Human Resource Updates
September 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 – 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.
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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.
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Upcoming 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
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Personnel File Audit Form
Human Resources File Review
Employee Name:
Hire Date:
File Review Date:
Title:
Dept.
Appropriate
Documentation
Documents
Comments
Yes / No
and Date Completed
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
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Evercheck
• 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?
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Orientation Update
• 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.
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HIPAA Compliance
• 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/
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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
• 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.
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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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