DR. JOHN WARNER HOSPITAL
CLINTON, ILLINOIS 61727
POLICY AND PROCEDURE
TITLE
HOSPITALWIDE EDUCATION PROGRAM
PAGE 1 OF 5
DEPARTMENT
STAFF DEVELOPMENT
DATE REVISED
09/27/04
PREPARED BY
HEIDI COOK R.N.
ORIGINAL DATE
POLICY #:
EDUC-2139
POLICY:
It is the policy of Dr. John Warner Hospital to provide annual and ongoing education to all
employees to maintain competence, promote professional growth and provide quality patient
care.
STAFF: All personnel
EQUIPMENT, FORMS & LOCATIONS:
Hospital Education Book in each department
New Employee Orientation Form #654; Hepatitis B Vaccine Form #507; and Employee Notice
of Reportable Conditions Form #125 in the Staff Development Department
Attendance Form #272; Workshop Attendance Request Form #378
PROCEDURE:
NEW EMPLOYEE ORIENTATION:
1.
All new employees will participate in the hospital orientation program prior to the start of
their department assignment.
2.
The Staff Development Department will:
a) Review the Hospital Education Book during orientation
b) Initiate the New Employee Orientation Checklist Form #654; attach the departmentspecific checklist; and, forward it to the employee’s assigned department for
completion.
c) Review and obtain signatures on Hepatitis B Vaccine Form #507
d) Review and obtain signatures on the Employee Notice of Reportable Conditions Form
#125; provide a copy to the employee; and, forward the original to the Human Resource
Department for inclusion in the employee personnel file.
3.
New employees will receive department specific and job specific orientation within their
assigned department. The Manager or Director of each department is responsible for
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reviewing and/or revising their department(s) orientation checklist on an annual basis.
4.
The New Employee/Department Specific Orientation checklist is to be completed within
the first thirty (30) days of hire and forwarded to the Human Resource Department for
inclusion in the employee’s personnel file.
5.
Any job skill which cannot be completed within the first ninety (90) days of employment
should be added to a competency checklist for the new employee to complete within the
first year of employment.
6.
Delays in orientation will be permitted for a valid medical emergency or other just reasons
as approved by the Department Manager/Director or the Human Resource Department.
7.
An employee may be exempt from all or portions of orientation if they are re-hired within
six (6) months and with the approval of the Department Manager or Director.
ANNUAL EDUCATION:
1.
All employees (full-time, part-time and registry) are required to participate in annual
hospital education by reviewing the Hospital Education Book and completing the post-test.
2.
The Education Book may be reviewed during a department meeting and assistance may be
requested from the Department Manager or Staff Development Department, if needed.
3.
Questions regarding the content of the Education Book should be directed to the
Department Manager or Staff Development Department.
4.
Completed Hospital Education post-tests should be returned to the Staff Development
Department within thirty (30) days following distribution.
5.
It is the responsibility of the Staff Development Department to review and/or revise the
Hospital Education Book and post-test annually.
6.
General topics included in the Hospital Education Book are (see the Education Book index
for a complete listing):
a) Infection Control
b) Hand Hygiene
c) Bloodborne Pathogens/ Sharps Safety
d) Body Mechanics/Back Injury Prevention
e) Ergonomics
f) Emergency Preparedness (i.e. Tornado Response)
g) Life Safety: Fire, Evacuation
h) Hazard Communication/MSDS
i) TB Education
j) Workplace Violence
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DEPARTMENT SPECIFIC EDUCATION:
1.
Department Managers are responsible for department-specific education. This may
include, but is not limited to:
a) Equipment use and precautions
b) Procedure review (i.e. use of personal protective equipment)
c) Department-specific safety topics and responses
d) Hazard Communication and Material Safety Data Sheets
2.
If a department manager initiates an education program than would benefit other
departments, it is the responsibility of that manager to coordinate and communicate this
information to other departments.
3.
Employee competence is to be assessed during the orientation process by the Department
Manager or designee through the use of a:
a) Job description identifying knowledge, skill and behavior requirements for specific job
classifications.
b) Department orientation checklists identifying basic competency elements.
4.
Department competencies are the responsibility of the Department Manager and may be
identified through:
a) Staff requests
b) High risk, low volume procedures/processes
c) Quality and risk management monitoring process
d) Changing technology
e) Introduction of new equipment
f) Therapeutic or pharmacological interventions
5.
Department Managers are responsible for maintaining department-specific documentation:
a) Attendance sheets
b) Meeting minutes
c) Competency checklist or post-tests
d) Workshop attendance
e) Educational offerings (video, magazine articles, equipment brochures, etc.)
TRAINING REIMBURSEMENT:
1.
Attendance at education or department meetings may be made mandatory by the
Department Manager or Administration. Off-duty employees who must attend a
mandatory meeting will be paid for the meeting time. Excused absences (i.e., death in
family, medical emergency, scheduled vacation) must be presented to the Department
Manager.
2.
Attendance at in-house education programs may be considered work time for pay purposes
and is at the discretion of the Department Manager.
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3.
Training which is mandated by the hospital that cannot be obtained while on duty will be
considered for paid time with the prior approval of the Department Manager. This training
includes CPR and ACLS.
a). Employees in patient care areas are required to have CPR Training. This includes, but
is not limited to: CAS, Lab, Nursing (all), Physical Therapy, Respiratory Therapy
and X-Ray.
b). Based on job classification and/or department manager requirements, designated staff
members are also required to participate in ACLS. This includes, but is not limited
to: ER, ICU, Cardiac Rehab, OR, SDS and CAS.
4.
Outside training may be reimbursed through the completion of a Workshop Attendance
Request form and the prior approval of the Department Manager and Administration.
5.
The hospital is not responsible for continuing education required to maintain a professional
license or for professional license renewal costs.
DOCUMENTATION:
Hospital Education post-tests
Attendance Sheets
COPIES SENT TO:
All Departments
REVISED AND SUPERSEDES:
Hospital Wide Education Program 9/27/04
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DIRECTOR OF HUMAN RESOURCES DATE
INITIAL
AND DATE
REVIEWED ________
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CEO SIGNATURE
DATE
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