2010 HR Standards Competency Tracking System

1. 2010 HR StandardsCompetency Tracking System Health System Human Resources November 2009

2. Standard HR.01.02.01 Elements of Performance for HR.01.02.01 • The hospital defines staff qualifications ~ Job Descriptions • EP: The hospital defines staff qualifications specific to their job responsibilities. • Every employee must have an up-to-date Job Description • JD/PE Templates are on the HR Website under HR Operations/Forms • http://hr.healthcare.ucla.edu/06_header_emp_forms.html • new content and language as of 1/1/09 • 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.01.02.01 Elements of Performance for HR.01.02.01 New for 2010: • EP: If blood transfusions and intravenous medications are administered by staff other than doctors, the staff members have special training for this duty. • Covered in Nursing Orientation • Specific competencies are completed on the units • Part of competencies in Outpatient Areas

4. Standard HR.01.02.05Elements of Performance for HR.01.02.05 • The organization verifies staff qualifications. • LICENSE, CERTIFICATION & REGISTRATION VERIFICATION • EP: Hospital verifies all licenses, certifications and registrations with the Primary Source and documents this verification upon hire and at time of renewal. • You must print the electronic copy of the verification form from the Board’s website or document the date and number you called on the telephone verification form. • Electronic verification is preferred. • MUST be completed prior to start date or at the latest on the employee’s first day of work. Renewal verification must be done prior to the expiration date. Otherwise, employee cannot work. • A hospital can lose its operating license if staff are practicing with expired credentials required for the job • 100% COMPLIANCE IS REQUIRED AT ALL TIMES!

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

7. Standard HR.01.02.05Elements of Performance for HR.01.02.05 • EP: The hospital verifies and documents that the applicant has the education and experience required by the job responsibilities • If the education is a prerequisite for a license, certification or registration, the Board will verify before granting the credential • Staffing Office has a clearinghouse to verify a degree and a vendor to check references • EP: 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 of the background checks are completed.

8. Standard HR.01.02.05Elements of Performance for HR.01.02.05 • EP: 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. SUMMARY: 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

9. Standard HR.01.02.05Elements of Performance for HR.01.02.05 • EP: 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. • EP: 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.

10. Standard HR.01.02.07Elements of Performance for HR.01.02.07 • The hospital determines how staff function within the organization. • EP: All staff who provide patient care, treatment, and services possess a current license, certification, or registration as required by law and regulation. • EP: 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.

11. Standard HR.01.02.07Elements of Performance for HR.01.02.07 • EP: Staff oversee the supervision of students when they provide patient care, treatment, and services as part of their training. • 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 • Verification of valid License/Certification/CPR Card (if applicable) • Annual Education Guide and Post Test • Review of Restraints Competency Module (if applicable) *NOTE: 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.

12. Standard HR.01.04.01Elements of Performance for HR.01.04.01 • The hospital provides Orientation to staff All staff must complete New Employee Orientation within 30 days of hire date • EP: The hospital determines the key safety content of orientation provided to staff • EP: The hospital orients its staff to the key safety content before staff provides care treatment, and services. Completion is documented. • EP: Includes relevant hospital-wide and unit-specific polices and procedures • Completion of Hospital Orientation and Department Specific Orientation is documented • Post test is completed in class or online ~ 100% Compliance is required.

13. 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 • EP: Specific job duties, including those related to infection prevention and control and assessing and managing pain. • EP: Sensitivity to cultural diversity based on their job duties and responsibilities. • EP: 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.

14. Standard HR.01.04.01Elements of Performance for HR.01.04.01 • EP: 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 • Policy HS 7311: Security for Prisoner/Patient Forensic Staff Orientation Education

15. Standard HR.01.04.01Elements of Performance for HR.01.04.01 Orientation also includes NEW HIRE PROCESS: • Abuse Reporting Forms (3 forms to sign – child, elder, domestic) • Confidentiality Form ~ 100% compliance is required • ON-LINE REQUIREMENTS: • Must be completed within 30 days of hire • Located on Mednet Home Page under Employee Required Training • Compliance Quiz • HIPAA Education & Training Program • C-ICARE Annual On-line Training ~ 100% compliance is required

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

17. Standard HR.01.05.03Elements of Performance for HR.01.05.03 • Staff participate in ongoing education and training. • EP: Staff participate and training that incorporates the skills of team communication, collaboration, and coordination of care. Staff participation is documented. • EP: 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.

18. Standard HR.01.05.03Elements of Performance for HR.01.05.03 • Staff participate in ongoing education and training. • All staff meet the Annual Education requirement by completing the Annual Education Guide found on the Mednet home page under Employee Required Training. • Educational topics reviewed and documented in departments, according to HR Standards, include: • Infection prevention and control • Assessing and managing pain • Ethical aspects of care, treatment and services • Patient population training • Team communication, collaboration and coordination

19. Standard HR.01.05.03Elements of Performance for HR.01.05.03 Annual Education

20. Standard HR.01.06.01Elements of Performance for HR.01.06.01 • Staff are competent to perform their responsibilities • INITIAL COMPETENCY ASSESSMENT • EP: The hospital defines the competencies it requires of its staff who provide patient care, treatment or services • Competencies are all the skills required to perform the job. These are found on the Job Description. • EP: The hospital uses assessment methods to determine the individual’s competence in the skills being assessed. This may include test taking, return demonstration, or the use of simulation. • 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.

21. Standard HR.01.06.01Elements of Performance for HR.01.06.01 • EP: An individual with the educational background, experience, or knowledge related to the skills being reviewed assesses competence. • The INITIAL COMPETENCY ASSESSMENT FORM must be used and the assessor must initial the form as each competency is successfully completed. Signature and date is required when all competencies have been assessed. • EP: Staff competence is initially assessed and documented as part of orientation 100% Compliance is required

22. Standard HR.01.06.01Elements of Performance for HR.01.06.01 • ANNUAL COMPETENCY ASSESSMENT • EP: Staff competence is assessed and documented once every three years, or more frequently as required by hospital policy or in accordance with law and regulation • Per UCLA Health System Policy: • Only the following competencies should be assessed annually: • HIGH RISK/LOW FREQUENCY • PROBLEM PRONE AREAS • REGULATORY REQUIREMENTS, i.e. blood administration; blood glucose • NEW COMPETENCIES Routine daily tasks may not be reviewed annually unless the employee is not able to perform them • EP: The hospital takes action when a staff member’s competence does not meet expectations 100% Compliance is required

23. Standard HR.01.06.01Elements of Performance for HR.01.06.01 • ANNUAL COMPETENCY ASSESSMENT • If you are in an area where your competencies are not required to be reviewed ANNUALLY for some or all of your staff members, 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, ORTHE SYSTEM WILL INDICATE THAT THE DEPARTMENT IS OUT OF COMPLIANCE • Change annual competency field from Y to N if not required.

24. Standard HR.01.07.01Elements of Performance for HR.01.07.01 • The hospital evaluates staff performance • EP: The hospital evaluates staff (and non employees brought in by licensed independent practitioner) based on performance expectations that reflect their job responsibilities. • EP: The hospital evaluates staff performance once every three years, or more frequently as required by hospital policy or law. This evaluation is documented. • According to UCLA policy, the PE is completed annually by the supervisor • Use JD/PE form from the on-line templates on HR Website • 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!

25. 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 at x40500 • Is your department appropriately listed on the Competency Report? • If not, contact Maria Olegario at x40500 • Reminder: 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. • Reminder: Reports are based on the entry. Please do your entry timely & accurately. Make sure the dates on the forms match the dates in the system. • DON’T HESITATE TO CALL US FOR QUESTIONS

26. COMPETENCY TRACKING SYSTEM