Hospital Staff Qualifications and Care Coordination

1. Human Resources Contains information unique to the patient which is used for patient identification; information needed to support the patient’s diagnosis and condition; information needed to justify the patient’s care, treatment and services March 2012

2. The hospital has the necessary staff to: Coordinate care in a community emergency. Support the care, treatment, and services it provides March 2012 Provide a consistent and efficient nurse to patient ratio

3. The Hospital defines staff qualifications: Specific to their job responsibilities Including special training As found in the written Job Descriptions

4. The hospital verifies and documents staff qualifications, including: Professional licensure, certifications, and registrations Criminal background checks, applicable health screenings, and required education Required experience

5. Before providing care, treatment, or services, the hospital confirms that nonemployees who are brought into the hospital by an LIP have the same qualifications and competencies required of employed individuals performing the same or similar services: The accredited organization request True False Within 12 ours after registration or inpatient admission

6. Advanced practice nurses who are licensed independent practitioners are credentialed and privileged only through the medical staff credentialing and privileging process: True False Completeness of data and information Legibility

7. The hospital provides orientation to staff, including: Key Safety information Relevant hospital-wide and unit specific policies and procedures Sensitivity to cultural diversity Patient rights and ethical aspects of care

8. Staff participate in on-going education and training To maintain or increase competency Whenever their responsibilities change Annually

9. Staff participate in on-going education and training Specific to the needs of the patient population served In the skills of team communication, collaboration, and coordination of care Including information about the need to report unanticipated adverse events and how to report these events On fall reduction

10. The hospital evaluates staff performance: Based on performance expectations that reflect job responsibilities Once every three years or more frequently as required by hospital policy Part of the hospital’s compensation program. Of hospital staff only.