Human Resources & Nursing

Transcription

1 2017 Hospital Breakfast Briefings Web-conference Series Human Resources & Nursing November 2, 2017 Faculty: Kathy Eichner, RN, MSN, CJCP Principal Consultant, Joint Commission Resources 1

2 Disclosure Statement Disclosure Statement The following staff and speakers have disclosed that they do not have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity: Kathy Eichner Leslie LaBelle George Riccio Steve Chinn The listed staff and speakers have verbally disclosed their arrangements and affiliations: Not Applicable to this presentation Furthermore, each of the previously named speakers has also attested that their discussions will not include any unapproved or offlabel use of products. 2

3 Publications and Record Restrictions The program may be electronically recorded by JCR and is subject to the protection of the copyright laws of the US. No individual or entity other than JCR may electronically record any portion of these programs for any purpose without the written permission of JCR. Any and all reproduction or publication of these proceedings and programs for commercial purposes by anyone other than JCR is prohibited. 3

4 Publications and Record Restrictions Copyright 2017 by Joint Commission Resources, Inc. All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Request for permission to make copies of any part of this work should be mailed to: Publication and Education Resources, Joint Commission Resources, 1515 West 22 nd Street Suite 1300W, Oak Brook, Illinois

5 Objectives Review key concepts in the Human Resources and Nursing Chapters Discuss revised and challenging Human Resource and Nursing requirements 5

6 Human Resources (HR) 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 Organization (WHO): World Health Report 2000 Health Systems: Improving Performance. Geneva: WHO, 2000.

8 Human Resources (HR) Chapter Outline I. Staff A. Staffing (HR ) B. Qualifications (HR , HR , HR ) C. Orientation (HR ) D. Training and Education (HR ) E. Competence (HR ) F. Evaluation of Performance (HR )

9 HR Chapter REFRESH Modifications Changes to the HR Chapter resulting from the REFRESH Project Review -- Phase 4 Pre-publication standards available on the TJC website. Multiple standards Moved Consolidated into existing standards Revised (minimal)

10 HR Chapter REFRESH Modifications Revised HR The hospital has the necessary staff to support the care, treatment, and services it provides. Now includes HR EP 1, 12, 13, 16 HR EP 1, 2, 3, 4, 5, 7, 16, 18, 19, 20

11 HR Effective January 1, 2018 EP 1 The hospital defines staff qualifications specific to their job responsibilities. EP 2 The hospital verifies and documents the following: Credentials of care providers using the primary source when licensure, certification, or registration is required by law and regulation to practice their profession. This is done at the time of hire and at the time credentials are renewed. Credentials of care providers (primary source not required) when licensure, certification, or registration is not required by law and regulation. This is done at the time of hire and at the time credentials are renewed.

12 HR Effective January 1, 2018 EP 3 The hospital verifies and documents that the applicant has the education and experience required by the job responsibilities. EP 4 The hospital obtains a criminal background check on the applicant as required by law and regulation or hospital policy. Criminal background checks are documented.

13 HR Effective January 1, 2018 EP 5 Staff comply with applicable health screening as required by law and regulation or hospital policy. Health screening compliance is documented. EP 7 Before providing care, treatment, and services, the hospital confirms that nonemployees who are brought into the hospital by a licensed independent practitioner to provide care, treatment, or services have the same qualifications and competencies required of employed individuals performing the same or similar services at the hospital.

14 HR Effective January 1, 2018 Standards moved here related to : CT and MRI technician qualifications Radiation physicists Swing Beds Psychiatric Hospitals

15 HR Chapter REFRESH Modifications Revised HR The hospital defines staff qualifications. HR The hospital provides orientation to staff Now includes HR EP 11, 12, 13, 14, 15 Consolidated EPs EP 1&2 to EP 1 EP 3, 4, 5, & 6 to EP 3

16 HR Effective January 1, 2018 Physician assistants and advanced practice registered nurses who practice within the hospital are credentialed, privileged, and reprivileged through the medical staff process or an equivalent process. Note: Advanced practice registered nurses who are licensed independent practitioners are credentialed and privileged only through the medical staff credentialing and privileging process. (See the "Medical Staff" [MS] chapter)

17 HR Effective January 1, 2018 EP 1 The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital is approved by the governing body.

18 HR Effective January 1, 2018 EP 2 The equivalent process for credentialing and privileging physician assistants and advanced practice registered nurses who practice within the hospital includes the following: A documented evaluation of the applicant s credentials. An evaluation of the applicant s current competence. Documented peer recommendations. Input from individuals and committees, including the medical staff, in order to make an informed decision regarding requests for privileges.

19 HR Effective January 1, 2018 The hospital determines how staff function within the organization. EP 1 All staff who provide patient care, treatment, and services possess a current license, certification, or registration, in accordance with law and regulation. EP 5 Staff supervise students when they provide patient care, treatment, and services as part of their training.

20 HR Effective January 1, 2018 The hospital provides orientation to staff. EP 1 The hospital orients its staff to the key safety content it identifies before staff provides care, treatment, and services. Completion of this orientation is documented. Note: Key safety content may include specific processes and procedures related to the provision of care, treatment, or services; the environment of care; and infection control.

21 HR Effective January 1, 2018 EP 3 The hospital orients staff on the following: Relevant hospital wide and unit-specific policies and procedures. Their specific job duties, including those related to infection prevention and control and assessing and managing pain. Sensitivity to cultural diversity based on their job duties and responsibilities. Patient rights, including ethical aspects of care, treatment, or services and the process used to address ethical issues based on their job duties and responsibilities. Completion of this orientation is documented.

22 HR Chapter REFRESH Modifications HR Staff participate in ongoing education and training Consolidated EPs EP 1&4 to EP 1

23 HR Effective January 1, 2018 Staff participate in ongoing education and training. EP 1 Staff participate in ongoing education and training to maintain or increase their competency, and as needed whenever staff responsibilities change. Staff participation is documented.

24 Top Noncompliant Standards for 1 st Half 2017 (Hospital) Standard EP % Noncompliance HR % HR % HR % HR % HR % HR % HR % HR % HR % HR % HR % 24

25 Top Non-Compliance Human Resources EPs (Hospital program, 2017) HR EP 1 When law or regulation requires care providers to be currently 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 his or her credentials are renewed HR EP 16 For psychiatric hospitals that use Joint Commission accreditation for deemed status purposes: The director of psychiatric nursing is a registered nurse who has a master s degree in psychiatric or mental health nursing, or its equivalent.. 25

26 Top Non-Compliance Human Resources EPs (Hospital program, 2017) HR EP 1 Staff participate in ongoing education and training to maintain or increase their competency. Staff participation is documented. HR EP 6 Staff competence is assessed and documented once every three years, or more frequently as required by hospital policy or in accordance with law and regulation. 26

27 Top Non-Compliance Human Resources EPs (Hospital program, 2017) HR EP 5 Staff competence is initially assessed and documented as part of orientation. HR EP 1 The hospital defines the competencies it requires of its staff who provide patient care, treatment, or services. HR EP 3 An individual with the educational background, experience, or knowledge related to the skills being reviewed assesses competence. 27

28 Top Non-Compliance Human Resources EPs (Hospital program, 2017) HR EP 1 The hospital defines staff qualifications specific to their job responsibilities. HR EP 2 When the hospital requires licensure, registration, or certification not required by law and regulation, the hospital both verifies these credentials and documents this verification at time of hire and when credentials are renewed. 28

29 Top Non-Compliance Human Resources EPs (Hospital program, 2017) HR EP 2 The hospital orients its staff to the key safety content before staff provides care, treatment, and services. Completion of this orientation is documented. HR EP 5 Staff comply with applicable health screening as required by law and regulation or hospital policy. Health screening compliance is documented. 29

30 Hot Topic in Training & Competencies Two biggest challenges in hospitals today High Level Disinfection & Sterilization Management of the Suicidal Risk patient Consistency in education and training Consistency in validation of competency Modifying training/revalidation when equipment and processes change Documentation 2016 Hospital in files Breakfast Briefings, Joint Commission Resources 30

31 Nursing (NR) 31

32 Nursing (NR) Chapter Chapter Outline I. Nurse Executive Role A. Authority B. Qualifications II. Nursing Services A. Directing organization-wide nursing services B. Establishing guidelines for nursing care delivery C. Providing nursing care, treatment, & services 2016 Hospital Breakfast Briefings, Joint Commission Resources 32

33 Nursing services NR The nurse executive directs the delivery of nursing care, treatment, and services. 1. Provides effective leadership and to coordinate leaders to deliver nursing care, treatment, and services 3. Nurse leader, at the executive level, assumes an active leadership role with the hospital s governing body, senior leadership, medical staff, management, and other clinical leaders in the hospital s decision-making structure and process. 5. The hospital defines the nurse executive s authority and responsibility (written). 33

34 Nursing services NR The nurse executive is a licensed professional registered nurse qualified by advanced education and management experience. 1. Established process to select 2. Currently licensed as an RN in accordance with law and regulation 3. Possesses advanced degree or the knowledge and skills 34

35 Nursing Services NR The nurse executive directs the hospital s nursing services The nurse executive coordinates: EP 2. How nursing care needs of the patient population are assessed, met, and evaluated. EP 3. Program to measure, analyze, and improve the quality of nursing care, treatment, and services. The nurse executive directs: EP 4. Plans to provide nursing care EP 5. How nursing care needs of the patient population are assessed, met, and evaluated. EP 6. Program to measure, analyze, and improve the quality of nursing care, treatment, and services. 35

36 Nursing Services NR Nurse executive establishes guidelines for the delivery of nursing 1. Standards of nursing practice 2. Nursing standards of patient care 3. Nursing policies & procedures 4. Nurse staffing plans 2016 Hospital Breakfast Briefings, Joint Commission Resources 36

37 Nursing Services NR The nurse executive directs the implementation of nursing policies and procedures, nursing standards, and a nurse staffing plan(s). 1.Approves nursing policies; nursing standards of patient care; and standards of nursing practice 4. Nurse executive responsible for the provision of nursing services 24 hours a day, 7 days a week 7.A registered nurse on site who provides or supervises the nursing services 8. For hospitals that use Joint Commission accreditation for deemed status purposes: A 2016 Hospital Breakfast Briefings, Joint Commission Resources registered nurse assigns the nursing care for each patient 37

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