Human Resource UpdatesSeptember 2014

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Survey Results - SMH• TJC Survey – week of Aug. 11th

• 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.

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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.

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Survey Results – SMHHR 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.

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Survey Results - RNPH•TJC Survey – Week of Aug. 12th

• 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.

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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 SurveysUpcoming Surveys

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• 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 – 4th 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 FormPersonnel File Audit FormHuman Resources File Review

Employee Name: Title: File Review Date:

Hire Date:   Dept.   

DocumentsAppropriate

DocumentationYes / 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 ELEMENTSAbuse, 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

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EvercheckEvercheck

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• 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 UpdateOrientation Update

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• 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

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• 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

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Flu Vaccine Survey

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• 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.

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