SHORE HEALTH SYSTEM DEPARTMENT OF NURSING POLICY SUBJECT: SHS NURSING SUPPLEMENTAL STAFF: DATE ESTABLISHED: 3/91



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Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 SHORE HEALTH SYSTEM DEPARTMENT OF NURSING Page 1 of 16 POLICY SUBJECT: SHS NURSING SUPPLEMENTAL STAFF: DATE ESTABLISHED: 3/91 REVISED: Effective 5/23/04, 8/10, 3/13 CROSS REFERENCE: REVIEWED: 1/08 1. Call-In Policy 2. Unit Based Competency Assessment Policy 3. Floating of Nursing Staff 4. Annual Education Update: HR -9 PURPOSE: To provide licensed and unlicensed staff to acute care inpatient units, emergency and surgical services within SHS as supplemental staff to meet patient care requirements. 1.0 Supplemental staff are 1.1 Employees of Shore Health System. 1.2 Utilized as adjuncts to the core staff on the individual units/departments to promote patient care. 1.3 May or may not receive benefits based on employment status. 2.0 Various employment statuses have been created to mutually meet the needs of Shore Health System and its employees. Employment statuses include: 2.1 Unit Based Relief 2.2 Supplemental Pool Relief 2.3 Supplemental Pool Per Diem 2.4 Supplemental Pool Per Diem ED RN Level 2 2.5 Supplemental Pool Per Diem RN QAEC only 2.6 MHE and DGH Float RNs 2.7 SHS Float RNs 2.8 Short Term Assignments 3.0 Specific requirements for each employment status are included in the following tables. Job Code: RN 4405 NT 3501 Collegiate - 4410 Unit Based Relief Unit secretary 2218 Surgical Tech - 3333 Experience Unlicensed staff - No specific requirement RN Novice Nurses must successfully complete SHS novice nurse program, no specific requirement for 1

Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 POLICY: SHS NURSING SUPPLEMENTAL STAFFING POOL Page 2 of 16 Required Worked Hours experienced nurses Minimum of 24 hours every 12 weeks Employees that, for a period of time are unable to meet the above commitment must Request a leave of absence from their Nurse Manager If employee has not worked in 6 months, MUST contact manager for remediation prior to working another shift No guaranteed hours ***Operating Room: 1. MUST be scheduled to work a minimum of 8 hours per pay period due to complexities of technology in the operating rooms. 2. In order to take call, must actually work a minimum of 32 hours/month in those specialties most often experienced during call time. 3. If at any time, the competency of the individual comes under question additional time on the unit may be required in order to re-establish competency and maintain employment Salary Based on years of experience All shift differentials and holiday pay are the same as those established for regular employees Reporting Structure Assigned Unit Nurse Manager Scheduling Unit based Relief: Per unit based guidelines Orientation New employee orientation Two day supplemental staff orientation Precepted unit orientation: Initial area of competency orientation should only require approximately 40 80 clinical hours Floating Unit based Relief: Per unit based guidelines Cancellation Occurs in 4 hour blocks. will only be cancelled for 4 hours once in a shift. (e.g. If scheduled 0700 to 1930 and not needed at 0700, the employee will be cancelled until 1100. If still not needed at 1100, staffing needs at 1500 need to be determined. If the employee will be needed at 1500, the employee will be offered the option to volunteer to stay home until 1500 hours or the employee will be expected to report to work at 1100. If it is determined that the employee will not be needed at 1500, the employee will be cancelled at 1100 for the remainder of the shift.) Call Based on unit guidelines Performance 90 day provisional 2

POLICY: SHS NURSING SUPPLEMENTAL STAFFING POOL Page 3 of 16 Appraisal Annual based on hire date Self & Peer evaluations must be completed and submitted to assigned Nurse Manager at least one month prior to annual appraisal. This is required for all RNs. Managers of some units may require unlicensed staff to complete self and peer evaluations. Must bring current skills checklist, updated nurse credentialing page, copy of nursing license, copy of BLS, ACLS, PALS, NNR card, and current national nursing certification as applicable. Employee encouraged to bring any additional documentation they desire for their evaluation (e.g. portfolio, etc.) Employee is to schedule an appointment with the manager to receive the annual appraisal on or before the due date. Every effort should be made to receive the appraisal in person. If this is not possible, a copy of the appraisal will be provided to HR. HR will send the appraisal by certified mail to the employee. If the signed appraisal is not returned within 30 days of the mailing, the appraisal will be placed in the employee s file with the mailing information. The appraisal date will be updated in Lawson. Employee Health Requirements Health Stream Education Required Certifications Professional Advancement Program Annual requirements due to be completed in assigned month of each calendar year Flu vaccine each fall per policy Annual education must be completed by October 1 st All additional assigned education must be completed by due dates Employee is responsible to check Healthstream every couple of weeks for added assignments. Required certifications such as ACLS, CPR, NNR, etc. Employees are required to achieve or renew these certifications on or before their expiration date. Not eligible Benefits None Staffing Roster Name appears on home unit cost center staffing roster Job Code: RN 4404 NT Supplemental Pool: Relief RN Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 Experience Unlicensed staff - No requirement RN Novice Nurses must successfully complete SHS 3

POLICY: SHS NURSING SUPPLEMENTAL STAFFING POOL Page 4 of 16 Required Worked Hours novice nurse program, no specific requirement for experienced nurses Minimum of 24 hours per every 12 weeks Employees that, for a period of time are unable to meet the above commitment must Request a leave of absence from their Nurse Manager If employee has not worked in 6 months, MUST contact manager for remediation prior to working another shift No guaranteed hours 4. Salary Based on years of experience All shift differentials and holiday pay are the same as those established for regular employees Reporting Structure Assigned Nurse Manager Assignment is made by the Staffing Coordinator who will notify the manager that the employee has been added to their list Scheduling Submit availability to Staffing Office Orientation New employee orientation Two day supplemental staff orientation Precepted unit orientation: Initial area of competency should only require approximately 40 clinical hours Floating MHE & DGH Cancellation Occurs in 4 hour blocks Call MHE & DGH Performance Appraisal Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 90 day provisional Annual based on hire date Self & Peer evaluations must be completed and submitted to assigned Nurse Manager at least one month prior to annual appraisal. This is required for all RNs Must bring current skills checklist, updated nurse credentialing page, copy of nursing license, copy of BLS, ACLS, PALS, NNR card, and current national nursing certification as applicable. Employee encouraged to bring any additional documentation they desire for their evaluation (e.g. portfolio, etc.) Employee is to schedule an appointment with the manager to receive the annual appraisal on or before the due date. Every effort should be made to receive the appraisal in person. If this is not possible, a copy of the appraisal will be provided to HR. HR will send the appraisal by 4

Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 POLICY: SHS NURSING SUPPLEMENTAL STAFFING POOL Page 5 of 16 Employee Health Requirements Health Stream Education Required Certifications Professional Advancement Program certified mail to the employee. If the signed appraisal is not returned within 30 days of the mailing, the appraisal will be placed in the employee s file with the mailing information. The appraisal date will be updated in Lawson. Annual requirements due to be completed in the month of May each calendar year Flu vaccine each fall per policy Annual education must be completed by October 1 st All additional assigned education must be completed by due dates Employee is responsible to check Healthstream every couple of weeks for added assignments. Required certifications such as ACLS, CPR, NNR, etc.- Employees are required to achieve or renew these certifications on or before their expiration date. Not eligible Benefits None Staffing Roster Name appears on the Supplemental Staff Cost Center Staffing Roster Daily Assignment Employee will call approximately 1 hour prior to the start of their shift to identify hospital and unit to report for duty For all shifts call the Staffing Office ext 5631 Job Code: RN- 4435 NT 3502 Sec/Tech US - 2250 Surg Tech- 3338 Supplemental Pool: Per Diem Experience 2000 hours recent acute care experience (within the last 5 years) for RN 1000 hours recent experience (within the last 5 years) as an unlicensed staff member for US, Sec/Tech, NT Required Worked Hours 150 hours per fiscal year (July 1 through June 30) Hours are prorated for employees starting after July 1 st Employees that, for a period of time are unable to meet the above commitment must Request a leave of absence from their Nurse Manager If employee has not worked in 6 months, MUST contact manager for remediation prior to working another shift 5

Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 POLICY: SHS NURSING SUPPLEMENTAL STAFFING POOL Page 6 of 16 No guaranteed hours ***Operating Room: 1. MUST be scheduled to work a minimum of 8 hours per pay period due to complexities of technology in the operating rooms. 2. In order to take call, must actually work a minimum of 32 hours/month in those specialties most often experienced during call time. 3. If at any time, the competency of the individual comes under question additional time on the unit may be required in order to re-establish competency and maintain employment Salary Based on clinical hours worked per pay period excluding non-clinical hours All shift differentials and holiday pay are the same as those established for regular employees Non clinical hours include, but are not limited to, orientation, mandatory education, and meetings which are paid at the base rate NT rate = $15/hr US rate = $12/hr RN rates are based on total hours worked per pay period Tier 1: 0 to 24 hr / PP = $32/hr Tier 2: 25 to 48 hr / PP = $36/hr Tier 3: 49 + hr/ PP = $40/hr Reporting Structure Assigned Nurse Manager Assignment is made by the Staffing Coordinator who will notify the manager that the employee has been added to their list Scheduling Submit availability to Staffing Office ED per diem RNs submit availability through webscheduler and ED managers complete schedule Orientation New employee orientation Two day supplemental staff orientation Initial Precepted unit orientation: Initial area of competency should only require approximately 40 clinical hours Additional areas of competency: Educator/Clinical Specialist, Nurse Manager, and Director of Nursing Resources will design in collaboration with employee Floating MHE & DGH Cancellation Occurs in 4 hour blocks Call Based on unit guidelines 6

Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 POLICY: SHS NURSING SUPPLEMENTAL STAFFING POOL Page 7 of 16 Performance Appraisal Employee Health Requirements Health Stream Education Required Certifications Professional Advancement Program 90 day provisional RNs - Annual due by May 31 st Unlicensed staff Annual due by April 30 th Self & Peer evaluations must be completed and submitted to your assigned Nurse Manager by April 30 th. This is required for all RNs Must bring current skills checklist, updated nurse credentialing page, copy of nursing license, copy of BLS, ACLS, PALS, NNR card, and current national nursing certification as applicable. Employee encouraged to bring any additional documentation they desire for their evaluation (e.g. portfolio, etc.) Employee is to schedule an appointment with the manager to receive the annual appraisal on or before the due date. Every effort should be made to receive the appraisal in person. If this is not possible, a copy of the appraisal will be provided to HR. HR will send the appraisal by certified mail to the employee. If the signed appraisal is not returned within 30 days of the mailing, the appraisal will be placed in the employee s file with the mailing information. The appraisal date will be updated in Lawson. Annual requirements due to be completed in May of each calendar Flu vaccine each fall per policy Annual education must be completed by October 1 st All additional assigned education must be completed by due dates Employee is responsible to check Healthstream every couple of weeks for added assignments. Required certifications such as ACLS, CPR, NNR, etc.- Employees are required to achieve or renew these certifications on or before their expiration date. Not eligible Benefits None Staffing Roster Name appears on Supplemental Staff Cost Center Staffing Roster Daily Assignment Employee will call approximately 1 hour prior to the start of their shift to identify hospital and unit to report for duty For all shifts call the Staffing Office ext 5631 Job Code: RN- Supplemental Pool: Per Diem ED RN Level 2 7

POLICY: SHS NURSING SUPPLEMENTAL STAFFING POOL Page 8 of 16 4447 Experience 2000 hours recent acute care experience Required Worked Hours 150 hours per fiscal year (July 1 through June 30) Hours are prorated for employees starting after July 1 st Employees that, for a period of time are unable to meet the above commitment must Request a leave of absence from their Nurse Manager If employee has not worked in 6 months, MUST contact manager for remediation prior to working another shift If employee has not worked in 6 months, MUST contact manager for remediation prior to working another shift No guaranteed hours Salary Based on hours worked per pay period, plus $2/hr All shift differentials and holiday pay are the same as those established for regular employees Reporting Structure Assigned Nurse Manager Scheduling Submit availability through webscheduler and ED managers complete schedule Orientation New employee orientation Two day supplemental staff orientation Initial Precepted unit orientation: Initial area of competency should only require approximately 40 clinical hours Additional areas of competency: Educator/Clinical Specialist, Nurse Manager, and Director of Nursing Resources will design in collaboration with employee Floating MHE, DGH, & QAEC Cancellation Occurs in 4 hour blocks Call Based on unit guidelines Performance Appraisal Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 90 day provisional RNs - Annual due by May 31 st Self & Peer evaluations must be completed and submitted to your assigned Nurse Manager by April 30 th. Must bring current skills checklist, updated nurse credentialing page, copy of nursing license, copy of BLS, ACLS, PALS, NNR card, and current national nursing certification as applicable. Employee encouraged to bring any additional documentation they desire for their evaluation (e.g. portfolio, etc.) Employee is to schedule an appointment with the manager to receive the annual appraisal on or before 8

POLICY: SHS NURSING SUPPLEMENTAL STAFFING POOL Page 9 of 16 Employee Health Requirements Health Stream Education Required Certifications Professional Advancement Program the due date. Every effort should be made to receive the appraisal in person. If this is not possible, a copy of the appraisal will be provided to HR. HR will send the appraisal by certified mail to the employee. If the signed appraisal is not returned within 30 days of the mailing, the appraisal will be placed in the employee s file with the mailing information. The appraisal date will be updated in Lawson. Annual requirements due to be completed in May of each calendar year Flu vaccine each fall per policy Annual education must be completed by October 1 st All additional assigned education must be completed by due dates Employee is responsible to check Healthstream every couple of weeks for added assignments. Required certifications such as ACLS, CPR, NNR, etc.- Employees are required to achieve or renew these certifications on or before their expiration date. Not eligible Benefits None Staffing Roster Name appears on Supplemental Staff Cost Center Staffing Roster Daily Assignment Employee will call approximately 1 hour prior to the start of their shift to identify hospital and unit to report for duty For all shifts call the Staffing Office ext 5631 Job Code: RN 4407 Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 Supplemental Pool: Per Diem RN QAEC only Experience 6000 hours recent acute care experience Required Worked Hours 150 hours per fiscal year (July 1 through June 30) Hours are prorated for employees starting after July 1 st Employees that, for a period of time are unable to meet the above commitment must Request a leave of absence from their Nurse Manager If employee has not worked in 6 months, MUST contact manager for remediation prior to working another shift If you have not worked in 6 months, MUST contact manager for remediation prior to working another shift No guaranteed hours Salary Based on hours worked per pay period 9

POLICY: SHS NURSING SUPPLEMENTAL STAFFING POOL Page 10 of 16 All shift differentials and holiday pay are the same as those established for regular employees Reporting Structure QAEC Nurse Manager Scheduling Submit availability to QAEC Orientation New employee orientation Two day supplemental staff orientation Precepted unit orientation: Initial area of competency should only require approximately 40 clinical hours Floating Work only at QAEC Cancellation Occurs in 4 hour blocks Call Based on unit guidelines Performance Appraisal Employee Health Requirements Health Stream Education Required Certifications Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 90 day provisional RNs - Annual due by May 31 st Self & Peer evaluations must be completed and submitted to your assigned Nurse Manager by April 30 th. Must bring current skills checklist, updated nurse credentialing page, copy of nursing license, copy of BLS, ACLS, PALS, NNR card, and current national nursing certification as applicable. Employee encouraged to bring any additional documentation they desire for their evaluation (e.g. portfolio, etc.) Employee is to schedule an appointment with the manager to receive the annual appraisal on or before the due date. Every effort should be made to receive the appraisal in person. If this is not possible, a copy of the appraisal will be provided to HR. HR will send the appraisal by certified mail to the employee. If the signed appraisal is not returned within 30 days of the mailing, the appraisal will be placed in the employee s file with the mailing information. The appraisal date will be updated in Lawson. Annual requirements due to be completed in May of each calendar year Flu vaccine each fall per policy Annual education must be completed by October 1 st All additional assigned education must be completed by due dates Employee is responsible to check Healthstream every couple of weeks for added assignments. Required certifications such as ACLS, CPR, NNR, etc.- Employees are required to achieve or renew these certifications on or before their expiration date. 10

POLICY: SHS NURSING SUPPLEMENTAL STAFFING POOL Page 11 of 16 Professional Not eligible Advancement Program Benefits None Staffing Roster Name appears on QAEC Staff Cost Center Staffing Job Code: RN - 4431 Roster MHE Float RNs DGH Float RNs Experience 2000 hours recent acute care experience Required Worked Based on hired FTE status Hours Salary Based on years of experience plus # of competencies ($1/hr above base rate) All shift differentials and holiday pay are the same as those established for regular employees Reporting Structure Director, Clinical/Financial Nursing Resources Scheduling Submit requests for time off to Staffing Office Submit vacation requests to Director, Nursing Resources Orientation New employee orientation Nursing orientation Initial Precepted unit orientation: Designed in collaboration with the Director Nursing Resources, Nurse Manager of unit involved, unit educator or clinical specialist and employee Additional areas of competency: Educator/Clinical Specialist, Nurse Manager, and Director of Nursing Resources will design in collaboration with employee Floating MHE Float primarily work at MHE DGH Float primarily work at DGH Cancellation Travelers, agency, per diem, & supplemental pool relief are cancelled prior to Float RN MHE & DGH Float RNs with 3 or more competencies are not cancelled Call Not required Performance Appraisal Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 90 day provisional Annual due by October 31st Self & Peer evaluations must be completed and submitted to Director, Nursing Resources in September Must bring current skills checklist, updated nurse credentialing page, copy of nursing license, copy of BLS, ACLS, PALs, NNR card, and current national nursing certification as applicable. Employee encouraged to bring any additional 11

POLICY: SHS NURSING SUPPLEMENTAL STAFFING POOL Page 12 of 16 Employee Health Requirements Health Stream Education Required Certifications Professional Advancement Program documentation they desire for their evaluation (e.g. portfolio, etc.) Annual requirements due to be completed in July of each calendar year Flu vaccine each fall per policy Annual education must be completed by October 1 st All additional assigned education must be completed by due dates Employee is responsible to check Healthstream every couple of weeks for added assignments. Required certifications such as ACLS, CPR, NNR, etc.- Employees are required to achieve or renew these certifications on or before their expiration date. Eligible Benefits Eligible Staffing Roster Name appears on Float Staff Cost Center Staffing Roster Daily Assignment Employee will call approximately 1 hour prior to the start of their shift to identify hospital and unit to report for duty For all shifts call the Staffing Office ext 5631 RN - 4432 SHS Float RNs Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 Experience 2000 hours recent acute care experience Required Worked Based on hired FTE status Hours Salary Based on years of experience plus # of competencies ($2/hr above base rate for SHS float) All shift differentials and holiday pay are the same as those established for regular employees Reporting Structure Director, Clinical/Financial Nursing Resources Scheduling Submit requests for time off to Staffing Office Submit vacation requests to Director, Nursing Resources Orientation New employee orientation Nursing orientation Initial Precepted unit orientation: Designed in collaboration with the Director Nursing Resources, Nurse Manager of unit involved, unit educator or clinical specialist and employee Additional areas of competency: Educator/Clinical Specialist, Nurse Manager, and Director of Nursing Resources will design in collaboration with employee Floating All nursing areas in SHS 12

POLICY: SHS NURSING SUPPLEMENTAL STAFFING POOL Page 13 of 16 Cancellation Travelers, agency, per diem, & relief are cancelled prior to Float RN SHS Float RNs are not cancelled Call Performance Appraisal Employee Health Requirements Health Stream Education Required Certifications Professional Advancement Program Not required 90 day provisional Annual due by October 31st Self & Peer evaluations must be completed and submitted to Director, Nursing Resources in September Must bring current skills checklist, updated nurse credentialing page, copy of nursing license, copy of BLS, ACLS, PALs, NNR card, and current national nursing certification as applicable. Employee is responsible to bring any additional documentation they desire for their evaluation (e.g. portfolio, etc.) Annual requirements due to be completed in July of each calendar year Flu vaccine each fall per policy Annual education must be completed by October 1 st All additional assigned education must be completed by due dates Employee is responsible to check Healthstream every couple of weeks for added assignments. Required certifications such as ACLS, CPR, NNR, etc.- Employees are required to achieve or renew these certifications on or before their expiration date. Eligible Benefits Eligible Staffing Roster Name appears on Float Staff Cost Center Staffing Roster Daily Assignment Employee will call approximately 1 hour prior to the start of their shift to identify hospital and unit to report for duty For all shifts call the Staffing Office ext 5631 RN - 4541 Short Term Assignments Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 Experience 2000 hours recent acute care experience Required Worked Based on hired FTE status Hours Salary $35/hr All shift differentials and holiday pay are the same as those established for regular employees 13

Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 POLICY: SHS NURSING SUPPLEMENTAL STAFFING POOL Page 14 of 16 Reporting Structure Manager of assigned unit Scheduling Per unit based guidelines Orientation New employee orientation Two day supplemental staff orientation Initial Precepted unit orientation: Initial area of competency should only require approximately 40 clinical hours Floating All nursing areas in SHS Cancellation Travelers, agency are cancelled prior to STA RN May be cancelled up to one shift length per pay period Call Not required Performance Completed at the end of the STA unless continuing Appraisal Employee Health Requirements Health Stream Education Required Certifications Professional Advancement Program employment at SHS as a staff nurse. Annual requirements due to be completed in July of each calendar year Flu vaccine each fall per policy Annual education must be completed by October 1 st All additional assigned education must be completed by due dates Employee is responsible to check Healthstream every couple of weeks for added assignments. Required certifications such as ACLS, CPR, NNR, etc.- Employees are required to achieve or renew these certifications on or before their expiration date. Not Eligible Benefits Not eligible Staffing Roster Name appears on the unit staffing roster PAR PAR is required if per diem RN is temporarily accepting a STA at the beginning and the end of the assignment. 14

Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 POLICY: SHS NURSING SUPPLEMENTAL STAFFING POOL Page 15 of 16 H:\POL-PRO\PERDIEM 15

Attachment EP9j, SHS Supplemental Nursing Staff Policy 4 8 13 H:\POL\PERDIEM H:\POL\SUPPLEMENTAL STAFF 16