2010 HR Standards
Management & Staff Education
Health System Human Resources
March 2010
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Human Resource Standards Overview
The HR Standards are the responsibility of HR but we need a strong
partnership with the departments in order to meet the requirements
HR Standard Topics include License, Certification, Registration Verification: Upon Hire and Renewal
Job Description
Orientation: House-wide and Dept./Unit Specific
Education, Experience and Clearance to Work
Annual Education and Training
Competencies: Initial and Annual
Performance Evaluation
Other Personnel: Non-Employees brought in by independent licensed
practitioners/students/volunteers/temporary staff
Measurement: Competency Tracking System
Documentation
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Immediate citation
RFI (Request for
Improvement) for HR
Staff without a current
TB test should not be
scheduled to work.
HR Joint Commission Chapter
 Why is the HR Compliance important?
HR Joint Commission Chapter defines the standards and expectations
The right thing to do in managing people in a Health Care environment
 We must be at 100% in all areas to avoid citations
Entry must be completed timely to be reflected on the bi-weekly reports
 During Joint Commission Surveys and DPH visits
There are always file reviews to ensure appropriate documentation of competency
assessment, performance evaluations, training documentation
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Job Descriptions - Standard HR.01.02.01
The hospital defines staff qualifications specific to their job responsibilities.
Do you have an up-to-date Job Descriptions (JDs) for each position/staff member?
JDs derived from the Scope of Service and Staffing Plans for each dept./unit
Every employee must have an up-to-date Job Description
JD/PE templates are on the HR Website under HR Operations/Forms
new content and language as of 1/1/09 that includes the CICARE Standards
and Workplace Conduct policy
JDs must be reviewed and signed by new hires during Dept Specific Orientation
Signed JDs must be placed in the employee files
100% Compliance is required
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Specific Competency – Standard HR.01.02.01
New for 2010:
 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 for job titles and clinics that
have the particular scope as part of their practice
100% Compliance is required
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License, Certification & Registration Verification –
Standard HR .01.02.05
IT IS YOUR RESPONSIBILITY TO VERIFY LICENSE & CERTIFICATION
AUTHENTICITY

Primary Source verification is required for all licenses, certifications and registrations upon hire
and prior to expiration or at renewal time.

Copies of a licenses or certifications are no longer acceptable

A copy of the primary source verification from the Board’s website must be printed

RENEWALS: On or prior to the expiration date of the license/certification

The copy is date stamped electronically / one day after the expiration date it is considered late
and hospital is cited

NEW HIRES: Prior to start date or on the employee’s first day of work.

Employees cannot work with an expired license.

Please make sure that any excused delay, employee on leave, employee was suspended is
documented in the file
 A HOSPITAL CAN LOSE ITS OPERATING LICENSE IF STAFF ARE PRACTICING WITH EXPIRED CREDENTIALS
REQUIRED FOR THE JOB.
100% Compliance is required
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Standard HR.01.02.05
Elements of Performance for HR.01.02.05
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Education, Experience & Clearance to Work –
Standard HR.01.02.05
HUMAN RESOURCES COMPLETES THESE REQUIREMENTS – AN EMPLOYEE
CAN NOT START UNTIL ALL CLEARANCE IS COMPLETED

Education and Experience verification  Staffing Office has a clearinghouse to verify a degree is required by the JD and a
vendor to check references.

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.

Pre-Employment Health Screenings as required by law and regulation or hospital policy.
 Completed by OHF, which is the official office of records.
 Health screenings must be completed prior to the start date.
100% Compliance is required
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Student Requirements and Oversight
Standard –HR. 01.02.07
 Do you have students in your area? How do you orient & train them?
 Staff oversee the supervision of students when they provide patient care,
treatment, and services as part of their training.

Same Orientation and Education requirements and documents as staff:
1.
Copy of Resume or completed Application for Assignment
2.
Verification of (3) signed Abuse Reporting Statements ~ (child, domestic, elder)
3.
Verification of signed Confidentiality Statement
4.
Verification of completed HIPAA Training Module and Post Test
5.
Evidence of Medical Criteria Clearance/TB Testing/Drug Screening completion
6.
Evidence of Background Check completion
7.
Verification of valid License/Certification/CPR Card (if applicable)
8.
Annual Education Guide and Post Test (Fulfills Orientation)
9.
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.
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Orientation Standard -- HR.01.04.01
NEW EMPLOYEE ORIENTATION & DEPT SPECIFIC ORIENTATION
 HR RESPONSIBILITY -- All staff must complete New Employee Orientation
within 30 days of hire date

Covers the following:

Introduction to CICARE; Hospital-wide Policies & Procedures; Fire & Safety; Infection
Control

Post test is completed in class or online. Forms placed in personnel file.
 DEPARTMENT RESPONSIBILITY -- Department Unit-Specific Orientation must be
completed within 7 days for the safety part and 30 days for the rest
 Additional Orientation Programs include: Nursing Orientation and Ambulatory
Care Orientation
100% Compliance is required
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Department/Unit Specific Orientation –
Standard HR.01.04.01

Complete the Dept Specific Orientation form for every new employee/transfer
 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

Review specific job duties, including those related to infection prevention
and control and assessing and managing pain.

Review sensitivity to cultural diversity based on their job duties and
responsibilities.

Review 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
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New Hire Requirements – Standard
HR.01.04.01
HR RESPONSIBILITY
Orientation also includes NEW HIRE PROCESS:



Abuse Reporting Forms (3 forms to sign – child, elder, domestic)
Confidentiality Form
ON-LINE REQUIREMENTS:

Must be completed within 30 days of hire

Located on Mednet Home Page under Employee Required Training
 Code of Conduct / Compliance Quiz (one time only)
 HIPAA Education & Training Program (one time only)
 C-ICARE Annual On-line Training (annual)
 UCOP Compliance Briefing (annual) – NEW REQUIREMENT as of 2/10
100% Compliance is required
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Ongoing Education and Training –
Standard HR.01.05.03
 Staff participate in ongoing education and training in order to

maintain or increase their competency.

whenever staff responsibilities change.

review the needs that are specific to the patient population served by the
hospital.

enhance the skills of team communication, collaboration, and coordination of
care.

includes information about the need to report unanticipated adverse events
and how to report these events.

Includes participation in fall reduction activities

Includes addressing the changes in a patient’s condition

What education & training do your provide to staff?

What is your education plan?

How do you find out the educational needs of staff?

How do you document education & training?
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Annual Education – Online Staff Employee
Handbook Quiz
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.
Competency Tracking System shows who is out of compliance so that you can remind
staff to complete the module online
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Standard HR.01.05.03
Elements of Performance for HR.01.05.03
Annual Education
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Initial Competencies --Standard HR.01.06.01
INITIAL COMPETENCY ASSESSMENT – DEPT RESPONSIBILITY

Competencies are all the skills required to perform the job.


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
Staff competence is initially assessed and documented as part of orientation


As defined on the job description.
Performed at point of hire or transfer to a new position
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 appropriate
assessor /preceptor/educator/supervisor must initial the form as each competency
is successfully completed. Signature and date is required when all competencies
have been assessed.
100% Compliance is required
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Annual Competency – Standard HR.01.06.01
ANNUAL COMPETENCY ASSESSMENT – DEPT RESPONSIBILITY
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
 The hospital takes action when a staff member’s competence does not meet
expectations
Action plans are developed with established timelines for review
100% Compliance is required
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Performance Evaluation – Standard
HR.01.07.01
The hospital evaluates staff performance

The hospital evaluates staff (and non employees brought in by licensed independent
practitioner) based on performance expectations that reflect their job responsibilities.

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
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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
REMINDERS:
 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.
 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.
 Verify licenses/certifications through primary source before start of work and prior to
renewal. Print online verification for file.
DON’T HESITATE TO CALL US FOR QUESTIONS!
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Survey HR Related Questions
How do you determine your staffing levels?
 Scope of Service along with budgets, the
following elements are included:
Availability of Service
Hours of service
How patients, etc., access their service
during “regularly” scheduled periods
How patients, etc., access their services
during “off-hours”
Patient care areas flex with volume and
acuity
Type(s) of staff available to serve the
customer. License/certification and other
education requirements
Number of staff (by category, if applicable)
Availability of Staff (scheduling, coverage,
on-call arrangements)
Acuity Methodology
Skill mix and number of staff required
Acuity system in place.
Benchmarking
a. What data do you collect and how do
you use the data?
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Survey HR Related Questions
 What is your process for competence assessment, maintenance and
improvement?
Initial & Annual Competency Assessment (refer to pages 18 & 19)
 How do you orient staff to your hospital, their job responsibilities and/or their
clinical responsibilities?
General Orientation -- cover all topics – policies, safety, HIPAA, Inf. Control
Department/Unit Specific Orientation – within 30 days of the date of the hire
Review Job Descriptions/Initial Competency Assessment Process
Before the orientation is completed employee is assigned a “buddy” for any
emergency situation
 DETAILS:
Throughout the year, education takes place through fire drills, EC rounds, EC surveys,
EC education posters
In case of emergency before completion of Orientation in dept., new employee is
paired up with another dept. employee for safety

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Survey HR Related Questions
What on-going staff education and training do you provide? How do you promote jobrelated educational and advancement goals of staff members?
On-going education and training classes are offered throughout the year
Managers are trained to assess learning needs specific to individuals and their unit/dept.
It’s part of Performance Evaluation, part of goals and education planning section
It can be part of competency assessment process as well
Each department is responsible for offering on-going development courses
HHR offers leadership courses
Web site for education resources
Paid development time
Web access to information for employees
Vendor provides training for new equipment
Staff offer suggestions for topics – some staff members may present or another speaker in house
Interview staff during Skills Day and ask them what they’d like dept. to review
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Survey HR Related Questions
 What is your population competencies process?
Age Specific competency training
New hires with patient contact are tested (Age Specific Module) and observed
during their orientation period
No patient contact, basics are reviewed at General Orientation and annual
education
Cultural Competencies
New Hire Orientation view a tape to introduce all new hires on the subject
In patient areas, more in-depth training is provided in unit specific orientation, in
department orientations
Self study module with a test - optional
On-going education and training classes are offered throughout the year
 Patient Population group – Consistent process on floors/units. Individualize as
necessary according to patient need
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Survey HR Related Questions
 How do you Communicate changes & new topics to the staff?
Chain of command/team dynamics
Huddles, Staff Meetings, HOT,

What are your vacancy and turnover rates?
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