CurrentsTo Medical Center Employees:At a recent communications meeting, Helena Bastian, Medical Center Human Resources director, updated the management team on the competency-related documentation needed to fulfill JCAHO standards. Helena's key points are highlighted below. It is very important that all managers review their department-based H R files and be sure documentation is in order as we prepare for the JCAHO survey expected in November. We know that surveyors can be “unforgiving” if any overdue performance evaluations are found or other competency-related documentation is not evident. Also, surveyors have been known to consider evaluations as improperly conducted if the record indicates an evaluation was overdue at the time it was conducted. A few years ago a revision was made to the Medical Center H R Performance Management Policy #16 to combine the job description and performance evaluation documents. The purpose of this change was to ensure evaluations accurately describe and relate to job duties and to eliminate some inconsistencies noted in the past. Also, a change was made to the policy language to indicate that evaluations are to be conducted within 45 days before or after the review date and this was intended to help avoid a survey violation for any “slightly overdue” evaluations. However, for internal tracking, the actual due date remains the annual performance evaluation date. The web-based Impromptu report is available for managers to keep abreast of evaluations that are due. All managers are asked to be diligent in timely completion of evaluations. Anyone with questions about overdue evaluations or the Performance Evaluation policy should contact Eric Frisch, Human Resources Manager, at 792-7908 or e-mail frishe@musc.edu. Thank you very much.
JCAHO Human Resources competency encoreHelena Bastian, Medical Center Human Resources director, told managers about the results from her department’s most recent file audits.Part of the upcoming JCAHO survey in November will include the auditing of employee files in an effort to check employee competency. The seven components to the employee file that the JCAHO is looking for are: job description, licensure verification, initial assessment of competency for employees hired since January 2000, a record of employee training in patient safety, error reporting, and team dynamics, most recent performance evaluation, age specific competency, and any records detailing the performance of specialized skills or competencies. Job descriptions must be current and must be signed by the employee, rater, reviewer, and dated. Descriptions should be specific to job function and the population served. Add performance criteria for clarification. Documentation of BLS and ACLS should be current. The initial assessment should include the EHS “clearance to work” form, a general orientation checklist, a clinical orientation checklist, respirator fit testing and POCT, a department and job specific orientation checklist, and competency assessments with documentation of age groups served. It is essential that managers or employees do not leave anything blank. The record of training can be found through the general orientation paperwork. The performance evaluation document must be signed and dated by the employee, the reviewer and rater within 45 days of the due date and included an annual skills competency checklist. Performance evaluations must also be completed annually for temporary employees. Age specific competencies must specify the age group served. All employees need to be rated for age specific competencies and clinical areas may be required to have more specific competencies in relation to job function. Policy Updates
The major change reflects the switch to online reporting. Two policies are undergoing additional revision, the patient safety policy and the patient identification policy. Clinical managers and directors were asked to review carefully and send feedback to Ellis at ellisro@musc.edu. Announcements
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