ACCREDITATION STANDA RDS Administratin HUMAN RESOURCES The facility must have methds in place t ensure staff are managed effectively t supprt the care, treatment and services it prvides. This standard addresses human resurce planning, recruitment f qualified and cmpetent staff, retentin f qualified and cmpetent staff, rles and accuntabilities, and enhancing staff perfrmance. HUMAN RESOURCE PLANNING Staff qualificatins and cmpetencies are established t ensure quality care and services Invlvement f key staff wh are knwledgeable abut advances in service delivery and technlgy and wh are able t determine the required cmpetencies f staff Identifying adequate staffing numbers Anticipating and respnding t changes in the envirnment Anticipating and assessing the impact f technlgical change Anticipating and respnding t ptential changes t wrkfrce and capacity needs HR plan ensures adequate staff resurces fr the scpe f services prvided HR plan is mnitred and revised as necessary HR has a prcess, in cmpliance with Cllege Bylaws and requirements, t renew, revise, and deny privileges NHMSFAP Cllege f Physicians and Surgens f British Clumbia Page 1 f 10
Administratin RECRUITMENT OF QUALIFIED AND COMPETENT STAFF The facility defines staff qualificatins in written plicy The medical directr has the respnsibility t ensure the facility is staffed apprpriately All staff must be apprpriately trained, qualified and cmpetent t carry ut their specific rles and respnsibilities The facility is staffed apprpriately t meet individual patient needs, maintain acceptable levels f safety fr bth patients and staff, as utlined in prvincial legislatin and Cllege regulatin The facility selects and recruits staff based n: active licensure and registratin r certificatin with the apprpriate prvincial r natinally recgnized regulatry and/r certificatin bdy verificatin f credentials with the primary surce (e.g. the Cllege, CRNBC, CLPNBC, CDSBC) and dcument verificatin upn hire and annually educatin knwledge, skills and experience reference checks criminal backgrund check applicable health screening http://www.wrksafebc.cm/publicatins/high_reslutin_publicatins/assets/pdf /bk129.pdf http://www.bccdc.ca/dis-cnd/cmm-manual/default.htm training and certificatin as applicable t type f facility and specified staff duties and respnsibilities: CPR Level HCP, ACLS, PALS, prcedural sedatin, medical device reprcessing, laser safety fficer training, basic laser safety training, radiatin safety training, WHMIS, difficult airway training Physician qualificatins All physicians wh perfrm surgery r prcedures in a nn-hspital facility must: be licensed and in gd standing with the Cllege f Physicians and Surgens f BC hld privileges in a nn-hspital facility apprved by the Cllege https://www.cpsbc.ca/files/pdf/nhmsfp-g-applicatin-fr-appintment-t- Facility.pdf hld current CPR Level HCP hld current ACLS training if, as the perating physician r endscpist, administering and/r mnitring a patient under IV sedatin and analgesia, when an anesthesilgist is nt present t administer/mnitr NHMSFAP Cllege f Physicians and Surgens f British Clumbia Page 2 f 10
Administratin All anesthesilgists wh prvide anesthesia in a nn-hspital facility must: be certified by the Ryal Cllege f Physicians and Surgens f Canada be licensed and in gd standing with the Cllege f Physicians and Surgens f BC hld privileges in a facility apprved by the Cllege https://www.cpsbc.ca/files/pdf/nhmsfp-g-applicatin-fr-appintment-t- Facility.pdf hld active hspital privileges in the practice f anesthesia, r hld current ACLS training and have cmpleted a difficult airway management curse (t be renewed every three years) acceptable t the Cllege if they have nt regularly practised anesthesia in a hspital setting within three years All general practitiners wh perfrm surgical assists in a nn-hspital facility must: be licensed and in gd standing with the Cllege f Physicians and Surgens f BC hld privileges in a nn-hspital facility apprved by the Cllege https://www.cpsbc.ca/files/pdf/nhmsfp-g-applicatin-fr-appintment-t- Facility.pdf hld current CPR Level HCP (recmmended) Dentist qualificatins All dentists wh perfrm dental surgery r prcedures in a nn-hspital facility must: be licensed and in gd standing with the Cllege f Dental Surgens f BC hld privileges in a facility apprved by the Cllege f Physicians and Surgens f BC hld current CPR Level HCP (recmmended) Pdiatrist qualificatins All pdiatrists wh perfrm pdiatry surgery r prcedures in a nn-hspital facility must: be licensed and in gd standing with the Cllege f Pdiatric Surgens f BC currently perfrm pdiatry surgical prcedures in a BC health authrity hspital hld privileges in a facility apprved by the Cllege f Physicians and Surgens f BC hld current CPR Level HCP (recmmended) NHMSFAP Cllege f Physicians and Surgens f British Clumbia Page 3 f 10
Administratin Nurse qualificatins in the perating r prcedure rm All registered nurses (RN) must: hld current, practising registratin with the CRNBC have cmpleted an apprved accredited pstgraduate periperative nursing prgram, r have submitted dcumented evidence t the facility supprting the equivalent in educatin and experience in periperative nursing acceptable t the Cllege hld current CPR Level HCP if administering and/r mnitring a patient under IV sedatin and analgesia, when an anesthesilgist is nt present: hld current ACLS training, and in additin t ACLS, have cmpleted a prcedural sedatin curse acceptable t the Cllege hld current PALS training r a pediatric critical interventin curse acceptable t the Cllege if prviding pediatric services All licensed practical nurses must: there must be, at minimum, ne RN n site per shift with current PALS training r equivalent it is recmmended that a facility servicing a pediatric ppulatin have a RN bth in the OR theatre and the pst-anesthesia recvery unit with current PALS training hld current, full registratin with the CLPNBC have cmpleted a recgnized perating rm certificatin prgram including bth thery and practical cmpnents scpe f practice in the nn-hspital setting is limited t scrub rle nly licensed practical nurses may nt relieve the circulating registered nurse fr cffee, lunch r ther duties he/she may nly circulate as a secnd circulatr in additin t a first circulatr registered nurse present in the rm hld current CPR Level HCP Nurse qualificatins in pst-anesthesia recvery All registered nurses must: hld current, practising registratin with the CRNBC have cmpleted an apprved pstgraduate critical care/pst-anesthesia recvery rm nursing certificatin prgram, r have submitted dcumented evidence t the facility supprting the equivalent in NHMSFAP Cllege f Physicians and Surgens f British Clumbia Page 4 f 10
Administratin educatin and experience in critical care/pst-anesthesia recvery nursing acceptable t the Cllege hld current CPR Level HCP hld current ACLS training if duties include vernight patient stay at the facility at least ne registered nurse with current training in ACLS and all ther members f the nursing staff with current training in cardipulmnary resuscitatin shall be n duty at all times when patients are in the facility the expected level f ACLS interventin must be clearly defined in the facility s plicy manual https://www.cpsbc.ca/files/pdf/nhmsfp-overnight-stay-guideline.pdf page 3 hld current PALS training r a pediatric critical interventin curse acceptable t the Cllege if prviding pediatric services there must be, at minimum, ne RN n site per shift with current PALS training r equivalent it is recmmended that a facility servicing a pediatric ppulatin have a RN bth in the OR theatre and the pstanesthesia recvery unit with current PALS training All licensed practical nurses must: hld current, full registratin with the CLPNBC have acute surgical ward experience and/r relevant experience and qualificatins apprpriate t the patient ppulatin limit scpe f practice in nn-hspital setting t being the secnd pst-anesthesia nurse in additin t a registered pst-anesthesia recvery nurse licensed practical nurses may nt relieve the pst-anesthesia registered nurse fr cffee, lunch r ther duties Hld current CPR level HCP Other staff qualificatins All diagnstic imaging technlgists must: be certified with the Canadian Assciatin f Medical Radiatin Technlgists (CAMRT), r be a certified cmbined labratry and X-ray technlgist (CLXT) have a defined scpe f practice fr CLXT staff that is in alignment with their educatin under their certificatin, a CLXT technlgist has a limited scpe f imaging examinatins that they may cnduct http://www.dap.rg/cmsfiles/file/2010%20diagnstic%20imaging%20accr editatin%20standards/updated%2011%20july%202012/radilgy%20201 0%20Revised%2011Jul12.pdf page 3 NHMSFAP Cllege f Physicians and Surgens f British Clumbia Page 5 f 10
Administratin All sngraphy technlgists must: be certified with the Canadian Assciatin f Registered Diagnstic Ultrasund Prfessinals (CARDUP), r be certified with the American Registry f Diagnstic Medical Sngraphers (ARDMS), r have received specific didactic and practical training, including perfrming vascular imaging (e.g. peripheral vascular) http://www.dap.rg/cmsfiles/file/2010%20diagnstic%20imaging%20accreditatin %20Standards/Updated%2011%20July%202012/Radilgy%202010%20Revised%20 11Jul12.pdf page 4 Medical device reprcessing (MDR) staff qualificatins Facilities are respnsible t ensure that any individual invlved in the cleaning, disinfectin and/r sterilizatin f medical devices is prperly trained and their practice is assessed n a regular basis All staff wh is invlved in reprcessing must be qualified thrugh educatin, training and experience: cmpletin f a recgnized qualificatin/certificatin curse in reprcessing (e.g. Sterile Prcessing Technician Certificate Prgram curse r Medical Device Reprcessing Technician Certificate Prgram curse) r demnstratin f the equivalent in training and experience acceptable t the Cllege, r if have nt cmpleted an MDR certificatin curse r cannt demnstrate equivalent training experience, must have cmpleted and passed the thery prtin f an MDR curse acceptable t the Cllege http://www.health.gv.bc.ca/library/publicatins/year/2011/best-practiceguidelines-cleaning.pdf pages 29, 44, 70 RETENTION OF QUALIFIED AND COMPETENT STAFF The facility has strategies t retain its staff and maintain cmpetent, qualified, and engaged wrkfrce Cntributins by staff are recgnized Prfessinal develpment is encuraged and supprted Wrklads are mnitred and managed Staff are invlved in decisin-making within the defined scpe f their rle Teamwrk and knwledge sharing is encuraged NHMSFAP Cllege f Physicians and Surgens f British Clumbia Page 6 f 10
Administratin ROLES AND ACCOUNTABILITIES The facility prvides staff with the infrmatin necessary t ensure that they are knwledgeable abut their rle and accuntabilities within the rganizatin and the terms and cnditins f their emplyment Ensure staff practises within their scpe f practice HR recrds prvide evidence dcumentatin f an emplyee s suitability fr their rle Qualificatins, credential, cmpetency and perfrmance evaluatins are verified and included as part f the emplyee s cnfidential recrd Psitin and/r jb descriptins exist fr all staff, and includes: psitin and/r jb summary nature and scpe f wrk qualificatins required reprting relatinships cnditins f emplyment perfrmance measures Psitin and/r jb descriptins are annually reviewed and revised t reflect: current practice changing perfrmance requirements, duties r qualificatins Reprting relatinships are clearly written in plicy and understd by staff: rganizatinal chart is available t staff reprting relatinships are cmmunicated t individual staff staff are aware f the reprting structure and wh t take directin frm Physician human resurce recrds are kept current fr all physicians and cntain: evidence f qualificatins, including current Cllege registratin evidence f credentialing and granting f privileges: cpy f initial Applicatin fr Appintment t a Nn-Hspital Medical and Surgical Facility cpy f Physician Annual Re-Applicatin fr Privileges evidence f annual perfrmance review and cmpliancy assessments immunizatin status at time f appintment health reprts as may be required by the rganizatin s human resurces plicies rientatin, cntinuing educatin and in-service training recrds evidence f prfessinal liability insurance cverage, if applicable evidence f criminal recrds check if in cntact with children NHMSFAP Cllege f Physicians and Surgens f British Clumbia Page 7 f 10
Administratin All ther emplyee human resurce recrds (e.g. nurses, dentists, pdiatrists, MDR technicians, etc.) are kept current fr all staff and cntain: evidence f qualificatins including current licensure and certificatin r registratin, if applicable evidence f credentialing and granting f privileges, if applicable evidence f educatin and training apprpriate fr the psitin psitin and/r jb descriptin immunizatin status at time emplyment cmmences health reprts as may be required by the rganizatin s human resurces plicies rientatin, cntinuing educatin and in-service training recrds perfrmance evaluatins cmpetency assessments recruitment infrmatin including references evidence f prfessinal liability insurance cverage, if applicable evidence f criminal recrds check if in cntact with children Human resurce recrds are maintained in a cnfidential manner: nly authrized individuals have access t recrds cnsent is btained frm the emplyee prir t release f infrmatin cntained in their human resurces recrd recrds are dispsed f apprpriately and in accrdance with legislatin ENHANCING STAFF PERFORMANCE The facility ensures that it functins within a culture that is supprtive f learning and cntinuus prfessinal develpment A key functin f enhancing perfrmance in a learning envirnment is perfrmance management, which allws fr staff perfrmance and cmpetence t be assessed and evaluated in rder t prvide cnstructive feedback, prvide training and educatin and make imprvements as necessary t ultimately imprve the quality and safety f medical and surgical services prvided t patients Orientatin is prvided t all new staff that includes the fllwing infrmatin: missin, visin, values, gals and bjectives facility prgrams and services safety rles and respnsibilities f the individual and key staff plicies f the facility and the respnsibility f staff t cmply relevant plicies and prcedures related t perfrming the duties f the psitin prtectin f patient cnfidentiality NHMSFAP Cllege f Physicians and Surgens f British Clumbia Page 8 f 10
Administratin prtectin f patient rights, including ethical aspects f care, prcedures and services quality imprvement and risk management practices dcumented assessments at the cmpletin f a prbatinary and/r rientatin perid Orientatin is prvided t existing staff in respnse t: changing rles new technlgy new methds changes in cmpetency demands new laws and regulatins Staff are supprted and prvided with nging educatin, training and prfessinal develpment t: maintain r increase their cmpetency and participatin is dcumented upgrade knwledge and skills as required when respnsibilities change t meet the needs f the facility s services prvided and participatin is dcumented maintain cmpetency requirements The facility mnitrs staff educatin and training t: determine if bjectives have been achieved ensure sharing and dispersin f knwledge identify imprvement pprtunities ensure that pprtunities fr reinfrcement f knwledge and re-training are made available as necessary take apprpriate actin when a staff member s cmpetence des nt meet expectatins REFERENCES Cllege f Physicians and Surgens f Alberta. Nn-hspital surgical facility - standards and guidelines [Internet]. Edmntn: Cllege f Physicians and Surgens f Alberta; 2012. [cited 2012 Sep 14]. Available nline: http://www.cpsa.ab.ca/libraries/pr_qfc_nn- Hspital/NHSF_Standards.sflb.ashx Cllege f Physicians and Surgens f British Clumbia. Bylaws [Internet]. Vancuver: Cllege f Physicians and Surgens f British Clumbia; 2009. [updated 2012 Jan]. Sectin A - Nn-hspital medical and surgical facilities prgram (NHMSFP) p. 67-77. [cited 2012 Sep 14]. Cllege f Physicians and Surgens f Ontari. Out-f-hspital premises (OHP) standards [Internet]. Trnt: Cllege f Physicians and Surgens f Ontari; 2010. [cited 2012 Sep 14]. Available nline: http://www.cps.n.ca/upladedfiles/plicies/guidelines/ffice/hp_standards.pdf NHMSFAP Cllege f Physicians and Surgens f British Clumbia Page 9 f 10
Administratin Diagnstic Accreditatin Prgram; Cllege f Physicians and Surgens f British Clumbia. Diagnstic imaging radilgy: accreditatin standard 2010. [Internet]. Vancuver: Diagnstic Accreditatin Prgram; 2010. Sectin: Human resurces [cited 2012 Sep 14]. Available nline: http://www.dap.rg/cmsfiles/file/2010%20diagnstic%20imaging%20accreditatin%20standar ds/updated%2011%20july%202012/radilgy%202010%20revised%2011jul12.pdf Operating Rm Nurses Assciatin f Canada (ORNAC). Standards, guidelines and psitin statements fr periperative registered nursing practice. Halifax: ORNAC; 2011. Sectin 1: ORNAC beliefs, prfessinal standards and cmpetencies - staffing the surgical suite; p.19-20 NHMSFAP Cllege f Physicians and Surgens f British Clumbia Page 10 f 10