GENERAL ADMINISTRATIVE: CLINICAL COMPETENCE ASSESSMENT

Transcription

1 GENERAL ADMINISTRATIVE: CLINICAL COMPETENCE ASSESSMENT Date Effective: 02/12 Page 1 of 5 I. PURPOSE: To provide guidelines for assessing, verifying and documenting staff competence. The Joint Commission on Accreditation of Health Care Organizations, State of California standards and regulatory requirements mandate staff competencies be assessed, verified and documented. In order to meet these requirements, the Medical Center maintains a system of initial and periodic employee competency validation. Reference and authority for this policy are cited below. II. POLICY: It is the policy of UC Irvine Medical Center to ensure qualified personnel provide care for our patients. The policy outlines how we assess and maintain staff competence (Attachment A ). Related Policies and Procedures: Performance Evaluation Licensure and Certification Annual Review Compliance Policy Background Check Supplemental Agency Patient Care Staff Date Written: 09/97 Prior Revision Dates: 05/06; 05/09 Author: Connie Worden, Approvals: No Changes February 25, 2012 No Changes May 4, 2009 Policy Review Committee February 4, 2003 Performance Improvement Committee February 12, 2003 Med Exec Committee February 24, 2003 Governing Body February 24,

2 Page 2 of 5 Attachment A PROTOCOL RESPONSIBLE PERSON(S)/DEPARTMENT Mechanisms for Competence Assessments: 1. Departmental Orientation Checklist. 2. Position Specific Orientation. 3. Initial Competency Assessment and Validation. 4. Annual Performance Evaluation (based on performance standards derived from the job description). 5. Employee Annual Update competency validation. 6. Employee Education Inventory. 7. Initial and ongoing licensure, registration and certification validation. Required Actions: 1. Determines the specific qualifications and competencies and establishes a job description for each position. 2. Reviews all job descriptions and competency requirements and revises as needed. 3. Ensures all documents related to competence assessment are complete and present in the employee files. 4. Maintains the employee files, which will include the following records: a. Current Job Description (HR Connect) b. Documentation of required current license, registration and/or certification, as applicable (Department c. Documentation of Initial Competence Assessment & Validation and Department Orientation (Department d. Employee Education Inventory (UC Learning) e. Certification of completion of Medical Center Orientation (UC Learning) f. Annual Performance Evaluation based on performance standards derived from the job description (HR Connect) g. Annual/ongoing competency assessment (Department h. Employee Annual Review (HR Connect) i. Age-Specific Competencies as applicable (Department 5. Transfers the above documents from an employee s departmental file to another department when the employee 2

3 Page 3 of 5 transfers to another department. 6. Maintains the personnel file which will include the following records: a. Application for Employment b. Job Description Prospective Employee / CNS/Educator 7. Completes an annual performance evaluation for each employee, and in conjunction with the CNS/Educator, will take appropriate action when competence is rated below standard. Options include coaching, retraining, implementation of performance improvement plans and/or corrective action as provided by policies or labor agreements. Competence Prior to Employment 1. Prior to an employment offer, the prospective employee shall be provided with a job description summary describing the qualifications, competencies, licensure, education and training required for the position. 2. The hiring authority or designee will interview the applicant and evaluate his/her training, education, experience, clinical skill level, licensure, and certification status. 3. The department shall conduct confidential background checks and verifications of previous employment on all final candidates for employment. Documentation of the background check and employment verification will be kept in a separate secure file. 4. The prospective employee will provide evidence of current licensure, registration and certification prior to the first day of work as appropriate. The prospective employee will not be cleared to work in his/her position until the documents are presented. Initial Competency Assessment and Validation 1. Ensures each employee s competence is assessed and documented as a component of the orientation to the organization, the department and the position. 2. Utilizes various methods to assess competence including, but not limited to: direct observation, chart reviews, written or oral examinations, return demonstration in a skills lab, self learning module with self test and direct interview, and CBT. 3. Ensures independent work assignments shall include only those duties and responsibilities for which competency has been validated. 4. Verifies initial competencies are demonstrated and ensures the documentation of competence will be placed in the departmental personnel file. 5. Understands that failure to demonstrate required competencies 3

4 Page 4 of 5 may result in corrective action, up to or including the employee s release from probation according to the terms of specific policy/labor contracts. 6. Identifies the critical competencies required for individuals who are not normally assigned to the unit, but provide patient care occasionally as a secondary assignment. Individuals are responsible for demonstrating these competencies and the manager (or designee) is responsible for providing to the primary manager (or designee) feedback related to competencies in the secondary unit. The completion of these competencies should also be documented and maintained in the employee file 7. Ensures competence assessment is complete on all employees who change departments and transfer into a new position. Director of Volunteers Hiring Authority Chancellor s Designee Performance Evaluation Ensures that the competence of all staff members is maintained, demonstrated, and improved on a continuing basis by conducting an annual performance evaluation according to the Performance Evaluation policy. Currency of Job Requirements Ensures required licenses, registrations and certifications are maintained according to the License and Certification Policy. Annual Report to the Governing Body Collects aggregate data from performance evaluations, stratified by skill type, annually. Staff learning needs will be identified based on analysis of this data and incorporated into the annual Report to the Governing Body. This information serves as a basis for formulation and implementation of the hospital-wide Education Plan. Volunteers 1. Ensures all volunteers complete Medical Center orientation. 2. Ensures all volunteers are competent in performance of their duties. Supplemental Staffing Services The competency of staff provided by contracted Supplemental Staffing Services is ensured as documented in the Supplemental Staffing policy. Medical Staff Oversees competence of the Medical Staff in accordance with the requirements of the Medical Staff Bylaws, Rules and Regulations, Medical Staff Policy and applicable regulatory agencies. 4

5 Page 5 of 5 Interdisciplinary Practices Committee Contracting Authority Allied Health Professionals Allied Health Professionals are granted services authorization through the UC Irvine Medical Staff under the auspices of the Interdisciplinary Practices Committee, in accordance with the requirements of the Medical Staff Bylaws, Rules and Regulations, Medical Center policy and applicable regulatory agencies. The following titles are included: a. Licensed Clinical Psychologist b. Certified Nurse Anesthetist c. Nurse Practitioner d. Physician s Assistant Clinical Contracted Services The competence of individuals providing patient care services through Clinical Service Contracts is evaluated in keeping with the terms and conditions of those contracts and this policy. 5