2009 HR Standards Competency Tracking System

1. 2009 HR StandardsCompetency Tracking System Health System Human Resources October 2008

2. Standard HR.01.02.01 ~ Elements of Performance for HR.01.02.01 • The organization defines staff qualifications ~ Job Descriptions • The hospital defines staff qualifications specific to their job responsibilities. • Every employee must have an up-to-date Job Descriptions • JD/PE Templates are on the HR Website under Forms • http://hr.healthcare.ucla.edu/06_header_emp_forms.html • 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

3. Standard HR.01.02.05Elements of Performance for HR.01.02.05 • The organization verifies staff qualifications. • LICENSE & CERTIFICATION VERIFICATION • Primary Source Verification must be done for all positions that require license or certification at new hire and at renewal. • You must document the verification by either printing the electronic copy of the verification or by documenting the date and number you called. • If electronic verification is available, it must be done, a phone call verification is not accepted. • Renewals must be done prior to the expiration not after • A hospital can lose it’s operating license if staff are practicing with expired license or certification required for the job • 100% COMPLIANCE IS REQUIRED AT ALL TIMES!

4. Standard HR.01.02.05Elements of Performance for HR.01.02.05 • The hospital verifies and documents that the applicant has the education and experience required by the job responsibilities. • Unless if the education is a prerequisite for licensure or certification. • 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 background checks are completed. • 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.

5. Standard HR.01.02.05Elements of Performance for HR.01.02.05 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 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.

6. Standard HR.01.02.05Elements of Performance for HR.01.02.05 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.

7. Standard HR.01.02.07Elements of Performance for HR.01.02.07 • The organization determines how staff function within the organization. • All staff who provide patient care, treatment, and services possess a current license, certification, or registration as required by law and regulation. • 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. • Staff oversee the supervision of students when they provide patient care, treatment, and services as part of their training.

8. Standard HR.01.04.01Elements of Performance for HR.01.04.01 The hospital provides Orientation to staff ~ New Employee Orientation ~~ all staff must attend within 30 days of hire date • Key safety content before staff provides care, treatment, and services. • Sensitivity to cultural diversity based on their job duties and responsibilities. • 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.

9. Standard HR.01.04.01Elements 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 • Relevant hospital-wide and unit-specific policies and procedures. • Specific job duties, including those related to infection prevention and control and assessing and managing pain. 100% Compliance is required.

10. Standard HR.01.04.01Elements of Performance for HR.01.04.01 NEW HIRE PAPERWORK • Abuse Reporting Forms ~ must be at 100% compliance • Confidentiality Form ~ must be at 100% compliance • MUST BE COMPLETED ON-LINE WITHIN 30 DAYS OF DATE OF HIRE ~ 100% compliance is required www.mednet.ucla.edu under required Training • Compliance Quiz • HIPAA Education & Training Program

11. Standard HR.01.04.01Elements of Performance for HR.01.04.01 7. 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

12. Standard HR.01.05.03Elements of Performance for HR.01.05.03 • Staff participate in ongoing education and training to maintain or increase their competency. Staff participation is documented. 4. Staff participate in ongoing education and training whenever staff responsibilities change. Staff participation is documented. 5. Staff participate in education and training that is specific to the needs of the patient population served by the hospital. Staff participation is documented.

13. Standard HR.01.05.03Elements of Performance for HR.01.05.03 6. Staff participate in education and training that incorporates the skills of team communication, collaboration, and coordination of care. Staff participation is documented. 7. 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.

14. Standard HR.01.06.01Elements of Performance for HR.01.06.01 • Staff are competent to perform their duties • INITIAL COMPETENCY ASSESSMENT • Competencies are all the skills required to perform the job, these are found on the Job Description. • 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. • The INITIAL COMPETENCY ASSESSMENT FORM must be used and the assessor must initial the form as each competency is successfully completed. • Assessment methods may include test taking, return demonstration, or the use of simulation. • 100% Compliance is required

15. Standard HR.01.06.01Elements of Performance for HR.01.06.01 • ANNUAL COMPETENCY ASSESSMENT • Only the following competencies should be assessed annually • HIGH RISK/LOW FREQUENCY • HIGH RISK/HIGH FREQUENCY • REGULATORY REQUIREMENTS • 100% Compliance is required

16. Standard HR.01.06.01Elements of Performance for HR.01.06.01 • ANNUAL COMPETENCY ASSESSMENT • Routine daily tasks may not be reviewed annually unless if the employee is not able to perform them • If you are in an area where your competencies are not reviewed annually 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 ~ THE SYSTEM WILL INDICATE THAT THE DEPARTMENT IS OUT OF COMPLIANCE

17. Standard HR.01.07.01Elements of Performance for HR.01.07.01 • The hospital evaluates staff based on performance expectations that reflect their job responsibilities. • The PE is completed annually by the supervisor • Use JD/PE form from the on-line templates • 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!

18. 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 • Is your department appropriately listed on the Competency Report? • If not, contact Maria Olegario at 40500 • 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. • Reports are based on the entry, do your entry timely & accurately • CALL US FOR QUESTIONS

19. COMPETENCY TRACKING SYSTEM

20. VERIFICATION CHECKLISTNon-Paid Students Orientation and Education requirements and documents: • Copy of Resume or completed Application for Assignment • Verification of (3) signed Abuse Reporting Statements ~ (child, domestic, elder) • Verification of signed Confidentiality Statement • Verification of completed HIPAA Training Module and Post Test • Evidence of Medical Criteria Clearance/TB Testing/Drug Screening completion • Evidence of Background Check completion

21. VERIFICATION CHECKLISTNon-Paid Students Orientation and Education requirements and documents: • Verification of valid License/Certification/CPR Card (if applicable) • Santa Monica-UCLA Medical Center and Orthopaedic Hospital Requirements: • Annual Education Guide and Post Test • RR UCLA Medical Center (Westwood) Requirements: • Self Study Orientation and Staff information Handbook and Post Test • Review of Restraints Competency Module (if applicable) • 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.