conducts performanceevaluations.

PerformanceEvaluation Policy

According to Hospital Policy, all employees must be evaluated every 12 months

There is a two month grace period for signature and review

When an employee transfers to another unit/department before the 12 month period, aninitial competency assessment & a Department Specific/Job Specific Orientation arecompleted in the NEW department and a new performance evaluation period starts on theday of the transfer

The evaluation period must cover 12 months or less

PEcompliance must be at 98% during a Joint Commission visit

The 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



13/24

13

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.



14/24

14

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 NursingDept.(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.



15/24

15

PerformanceE

valuation Policy

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

departments must document request ahead of time

patient care may not be interrupted at any time

What do you do if you dont want to take care of a patient?

Talk to your supervisor

Complete request form as soon as possible, so that supervisor is aware forstaffing purposes

Forensics PolicyWhen a prisoner is admitted to the hospital, forensic staff is educated by security on ouremergency procedures and codes.

When a prisoner comes to Med Plaza for an appointment, department must notifyUCPD to alert them.

HR PoliciesHR Policies



16/24

16

HR FormsHR Forms

To access the most up-to-date HRF

ormsPlease go to http://hr.healthcare.ucla.edu/

Click on the

Employee

section



17/24

17

HR FormsHR Forms

Click on

All HR

Forms



18/24

18

HR FormsHR Forms

Click on

RegularStaff



19/24

19

HR FormsHR Forms

Click on

RegularStaff



20/24

20

HR Tracking SystemHR Tracking System

Do you have access to the HR Tracking System?

Call Maria Olegario at x48622 to get your access

Review yourown compliance regularly, prior to reportsbeing sent out.

Ensure compliance for all your accounts



21/24

21


Click on

MoreServices



22/24

22


Click on

HRWeb

Applications



23/24

23


Click on

CompetencyTracking



24/24

24

HR ContactsHR Contacts

Kety Duron at 40500

Debby Brown at 40500

Salpy Akaragian at 46903Maria Olegario at 48622 (for access to the HR tracking

system)


human resources standards-prince dudhatra-9724949948

Documents