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Human Resources Standards October 2005. Management of Human Resources Chapter. 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 staff Assesses, maintains and improves staff competence

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Human Resources Standards October 2005

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management of human resources chapter
Management of Human Resources Chapter
  • 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 staff
    • Assesses, maintains and improves staff competence
  • There are 8 HR Standards
    • Three under Planning
    • Three under Orientation, Training & education
    • Two under Competence Assessment
2005 hr standards
2005 HR Standards
  • HR.1.10 --The organization provides an adequate number and mix 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?
        • Per Diem 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
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2005 HR Standards
  • HR.1.20 -- The organization has a process to ensure that a person’s 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 Descriptions
    • Five 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 employee’s duties have changed, the job description is updated. Input from both the employee and supervisor is taken into consideration.
2005 hr standards5
2005 HR Standards
  • HR.1.30 --The organization uses data and clinical/service screening indicators and human resources screening indicators to assess and continuously improve staffing effectiveness.
      • Human Resources Indicators: RN Hours per Patient Day
      • Clinical/Service Indicator: Number of Patient Falls
    • Human Resources is working with Nursing staff to gather data and information on patient falls. Further drill downs will be conducted in Nursing Units where falls occur.
      • Human Resources Indicators: FTE/AOB
      • Clinical/Service Indicator: Overall Satisfaction with Care question on NRC Patient Satisfaction Survey
    • Human Resources is working with Nursing Units to do some drill downs in areas where there is a significant increase or decrease in the patient satisfaction scores from one quarter to the next.
2005 hr standards6
2005 HR Standards
  • 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
        • TEMPLATE should be expanded to include items unique to your area
        • Review Patient Safety standards
        • Environment of Care items
        • Cultural Diversity & Sensitivity
        • Departmental policies
    • Volunteers should always be directed to the Volunteer Office for orientation and training.
2005 hr standards7
2005 HR Standards
  • HR.2.20 -- Staff members, licensed independent practitioners, students and volunteers can describe or demonstrate their roles and responsibilities based on specific job duties or responsibilities relative to safety.
  • Make sure you document on the Department/Job Specific Orientation form that staff 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
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2005 HR Standards
  • HR.2.30 -- Ongoing education, including in-services, training and 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
          • Performance Evaluation - “future plans and goals”
hr standards
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

2005 HR Standards

  • 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
2005 hr standards11
2005 HR Standards
  • 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
2005 hr standards12
2005 HR Standards

HR.3.20 The organization periodically conducts performance evaluations.

Performance Evaluation 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, an initial competency assessment & a Department Specific/Job Specific Orientation are completed in the NEW department and a new performance evaluation period starts on the day of the transfer
  • The evaluation period must cover 12 months or less
  • PE compliance must be at 98% during a Joint Commission visit
    • The next visit will be unannounced so, we have to be at 98% at all times
    • The last 18 months prior to a visit are also looked at
back up documentation
Back 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.

back up documentation14
Back 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 Nursing Dept.(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.
hr policies
HR Policies

Performance Evaluation Policy

Staff Rights Policy

  • Employees may request not to participate in care or treatment of a patient based 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 don’t want to take care of a patient?
        • Talk to your supervisor
        • Complete request form as soon as possible, so that supervisor is aware for staffing purposes

Forensics Policy

    • When a prisoner is admitted to the hospital, forensic staff is educated by security on our emergency procedures and codes.
    • When a prisoner comes to Med Plaza for an appointment, department must notify UCPD to alert them.
hr forms
HR Forms

To access the most up-to-date HR Forms

Please go to

Click on the



hr forms17
HR Forms

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All HR


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HR Forms

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HR Forms

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hr tracking system
HR Tracking System
  • Do you have access to the HR Tracking System?
  • Call Maria Olegario at x48622 to get your access
  • Review your own compliance regularly, prior to reports being sent out.
  • Ensure compliance for all your accounts
hr tracking system21
HR Tracking System

Click on



hr tracking system22
HR Tracking System

Click on




hr tracking system23
HR Tracking System

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hr contacts
HR Contacts
  • Kety Duron at 40500
  • Debby Brown at 40500
  • Salpy Akaragian at 46903
  • Maria Olegario at 48622 (for access to the HR tracking system)