Department Representative Meeting Survey Preparation To Meet TJC Standards March 2013

1. Department Representative MeetingSurvey PreparationTo MeetTJC StandardsMarch 2013

2. Standard HR.01.02.05The Hospital Verifies Staff Qualifications Elements of Performance: EP 1: When law or regulation (or hospital EP 2) requires care providers to be currently licensed, certified, or registered to practice their professions, the hospital both verifies these credentials with the primary source and documents this verification when a provider is hired and when his or her credentials are renewed.

3. Standard HR.01.02.05The Hospital Verifies Staff Qualifications Supportive Finding / Explanation: • It is the responsibility of the department mgr/designee (or Nursing Admin for RN and LVNs) to ensure that all individuals employed in a position requiring a license, CPR certificate, certification and/or degree, assure that primary source verification requirements are met and are current. • It is the responsibility of the employees in such positions to maintain appropriate licensure, CPR card, certification, and to renew their license and/or certification prior to the expiration date. • Staff cannot work with an expired license, not even with a cancelled check and copy of renewal paperwork. • Current Primary Source Verification Printouts must be in all applicable personnel files.

4. BOARD OF REGISTERED NURSING Related Licenses/Registrations/Permits No records returned Disciplinary Actions No information available from this agency This information is updated Monday through Friday - Last updated: MAR-14-2013 (late primary source verification by 2 weeks) DisclaimerAll information provided by the Department of Consumer Affairs on this web page, and on its other web pages and internet sites, is made available to provide immediate access for the convenience of interested persons. While the Department believes the information to be reliable, human or mechanical error remains a possibility, as does delay in the posting or updating of information. Therefore, the Department makes no guarantee as to the accuracy, completeness, timeliness, currency, or correct sequencing of the information. Neither the Department, nor any of the sources of the information, shall be responsible for any errors or omissions, or for the use or results obtained from the use of this information. Other specific cautionary notices may be included on other web pages maintained by the Department. All access to and use of this web page and any other web page or internet site of the Department is governed by the Disclaimers and Conditions for Access and Use as set forth at California Department of Consumer Affairs' Disclaimer Information and Use Information.

5. BOARD OF REGISTERED NURSING Related Licenses/Registrations/Permits No records returned Disciplinary Actions No information available from this agency This information is updated Monday through Friday - Last updated: MAR-14-2013 (Verified ON TIME!) DisclaimerAll information provided by the Department of Consumer Affairs on this web page, and on its other web pages and internet sites, is made available to provide immediate access for the convenience of interested persons. While the Department believes the information to be reliable, human or mechanical error remains a possibility, as does delay in the posting or updating of information. Therefore, the Department makes no guarantee as to the accuracy, completeness, timeliness, currency, or correct sequencing of the information. Neither the Department, nor any of the sources of the information, shall be responsible for any errors or omissions, or for the use or results obtained from the use of this information. Other specific cautionary notices may be included on other web pages maintained by the Department. All access to and use of this web page and any other web page or internet site of the Department is governed by the Disclaimers and Conditions for Access and Use as set forth at California Department of Consumer Affairs' Disclaimer Information and Use Information.

6. CPR Card Update • As of 2/1/13, the American Heart Association (AHA) revised the format of the CPR cards. • The AHA requires the appropriate course completion cards be stamped, typed, or computer printed to reduce the risk of course completion cards being altered. • A valid AHA card is the original card with all the information printed (handwritten is not acceptable except for the card holder’s signature). 

7. Standard HR.01.02.05The Hospital Verifies Staff Qualifications • Elements of Performance: :EP 3: The hospital verifies and documents that the applicant has the education and experience required by the job responsibilities. Supportive Finding/Explanation • In the case that a degree/education is a prerequisite in order to receive a license, it is not required that a copy of the degree be kept in the file. Advanced degrees require proof in the file if required on JD, but no licensure is required for the position. • Staffing Office has a clearinghouse to verify degree and a vendor to check references.

8. Standards related to Cultural Diversity HR.01.04.01 The Hospital Provides Orientation to Staff. EP5: The hospital orients staff on the following : Sensitivity to cultural diversity based on their job duties and responsibilities Standard HR.01.05.03 Staff Participate In Ongoing Education and Training. EP 5: Staff participate in education and training that is specific to the needs of the patient population served by the hospital.

9. LGBT Education • A new video available for all UCLA Health staff called “Anyone Can Be An Ally, Speaking Up for an LGBT Inclusive Workplace.  • This video demonstrates how anyone can be an “ally” in helping to create a respectful workplace that is inclusive of gay, lesbian, bisexual and transgender co-workers. • It can help employees and managers build bridges of mutual respect and provide skills to become allies who speak up on behalf of others.  It is not about changing the beliefs of others, but about changing behaviors and putting a face on the issues confronting LGBT workers. •  You can find it on the UCLA Health System Human Resources website under Training and the e-Learning Library.  Click on the Anyone Can Be An Ally link to watch.  • It is not a specific requirement yet, but it is an important issue to address and this video is a valuable tool to open up the discussion in a department staff meeting or huddle. 

10. Training & Development / E-Learning Library Department Specific Required Training · All Can Prevent A Fall · Annual EKG Competency · Annual Nursing Department Test  · Annual Stroke Training · Annual Chemotherapy Training (Chemo Verified RNs Only) · Anyone Can Be An Ally · Call Bell Training for Med/Surg · Call Bell - ICU Training · Call Bell - Response Training - Video Only Training · Call Bell - ICU Do-Over Video · Call Bell - Response Training Video · Capnography Learning Module for Procedural Sedation · Central Venous Catheter Care Training (RN's Only)  · Clinical Care Partners - Role In Safety · HBS - Time and Attendance System · HIPAA Privacy and Information Security Training for New Workforce Members · Improving Patient Experience Through Communication About Medication · MedSled Training · Safe Patient Handling Training · Sepsis Training · UCLA Bariatric Inservices .

11. Standard HR.01.07.01 The Hospital Evaluates Staff Performance Elements of Performance: EP 1: The hospital evaluates staff based on performance expectations that reflect their job responsibilities. EP 2: The hospital evaluates staff performance once every 3 years, or more frequently as required by hospital policy or in accordance with law and regulation. • UCLA Health System policy requires every employee to receive a performance evaluation once every 12 months.

12. Standard HR.01.07.01 The Hospital Evaluates Staff Performance Supportive Finding / Explanation: • Performance Evaluations shall be completed for all employees, at every level in the organization, at least every twelve (12) months by the employee's immediate supervisor or designee. • A grace period of 60 days is in place to allow for completion, meeting with the employee and signature gathering. Employees are evaluated on all duties described on their Job Description. The job description and the performance evaluation are a combined tool to insure all elements of the job description are reviewed and evaluated annually.

13. Must check one or both boxes Must fill in eval period dates Must check applicable age groups

14. This content is the most current

16. New PE Content Soon To Come… • INSTITUTIONAL AND/OR PROFESSIONAL STANDARDS • Comply with HIPAA and Confidentiality Policies and Procedures as they apply to the job • Comply with Department of Public Health (DPH), The Joint Commission and other accreditation and regulatory agencies standards • Adhere to all Hospital Policies and Procedures • Knowledge and adherence to Infection Control and Environment of Care Guidelines and Procedures as described in the annual education module • Demonstrate adherence to the requirements for using the electronic medical record • Demonstrates understanding of institutional and department specific emergency management procedures/responsibilities to maintain personal, patient, and co-worker safety, maintains competencies in these areas, and participates in disaster/emergency related exercises and education. • Demonstrates understanding of institutional and department specific safe patient handling procedures/responsibilities and maintain a level of competency on the proper use of departmental lift equipment to ensure personal, co-worker and patient safety

17. Must check required boxes! SKA section must be completed if form being used as a JD Specify Required or Preferred.

18. Evaluator needs to complete this section for final comments Evaluator needs to complete this section so employee knows what goals are for next year Employee needs to identify any education changes here • Date signed MUST be within 60 days of period of evaluation identified on first page of form • HR Tracking Entry: • **date signed on eval is entered as “date completed” in PE field • ** “date expiring” is based on end date of period of evaluation identified on first page (month and day) and one year later

19. Form can be found on HR website under HR Requirements & Forms HR File Review Form

20. Upcoming Surveys CMS Transplant Survey Patient Safety Licensing Survey TJC Hospital Licensing Survey (by August 2013) • All surveys in open window for a visit • No announced dates • File Review Session will be part of all surveys • Please call HR if you have any Questions