Human Resources Metrics Cook County Health HR Committee...Jun 19, 2020 · Chief Human Resources Officer June 19, 2020. COVID 19 Response Update. COVID-19 Response 3 ... Job description

Human Resources MetricsCook County Health HR CommitteeBarbara PryorChief Human Resources OfficerJune 19, 2020

COVID 19 ResponseUpdate

COVID-19 Response

3

Employee Assistance Resourcesq Magellan Healthcare / CCH Behavioral Health / Pych

v Dealing with anxiety related to outbreakv Information Provided:

§ Crisis Communication§ Mind Your Mental Health § Health and Wellness Library

Return to Work Task Forceq Safety Measures

§ Universal Masking§ Plexiglass installation in patient facing areas§ Increased cleaning of high touch surfaces§ Placement of Physical Distance Markers§ Rotation of staff schedules, shifts, start times

q Phase I – June 15th§ Return of Employees with Private Offices/ Workspaces

q Phase II – July 15th§ Balance of Staff

HR Update

The Joint CommissionCook County Health Accreditation

Human Resources Accreditation Requirements

5

Staff StandardsThe accreditation standards address how Human Resources verifies that its doctors, nurses, and other staff are qualified and competent:

Focus Area Standard Label

Standard Text

Qualifications HR.01.01.01

HR.01.02.07

The hospital defines staff qualifications specific to their job responsibilities.

The hospital determines how staff function within the organization.

Staffing HR.01.02.05 The hospital has the necessary staff to support the care, treatment, and services it provides.

Orientation HR.01.04.01 The hospital provides orientation to staff.

Competence HR.01.06.01 Staff are competent to perform their responsibilities

Evaluation of Performance HR.01.07.01 The hospital evaluates staff performance.

Training & Education HR.01.05.03 Staff participate in ongoing education and training.

Accreditation

6

Why Become Accredited ?Accreditation demonstrates commitment to giving safe, high quality health care and to continuallyworking to improve that care.

• Ongoing Performance Improvementü Address deficiencies that take up valuable

staff time that could be spent caring for patients.

• Build a solid quality foundationü Regulationsü Licensureü Certifications

• A majority of US state governments recognize Joint Commission accreditation as a condition of licensure for the receipt of Medicaid and Medicare reimbursements

• Become a High Reliability Organization

• Recognition

• Competitive Advantageü Quality Check Website and Reports

Internal Drivers External Drivers

The Survey Process

7

What to expect?

• All regular Joint Commission accreditation surveys are unannounced.

• Joint Commission surveyors visit accredited health care organizations to evaluate standards of compliance a minimum of:• Once every thirty-six (36) months and, • Once every two (2) years for laboratories.

• Surveyors are highly trained experts who are:• Doctors, nurses, hospital administrators, laboratory medical technologists, and other health care

professionals.• We generally expect at least two (2) surveyors over two days.

• During the survey, surveyors select employee files randomly and use their employee file as a roadmap to evaluate standards compliance.

Elements of Performance

1

Define Staff Qualifications

2

Verify and Documents Credentials

3

Verify Education & Experience

4

Background Check

7

Nonemployee (Vendor)

Compliance

8

Human Resources Accreditation RequirementsElements of Performance: CCH defines staff Qualifications

All staff who provide patient care possess a

current license, certification, or registration, in

accordance with law and regulation.

Staff function within scope of license

Staff supervise students when they provide patient care

HR.01.01.01CCH defines staff qualifications specific

to their job responsibilities.

HR.01.02.07 CCH determines how staff function

within the organization.


9

HR.01.02.05 CCH has the necessary staff to support the care, treatment, and services it provides.

Element of Performance

1• Primary Source Verification of license,

certification, or registration.

Element of Performance

2• Primary Source Verification when required by

hospital but not law and regulation

• CCH verify staff qualifications & Licensure

Primary Source Verification (PSV)

What is Primary Source Verification?The Joint Commission defines it as “verification

of an individual practitioner’s reported qualifications by the original source or approved

agent of that source.”

Why is it important?These requirements help safeguard the general public against individuals practicing medicine

who are illegitimate and unqualified.

Elements of Performance: CCH HR Verification


10

HR.01.04.01

The hospital orients its staff to the key safety content before staff provides care, treatment,

and or services. Completion of this orientation is documented.

• Orients staff to key safety content before staff provides care, treatment, or services

Element of Performance 1

• Relevant policies and procedures• Specific job duties, including infection prevention and control

and assessing and managing pain• Sensitivity to cultural diversity• Patient rights, including ethical aspects of care• Documented


Human Resources- New Hireü All staff should have attended a Human

Resource Orientation Session

ü Completion of training requirements in LMS within 60 days of start date

Department- Promotions/ Transfers ü All staff should be trained and orientated

on the expectations outlined within their Job description

ü All staff should be trained and assessed on departmental specific competencies; these assessments should be documented

ü A Departmental Orientation checklist should be completed within 45 days from the date of promotion/transfer into a new position and sent to Human Resources

Elements of Performance: CCH provides orientation to staff.


11

HR.01.06.01

Competencies are the Staff’s proven ability to do their job successfully or efficiently

• Defines the competencies for staff who provide patient care, treatment, or services


• Competency assessed by qualified staff


• Competence initially assessed at orientation


• Competence assessed and documented at least once every three years, or per policy


ü Managers should review the job descriptions with their team to ensure there is an understanding of expectation of their responsibilities

Elements of Performance: CCH staff are competent to perform their responsibilities


12

HR.01.07.01

The hospital evaluates staff based on performance expectations that reflect their job responsibilities.

• Evaluates staff based on their job responsibilities.


• Evaluates staff performance at least once every three years, or per policy.


• Organization reviews nonemployee individual’s competencies and performance at the same frequency as individuals employed by the organization.


ü All staff members must receive a written

performance evaluationas defined by CCH

Personnel rules

Elements of Performance: CCH management evaluates staff performance.

Joint Commission Readiness

13

Human Resources Employee File PreparednessInteroffice Joint Commission Audit form was created as a

check off list to ensure compliance of employee files.

ü Job Descriptionü Transcripts / Educational Requirements

ü Applicable Licensesü Pre-employment Screening Verification

ü New Hire Hospital Orientation Acknowledgement Form

ü Sanctions Email Verification

ü Updated Licenseü ACLS/PALS/CPRü Certificationsü LMS/Annual Trainingü Department Orientation Formü Performance Appraisal Every 3 years

ü Competencies

14

Provident – Metrics

CLINICAL AUDITS Cleared,

85%

CLINICAL AUDITS

Open, 15%

PRECENTAGE OF COMPLIANCE

CLINICAL AUDITS Cleared CLINICAL AUDITS Open

v Open: Files not complete v Cleared: Files are complete

27

29

29

23

14

19

16

0

8

5

1

1

6

2

5

8

3

3

0

1

0 5 10 15 20 25 30 35

Pharmacy

Preoperative…

ER Nursing

Medical Unit - 8…

Lab Services

Sengstacke

Radiology

Nurse Managers

Respiratory

Physical Therapy

DEPARTMENTAL REVIEW

CLINICAL AUDITS Open CLINICAL AUDITS Cleared

Joint Commission Readiness

Metrics

FY 2020 CCH HR Activity Report

16Does not include Consultants, Registry and House Staff

Thru 05/31/2020

242231

6846

0

50

100

150

200

250

300

Quarter 1

Quarter 2

Quarter 3

Quarter 4

FILLED POSITIONS 2019 Filled (473) | Externals (319)

2020 Filled (114) | Externals (83)157 125

172

84

0

100

200

Q U A R T E R 1

Q U A R T E R 2

Q U A R T E R 3

Q U A R T E R 4

SEPARATIONS2019 Separations (282) 2020 Separations (256)

Deceased Discharged Resignation RetirementFY19 (282) 1 50 115 116FY20 (256) 6 25 102 123

1

50

115 116

625

102123

0

20

40

60

80

100

120

140

24%

76%

NET

External Hire - 83Separations-256

-173

Cook County Health HR Activity Report – Hiring Snapshot

17

715 50

145 51

260

30114

0

50

100

150

200

250

300

350

400

Pre-Rec

ruitin

g

To be

poste

d

Curren

tly po

sted

In va

lidati

on

Awaiting

refer

ral/ re

post

Interv

iews i

n Proc

ess

Offer b

eing e

xtend

ed

Candid

ate in

proc

ess

Hire da

te se

t

Vacan

cies F

illed

Cou

nt o

f pos

ition

s227 Positions in Recruitment

Thru 05/31/2020

143 ( 63%) of the positions in process, are in the post-validation phase

Shared Responsibility Human Resources Management Finance / Human Resources Shared Responsibility

Clinical Positions 157| 69%Non-Clinical Positions 70| 31%

83 / 73% Externals

Budget43%

Position Control14%

Classification & Compensation

43%

Hiring PlanOf the 227 positions in Human Resources, 163 were approved by the Department of Budget & Management Services:

18

Nurse Managed CareTechnician/

Technologist/Lab

BehavioralHealth Physician Procurement Other Physician

Assistant Finance Environmental Pharmacy Trade

4/30/2020 |152 68 27 23 9 7 5 4 4 2 1 1 15/31/2020 | 163 73 23 29 9 11 5 4 4 2 1 1 1

0

10

20

30

40

50

60

70

80

Nursing Positions Note: • 22 RTHs - Shift Bid/Lateral Transfers• 73 RTHs - In Recruitment Cycle• 10 RTHs - Filled

105 RTHs Approved

Cook County Health HR Activity Report

19

0

139

11095 90 90 90

203

140

10895.9 96.4 100 92

0

50

100

150

200

250

FY14 FY15 FY16 FY17 FY18 FY19 FY20

Average Time to Fill(Without Credentialed1)

Goal Actual

Improve/Reduce Average Time to Hire*

1Credentialed Positions: Physicians, Psychologist, Physician Assistant I and Advanced Practice Nurses.

Thank you.

Appendix

22

2 3 23

1 1 16

1 1012

32

0

20

40

60

80

100

120

Pre-Rec

ruitin

g

To be

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Curren

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In va

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Awaiting

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cies F

illed

Cou

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f pos

ition

s67 Positions in Process

Thru 05/31/2020

39 ( 58%) of the positions in process are in the post-validation phase

Shared Responsibility Human Resources Management Human Resources Shared Responsibility

21 / 48% Externals

Cook County Health HR Activity Report Nursing Hiring: CNI, CNII

Cook County Health HR Activity Report – Revenue Cycle

23

0 0

4

0

1

00 0 0

1

0

1

2

3

4

5

6

Pre-Rec

ruitin

g

To be

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Curren

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In va

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Awaiting

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Hire da

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illed

Cou

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ition

s5 Positions in process

Thru 05/31/2020

Shared Responsibility Human Resources Management Human Resources Shared Responsibility