Fundamental accreditation review series. Human resources April 12, 2016

Transcription

1 Fundamental accreditation review series Human resources April 12, 2016

2 Vizient: your accreditation partner A key element of an organization focused on patient safety and performance excellence is their leadership. Structure, responsibilities, accountability, process and operation requirements are outlined in a variety of Centers for Medicare & Medicaid Services (CMS) conditions of participation, as well as voluntary accrediting body requirements. We are here to help. This webinar series is just one way we connect you to the latest requirements and the strategies for operating within them. Today, you ll learn about the fundamentals of human resources from the perspective of the condition of participation, with additional details from The Joint Commission (TJC) human resources standards. 2

3 Faculty Natalie Webb, BS, RN, CPHQ Program manager, PI collaboratives & advisory (317) Jenny Manderino, RN, MSN Adviser, Accreditation LifeCare Oklahoma/Arkansas (620)

4 Disclosure information Neither Natalie Webb nor Jenny Manderino has any relevant financial or nonfinancial relationships to disclose. 4

5 Objectives Recite one expectation of the accreditation standards/regulatory requirements for human resources Summarize effectively an organization s current process to meet the intent of the standards/regulatory requirements Describe how the accreditation/regulatory process positions organizations for effective and reliable delivery of safe, high quality patient care 5

6 Polling questions: Does your organization have a centralized process for validating primary source licensure, or is each manager required to do primary source validation? 1. Centralized process 2. Department manager 3. Combination of centralized and local How often does your organization assess staff competency? 1. Annually 2. Every two years 3. Every three years 4. Other 6

7 Human resources is the most important contribution to the quality of health care because the performance of health care systems depends ultimately on the knowledge, skills and motivation of the people responsible for delivering services World Health Report 2000 Health Systems 7

8 Human resources standards

9 Human resources standards foundational requirements Organizations must: Have the necessary staff to support the patient care it provides Define staff qualifications Verify staff qualifications Determine how staff function within an organization Provide orientation to staff Provide ongoing education and training Ensure staff are competent Evaluate staff performance 9

10 Hospital has necessary staff to support the care, treatment and services provided Qualified dietician on a full-time, part-time, or consultative basis Full-time, part-time, or consulting pharmacist develops, supervises and coordinates all the activities of the pharmacy department or pharmacy services Pertinent requirements CMS CoP TJC HR Pharmaceutical services Staffing 10

11 Hospital defines staff qualifications Define staff qualifications specific to job responsibilities Pertinent requirements CMS CoP Nursing services CMS CoP CMS CoP CMS CoP CMS CoP CMS CoP CMS CoP CMS CoP CMS CoP CMS CoP CMS CoP TJC HR Medical records Radiologic services Food & dietetic services Discharge planning Surgical services Nuclear medicine services Outpatient services Emergency services Rehabilitation services Respiratory care services Qualifications 11

12 Hospital verifies staff qualifications Law and regulation requires providers to be 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 credentials are renewed Verify and document that applicant has education and experience required by job responsibilities Obtains criminal background checks and is documented Comply with health screening and is documented Nonemployees brought into the hospital by licensed independent practitioner (LIP) have same qualifications and competencies required by employed individuals performing the similar services 12

13 Hospital verifies staff qualifications Physician assistant and advanced practice registered nurses who practice within the hospital are credentialed, privileged, and reprivileged through the medical staff process or an equivalent process The equivalent process for mid-level practitioners is approved by the governing body - Evaluation of applicant credentials - Evaluation of applicant current competency - Peer recommendations - Input from individuals and committees, including medical executive committee 13

14 Hospital verifies staff qualifications Hospital verifies and documents that diagnostic medical physicists who support CT services have board certification in: - Diagnostic radiologic physics or - Radiologic physics By: - American Board of Radiology, or - In diagnostic imaging physics by the American Board of Medical Physics, or - In diagnostic radiological physics by the Canadian College of Physicists in Medicine, or Meet the following requirements: - Graduate degree in physics, medical physics, biophysics, radiologic physics, medical health physics, or a closely related science or engineering discipline from an accredited college or university 14

15 Hospital verifies staff qualifications Meet the following requirements: Graduate degree in physics, medical physics, biophysics, radiologic physics, medical health physics, or a closely related science or engineering discipline from an accredited college or university College coursework in the biological sciences with at least one course in biology or radiation biology and one course in anatomy, physiology or similar topic Documented experience in a clinical CT environment conducting at least 10 CT performance evaluations under direct supervision of a board certified medical physicist 15

16 Hospital verifies staff qualifications Pertinent requirements CMS CoP CMS CoP Compliance with federal, state and local laws Governing body CMS CoP CMS CoP CMS CoP CMS CoP CMS CoP CMS CoP CMS CoP CMS CoP TJC HR Medical staff Nursing services Food and dietetics Surgical services Outpatient services Emergency services Rehabilitation services Respiratory care services Qualifications 16

17 Hospital determines how staff function within the organization Staff possess a current license, certification or registration TJC deficiency can trigger a situational condition Staff practice within the scope of their license, certification or registration TJC deficiency can trigger a situation condition Staff oversee the supervision of students Pertinent requirements CMS CoP CMS CoP CMS CoP TJC HR Nursing services Surgical services Rehabilitation services Qualifications 17

18 Hospital provides orientation to staff Hospital decides key safety content of orientation provided to staff Hospital orients staff to key safety content before they provide care Orientation is documented Hospital orients staff on: - Key safety content (fire, infection control, etc.) - Relevant hospital-wide and unit-specific policies and procedures - Sensitivity to cultural diversity - Patient rights 18

19 Hospital provides orientation to staff Hospital orients external law enforcement and security personnel on the following: How to interact with patients Procedures for responding to unusual events and incidents The hospital's channels of clinical, security and administrative communication Distinction between the Pertinent requirements administrative and clinical CMS CoP seclusion and restraint CMS CoP Patient rights Nursing services CMS CoP CMS CoP TJC HR Physical environment Infection control Orientation 19

20 Staff participate in ongoing education and training Staff participate in ongoing education and training, and then when job responsibilities change Staff participate in education and training that: - Is specific to the needs of patient population served by the hospital - Incorporates 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 - Fall reduction activities Provides education and training on identifying early warning signs of a change in a patient s deteriorating condition and how to respond Above education and training is documented 20

21 Staff participate in ongoing education and training Hospital verifies and documents technologists who perform CT exams participate in ongoing education that includes annual training on the following: Radiation dose optimization techniques and tools for pediatric and adult patients addressed in the image Gently and Image Wisely campaigns Safe procedures for operation of the types of CT equipment they will use 21

22 Staff participate in ongoing education and training Hospital verifies and documents that technologists, who perform MRI examinations, are attending ongoing education that includes annual training on safe MRI practices in the MRI environment, including the following: Patient screening criteria that addresses ferromagnetic items, electrically conductive items, medical implants and devices and risk for nephrogenic systemic fibrosis Proper patient and equipment positioning activities to avoid thermal injuries Equipment and supplies that have been determined to be acceptable for use in the MRI environment MRI safety responses and MRI shutdown procedures Patient hearing protection Management of patients with claustrophobia, anxiety, or emotional distress TJC HR Pertinent requirements Training and education 22

23 Staff are competent to perform their responsibilities Define competencies it requires of its staff who provide patient care Use assessment methods to determine the individual s competence - Test taking, return demonstration or use of simulation Individual with the educational background, experience or knowledge related to the skills being reviewed assesses competence Staff competence is initially assessed and documented as part of orientation Staff competence is assessed and documented once every three years or more frequently as required by hospital policy Hospital takes action when staff competence does not meet expectations 23

24 Staff are competent to perform their responsibilities Pertinent requirements CMS CoP CMS CoP CMS CoP CMS CoP CMS CoP CMS CoP CMS CoP CMS CoP TJC HR Nursing services Radiologic services Food and dietetics Nuclear medicine services Outpatient services Emergency services Rehabilitation services Respiratory care services Competence 24

25 Hospital evaluates staff performance Staff are evaluated based on performance expectations that reflect their job descriptions Staff are evaluated once every three years or more frequently as required by hospital policy - Evaluations are documented LIP brings a nonemployee into the hospital to provide care, the hospital reviews the individuals competencies and performance at the same frequency as individuals employed by the hospital Pertinent requirements HR Evaluation of performance 25

26 Hiring process Clearly established requirements Primary source verification (as applicable) Interview Reference check Health screening (as applicable) Established, thorough process 26

27 Understanding the human resources education requirements Orientation Annual and ongoing education Competency 27

28 Orientation Organization orientation One-time event Organization welcome and first impression Key leader involvement Varied teaching methods Provide documented references and resources Required for all personnel Organizational policies and procedures Organization policies and procedures Required education: infection control, cultural diversity, fire safety, etc. Department and position-specific orientation At hire Position changes new duties added, transfers to new or different unit Unit manager involvement, key unit educators, preceptors Provide documented references and resources Required for all personnel Department-specific policies and procedures Department-specific skills checklist 28

29 Annual ongoing education Done at a set time (annually, bi-annually, triennially) Most organizations use computer-based training delivery applications Includes required education such as fire safety, corporate compliance, abuse and neglect, etc. 29

30 Competency Initial competency Documentation required Completed within a predetermined timeframe Varied according to position Needs to be assessed by someone with similar skill Includes various assessment methods Ongoing competency and training Documentation is required Timing of renewal will vary depending on competency Training implies an ongoing program to provide enhanced training, refresher training, or new training to support new requirements Periodic needs assessments or tracer results will help define training needs Needs to be performed by someone with similar clinical skills knowledge Includes various assessment methods Specific based on position 30

31 Survey process

32 What to expect when competence is surveyed Suggested participants: Staff responsible for: Human resources (HR) process Orientation and education Assessment of competence Staff whose files are being reviewed For TJC surveys the session duration is generally 30 to 60 minutes and is typically held toward the latter part of the survey 32

33 What to expect when competence is surveyed Surveyors are interested in: Learning about organization s HR process Learning about organization s orientation - Is it standard for employees as well as contract staff? - Is it consistent from department to department? - Is it consistent for disciplines that work in a variety of departments? Staff that the surveyor has encountered during individual tracers and department visits are likely to be interviewed, and their files are likely to be pulled for review Documentation related to the content of orientation, education and training 33

34 HR top survey findings from 2015

35 2015 survey findings HR file review hospital was not able to provide documentation that they had defined specific qualifications for the infection preventionist Hospital policy on language interpretation does not specify the qualifications for staff member to be utilized as a translator or how those qualifications would be verified Primary source licensure verification was completed after the license had expired and been renewed Primary source licensure verification was done after the date of hire Review of contracted non-licensed scribe it was noted that the organization had no process in place to verify and document the education required in the job description. The organization required either a high school diploma or a GED. 35

36 2015 survey findings Registered radiology technologist with additional MRI qualifications required re-registration. The organization did not verify the re-registration before expiration. Primary source verified but no documentation of date completed Late primary source verification of LPN, social workers, respiratory therapist, RN, pharmacist ER nurses BLS and ACLS certification had expired. Hospital required current BLS and ACLS Radiology practitioner assistant practices out of the scope of licensure Organization did not determine key safety content of orientation for contracted housekeeping staff Phlebotomist did not have documentation of ongoing competency L&D RN did not have documented competency related to caring for the c-section patient population 36

37 2015 survey findings Sterile processing technician had initial orientation and competency assessment in Additional competency assessment regarding sterilization procedures occurred in 2006 no other competency assessment related to this critical job component was documented in the file. Sterile processing technician responsible for processing surgical instruments had initial orientation and competency. The competency assessment included assessment of high-level disinfection of endoscopes, but did not include assessment of competency for autoclave testing. IMMEDIATE THREAT TO HEALTH AND SAFETY 37

38 2015 survey findings There was no documented evidence that a employee who was processing TEE probes had any education, training or competency for cleaning and high-level disinfection for the TEE probes. During tracer activity the nurses did not know how to identify which alarms were sounding. In addition, the nurses did not know the limits that the monitors should be set on. HR files did not contain evidence of education and training for fall reduction activities Infection preventionist and social worker did not have defined competencies on file No competencies were developed or used for individuals that were cleaning and disinfecting the endoscopes in the clinic setting Hospital could not show evidence that an assessment method to determine competency of the dietician was determined 38

39 2015 survey findings Pharmacist working in pediatrics, PICU and NICU did not have any defined competencies in the areas assigned RN assessed skills/competency of social worker and occupational therapist. There was no input from staff who had same educational background and skills of social worker or occupational therapist There was no documented evidence that the dietitian s competence was initially assessed as part of orientation Lead pulmonary equipment aide had no documentation of competence assessed over two years for cleaning and low-level disinfection requirement for respiratory equipment RN who provided moderate sedation to patients in the cath lab had not had education regarding moderate sedation management in two years. Hospital policy stated moderate sedation competency was to be evaluated and documented during orientation and then annually. 39

40 Summary 1. Define and document qualifications and responsibilities for all positions (front line to C-suite) 2. Define requirements for orientation, training and competency Hospital-wide Department-specific Position-specific 3. Establish timeframes for orientation, training and competency assessment 4. Document orientation, training and competency assessment At hire When job changes 40

41 Polling results: Does your organization have a centralized process for validating primary source licensure, or is each manager required to do primary source validation? 1. Centralized process 2. Department manager 3. Combination of centralized and local How often does your organization assess staff competency? 1. Annually 2. Every two years 3. Every three years 4. Other 41

42 Questions

43 2016 Fundamental Accreditation Review Series schedule Human Resources Webinar Description Date Times Basic Review of CMS Conditions of Participation and other voluntary accreditation requirements related to the monthly topics; review of organization s process to meet the fundamental intent positioning organizations for effective/reliable delivery of safe, high, quality care. Eastern Central Mountain Pacific April 12, 2016 noon-1:30 p.m. 11 a.m.-12:30 p.m :30 a.m. 9-10:30 a.m. Medication Management May 10, 2016 noon-1:30 p.m. 11 a.m.-12:30 p.m :30 a.m. 9-10:30 a.m. Environment of Care/Life Safety June 14, 2016 noon-1:30 p.m. 11 a.m.-12:30 p.m :30 a.m. 9-10:30 a.m. Emergency Management July 12, 2016 noon-1:30 p.m. 11 a.m.-12:30 p.m :30 a.m. 9-10:30 a.m. Rights and Responsibilities of the Individual Aug. 9, 2016 noon-1:30 p.m. 11 a.m.-12:30 p.m :30 a.m. 9-10:30 a.m. Provision of Care Sept. 13, 2016 noon-1:30 p.m. 11 a.m.-12:30 p.m :30 a.m. 9-10:30 a.m. Infection Prevention and Control Oct. 11, 2016 noon-1:30 p.m. 11 a.m.-12:30 p.m :30 a.m. 9-10:30 a.m. Transplant Safety/Waived Testing Nov. 8, 2016 noon-1:30 p.m. 11 a.m.-12:30 p.m :30 a.m. 9-10:30 a.m. Information Management/Record of Care (Practice and Documentation) Dec. 13, 2016 noon-1:30 p.m. 11 a.m.-12:30 p.m :30 a.m. 9-10:30 a.m. Register here for the webinar series or contact Darlene Long, member support specialist, at [email protected] for more information. 43

44 2016 Advanced Accreditation Education Series schedule Webinar Description Date Times Eastern Central Mountain Pacific Medication Management: Opioid Utilization/Safety CMS and CDC have highlighted the safety issues associated with opioid utilization. This program will address some of the recommended assessments and strategies for addressing these issues. May 23, 2016 noon-1:30 p.m. 11 a.m.-12:30 p.m :30 a.m. 9-10:30 a.m. Adverse Decision Process/Response and Recovery Organizations are getting hit with condition level findings as well as adverse accreditations, this program will explore the response and recovery process. June 27, 2016 noon-1:30 p.m. 11 a.m.- 12:30 p.m :30 a.m. 9-10:30 a.m. Health IT Management Studies have shown that while electronic medical records have introduced efficiencies, they have also presented safety challenges. This program will cover information about safe practices. July 25, 2016 noon-1:30 p.m. 11 a.m.- 12:30 p.m :30 a.m. 9-10:30 a.m. Radiology Standards: MRI/Zones/Mobile Units An overview of radiology standard revisions including Safe MR Practice utilizing a zone floor plan and controlled access as well as requirement for mobile units will be covered during this webinar. Aug. 22, 2016 noon-1:30 p.m. 11 a.m.- 12:30 p.m :30 a.m. 9-10:30 a.m. Contract Management CMS requires a consistent, systematic method for monitoring performance and quality of contract services. The objective of this program is to highlight recommended review methodologies. Sept. 26, 2016 noon-1:30 p.m. 11 a.m.- 12:30 p.m :30 a.m. 9-10:30 a.m. Infection Control Sterilization, high-level disinfection, low-level disinfection all top the list of most problematic issues. During this program, the goal will be to help organizations identify strategies to ensure continuous readiness for patients. Oct noon-1:30 p.m. 11 a.m.- 12:30 p.m :30 a.m. 9-10:30 a.m. Home Care Program The Home Care regulatory landscape changes each year. This program will review new, revised and problematic issues relative to Home Care Accreditation. Nov. 28, 2016 noon-1:30 p.m. 11 a.m.- 12:30 p.m :30 a.m. 9-10:30 a.m. Register here for the webinar series or contact Darlene Long, member support specialist, at [email protected] for more information. 44

45 Accreditation advisory services For information on our comprehensive accreditation advisory services, contact Diana Scott, senior director, accreditation programs, at 45

46 Contact Natalie Webb at for more information on upcoming accreditation education programs. This information is proprietary and highly confidential. Any unauthorized dissemination, distribution or copying is strictly prohibited. Any violation of this prohibition may be subject to penalties and recourse under the law. Copyright 2016 Vizient, Inc. All rights reserved.