Health Care Staffing Certification Written Documentation Requirements 2010
Appendix C Certification Review Process: Documentation Requirements This table is provided as a reference that can be used by both the health care staffing services (HCSS) firm and the reviewer. In some instances, documentation is required to demonstrate compliance with standards and elements of performance (EPs). In other situations, documentation may help the reviewer determine if requirements are met; however, the standards and EPs do not require the organization to have material available in writing. In those instances, the HCSS firm will demonstrate compliance with the standards and EPs by using other methods. HCSS Refreshed Core, January 2010 AXC 1
Leadership Standards HSLD.1 The HCSS firm clearly defines its leadership roles. Organizational chart Health information and personnel records HSLD.2 The HCSS firm has a code of business ethics. Written code of business ethics Marketing materials Health Care Staffing Services Certification Manual HSLD.3 The HCSS firm addresses existing or potential conflicts of interest related to its internal and external relationships. HSLD.4 The HCSS firm complies with applicable laws and regulations. HSLD.5 The services contracted for by the HCSS firm are provided to customers. HSLD.6 The HCSS firm is accessible to customers and staff. HSLD.7 The HCSS firm addresses the resolution of complaints from customers and staff. HSLD.8 The HCSS firm identifies and takes steps to reduce safety risks. HSLD.9 The HCSS firm addresses emergency management. Written agreements Written description of complaint process Written emergency management plan Marketing materials Laws and regulations List of customers List of subcontractors Marketing materials Blinded copy of complaints, including resolution information Occupational safety reports or logs Near miss and sentinel event (example: root cause analysis) reports Hazard vulnerability analysis Employee and customer handouts Results of plan testing and annual updates HCSS Refreshed Core, January 2010 Continued on next page AXC 2
Appendix C Human Resources Management Standards HSHR.1 The HCSS firm confirms that a person s qualifications are consistent with his or her assignment(s). HSHR.2 As part of the hiring process, the HCSS firm determines that a person s qualifications and competencies are consistent with his or her job responsibilities. HSHR.3 The HCSS firm provides orientation to clinical staff regarding initial job training and information. Health information records Written policy List of active staff, by professional discipline List of current staff, by professional discipline Materials given to customers that outline competence and qualifications Job descriptions Orientation materials Examples of assignments/placements HCSS Refreshed Core, January 2010 AXC 3 HSHR.4 The HCSS firm assesses and reassesses the competence of clinical staff and clinical staff supervisors. Competency and assessment materials HSHR.5 The HCSS firm encourages the improvement of clinical staff competence through ongoing educational activities. Formal educational activities, either offered to clinical staff or to which clinical staff are referred Performance measurement data HSHR.6 The HCSS firm evaluates the performance of clinical staff. Performance evaluation forms, by discipline Analysis of negative trends of clinical staff performance Continued on next page
Information Management Standards HSIM.1 Information management processes meet internal and external List of active customers information needs. HSIM.2 The HCSS firm maintains health Health information records information and personnel records for clinical staff. Health Care Staffing Services Certification Manual HSIM.3 The HCSS firm preserves the confidentiality and security of information about clinical staff and customers. HSIM.4 The HCSS firm has a process for maintaining continuity of information. Written policy Staff and customer handouts Business continuity plan Continued on next page HCSS Refreshed Core, January 2010 AXC 4
Appendix C Performance Measurement and Improvement Standards HSPM.1 The HCSS firm plans an organized, comprehensive approach to performance improvement. HSPM.2 The HCSS firm maintains the quality and integrity of its data. Performance improvement plans Performance improvement reports HCSS Refreshed Core, January 2010 AXC 5 HSPM.3 The HCSS firm collects data to evaluate Performance measure data reports processes and outcomes. Current and past customers list HSPM.4 The HCSS firm analyzes its data. Data analysis tools Performance improvement plans