3 Survey Results - SMH TJC Survey – week of Aug. 11 th HR File Review Session and HR Competency Assessment Interview 60 staff names sent to HR who interacted with surveyors 14 official file requests on Day 3 and 4. Files were from: GI Lab, Nutrition, Sterile Processing, Rehab, Peds, Resp. Therapy, Security, Oncology, ICU and Davita Dialysis. Titles were ACCP, Nutrition Director, Sterile Tech, PT, CN II, Resp Therapist, Pharmacist, Security Officer and RN.
4 Survey Results - SMH Managers spoke for their own files. They all did an amazing job sharing their dept orientation, competency and evaluation process. Surveyor was very impressed with investment in training of all staff. Specific questions about who assesses competencies of staff. Reviewed job description details. Make sure assessor has qualifications to assess staff. Scavenger hunts are a plus! Current licenses, TB and fit testing was also reviewed.
5 Survey Results – SMH HR Competency Assessment Interview Surveyor usually bring issues to resolve to this meeting that they encountered on the floors. No issues to bring/resolve. Interview questions were focused on hiring practices, Talent Plus, employee relations, turnover rate, employee satisfaction, employee expectations and our culture. Surveyor was very complimentary on all HR processes.
6 Survey Results - RNPH TJC Survey – Week of Aug. 12 th HR File Review Session 33 staff names sent to HR who interacted with surveyors. 19 official files requests on Day 2 and 3. 15 files from RNPH depts. and 4 were from medical center depts. Titles were RNs, Social Workers,, Nurse Managers, OT, CCP, Nursing Director, Social Work Director, Pharmacist, Dietitian, Nurse Educator, Assoc. Chief of Social Work, Child Development Assoc., and Registry RN.
7 Survey Results - RNPH Interview questions were about orientation, education and competencies. Specific questions about the people who reviewed initial and annual competencies and whether they were working in the same discipline and had expertise to assess comps. Were managers/directors oriented before they trained staff in specific areas. Reviewed licenses and evaluations and health information as well. Surveyor was very complimentary. Stated that RNPH was ahead of the curve and she was pleased that such a large organization maintained many long term employees. RNPH did not have a separate competency assessment interview.
Upcoming Surveys 8 CDPH Radiology Site Visit – Next 2 weeks CAP Survey – Lab – Now thru Nov. 3rd Combined AABB/CAP – Div of Transfusion Svcs. – Oct. 6-17, 2014 AABB – BPC – 4 th Quarter 2014 Comprehensive Stroke Center Recertification Survey – Sept. 2014 CDPH Patient Safety Licensing Survey – 2015 Specialized focus in these surveys, but require tracers, staff interviews and file reviews. If file is requested from your area, complete file audit form with completion dates and any follow-up comments and send along with the file to HR. http://uclahealth.org/body.cfm?id=45
Personnel File Audit Form Human Resources File Review Employee Name:Title: File Review Date: Hire Date: Dept. Documents Appropriate Documentation Yes / No and Date Completed Comments Follow Up: JOINT COMMISSION & DPH REQUIRED ELEMENTS Age Specific Trng (if app.)/Module & Post Test Annual/Age Spec. Comp. Assessment: Year 1 Annual/Age Spec. Comp. Assessment: Year 2 Annual/Age Spec. Comp. Assessment: Year 3 (survey year) Performance Evaluation: Year 1 Performance Evaluation: Year 2 Performance Evaluation: Year 3 (survey year) Department /Job Specific Orientation CPR Licenses/Certifications/Source Verification (when verified and when expiring)? DPH and UCLA REQUIRED ELEMENTS Abuse, Child Abuse, Adult Abuse, Domestic Confidentiality Agreement CICARE Module and Post Test (Cert.) Compliance Post Test (Cert.) Cultural Competency Post Test (Cert.) Annual Education Post test (Cert.) Hospital Orientation & Post Test HIPAA Privacy & Info Security Trng & P&P (Cert.) Initial Competency Assessment Job Description Employee Physical OHF Office of Records TB Test OHF Office of Records HR File Review Form – Sept 2014 9
Evercheck 10 Majority of licenses in RR, SMH and RNPH have all been entered into the system with dept. monitors to oversee the notification emails. Dietitians still need to be added to Evercheck database. FPG and SOM licenses will be next focus. Any other licenses not entered for RR, SMH or RNPH? HR’s Random Audit Check Say YES! We will be able to stop using license verification printouts from the online Professional Board at your next renewal IF the license is in Evercheck. We did not get to test it out at TJC Surveys. Used verification printouts from all files. Maybe for next surveys. For those using it – feedback?
Orientation Update 11 Program is under review. New format will begin January 2015. Orientation will continue to be held on the new hire’s start date. Nursing Orientation and Ambulatory Care Orientation also undergoing revisions in format and presentation. SOM: Not part of new onboarding process as of now. SOM clinical staff in licensed space attend as close to start date as possible. Lunches are now being provided in class. Veg or Non-Veg. --SOM: call Staffing with lunch request if not going through onboarding with HR, but attending Health System Orient. Transfers – Attend benefits session. Begins at 3:15pm after ID badge/parking distribution.
HIPAA Compliance 12 OIG requirement is that HIPAA is completed by third day of employment. New hires complete HIPAA during onboarding and before start date. Transfers, students, interns and ANYONE with an affiliation to UCLA MUST also have proof of HIPAA compliance. Please verify completion of HIPAA on first day. Do not assume it was done already. Serious fines for missing 3 day deadline. Visit from OIG every 6 months to review HIPAA compliance/
Transfers Treat them as if they are new hires Confirm that all of their requirements have been completed or have a timeline for completion. This includes: HIPAA and all other online modules/tests Job Description Dept. Orientation Initial Competencies License Verification/Evercheck entry Possibly: Health System Orientation, Physical and TB Update HR Tracking with new completion/due dates 13
Flu Vaccine Survey 14 There will be a Flu Vaccine Survey for 2014-2015. This is a DPH requirement. We will track compliance from Oct. 2014 - April 2015. Instructions from OHF will come out via email. As of now, HR Tracking has automated expiration date of 9/30/14 for all staff. There is nothing to complete right now until vaccine and survey are available. Online flu vaccine survey will download completion date into HR Tracking. No manual entry necessary.
Personnel Files For those depts. that keep their own personnel files: Must follow guidelines on HR website in order to collect all required docs in sequential order. http://uclahealth.org/body.cfm?id=45 There can only be one Master personnel file. Many depts keep copies of employee forms if master file is in HR. Do not call it a shadow file. See handout for personnel file guidelines. 15