Related Documents: HR003O

Comments:   HR002Fa is a Check List for Competencies; HR002b is for Orientation

Because some forms are difficult to convert to the format needed to display them properly here, you can view of obtain then as noted in the formats noted below.

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View or Download the Competency Check List Form in Adobe Acrobat Reader Format:  HR002Fa.pdf
View or Download the Orientation Check List Form in Adobe Acrobat Reader Format:  HR002Fb.pdf
Download both of the above forms in Word95 format zipped in a self extracting file: HR002F.exe

Related Documents: HR002F

Comments:   Includes Competency Assessment Tools for Age Specific Competency, Abuse, and Cultural

Because some forms are difficult to convert to the format needed to display them properly here, you can view of obtain then as noted in the formats noted below.

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View or Download the Competency Assessment Tool in Adobe Acrobat Reader Format:  HR003O.pdf
Download both of the above document in Word95 format zipped in a self extracting file:   HR003O.exe

Viewable or Downloadable Files:
View or Download the Medical Staff Coordinator Job Descriptionl in Adobe Acrobat Reader Format:  HR004O.pdf
Download the above document in Word95 format zipped in a self extracting file:   HR0040.exe
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JOB DESCRIPTION

DEPARTMENT: Medical Staff Services

JOB TITLE: Medical Staff Coordinator

JOB CODE:

POSITION SUMMARY: Responsible for coordination and oversight of the Medical Staff Services Department, including physician and allied health credentialing and recredentialing, meeting management, flow of information from medical staff committees through the Medical Executive Committee and the Governing Board. Assists with JCAHO Survey preparation for the medical staff/leadership function, including staff and medical staff education regarding accreditation standards. Works closely with medical staff leaders, hospital administration, and legal counsel with regard to medical staff and bylaws issues.

PRINCIPAL DUTIES AND RESPONSIBILITIES

1. Maintains open communication with the Medical Staff, Administration, Hospital Departments, practitioner’s office staff, and related health agencies. Identifies and works to solve problems as they arise.
2. Maintains knowledge of standards of the Joint Commission on Accreditation of Healthcare Organizations, National Committee on Quality Assurance, and State and Federal regulations related to Medical Staff organization.
3. Maintains working knowledge of the Medical Staff Bylaws, Rules and Regulations, and Hospital policies, and works to ensure the medical staff’s compliance with the stated parameters.
4. Oversees the processing of all Medical Staff and Allied Health Staff credentialing and recredentiaing applications in accordance with Medical Staff Bylaws, Rules and Regulations, JCAHO standards, and State and Federal law.
5. Assists the Credentials Committee with development of privilege criteria, privilege delineations, and other documents necessary to an effective credentialing process.
6. Provides oversight, education, and training, to Medical Staff Services Department staff members.
7. Provides supportive services to Medical Staff leaders in fulfilling the responsibilities of their offices. Participates with same in developing policies for the Medical Staff, and in monitoring the continuity of Medical Staff activities.
8. Attends Medical Staff meetings as necessary. Assists as needed with agenda and materials preparation. Records minutes at specified committees.
9. Maintains confidential credentials files and electronic medical staff database.
10. Exhibits a high degree of responsibility for confidential matters.
11. Oversees the development of departmental policies and procedures.
12. Assists in the development of a departmental operating and capital budget.
13. Assumes other related responsibilities as required.

POSITION REQUIREMENTS:

Degree in business or health related field desired. Previous experience in a Medical Staff Services Administrative position required. Excellent interpersonal skills, including the ability to communicate professionally, both verbally and in writing. Willingness to maintain a flexible work schedule as needed. CMSC and/or CPCS Certification by the National Association Medical Staff Services required, or obtained within two years. Affiliation with the National Association Medical Staff Services and the State Association Medical Staff Services strongly encouraged.

Viewable or Downloadable Files:
View or Download the article in Adobe Acrobat Reader Format:  HR005O.pdf
Download the above article in Word95 format zipped in a self extracting file:   HR0050.exe
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• RN Cancer Center
• RN Critical Care Unit
• RN Clinic
• RN Emergency Department
• RN Endoscopy
• RN Medical Surgical Department
• RN Mental Health Center
• RN Obstetrics, Nursery, Labor and Delivery
• RN Operating Room
• RN Post Anesthesia Care Unit/Anesthesia Care Unit
• RN Radiology
• RN Renal
• RN Residential Health Care Facility
  
  

Viewable or Downloadable Files:
View or Download in Adobe Acrobat Reader Format:  HR006O.pdf
*Please note, this is a very large file (51 pages) so it may take some time to open.
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1. These files of job descriptions/performance evaluations demonstrate content, not format. The final format in my facility includes a front page with position summary, qualification, and performance improvement plan, a second page with hospital-wide requirements relating to attendence, safety, courtesy, etc., a scoring scale (1=does not meet criteria, 2=meets criteria, 3=occ. exceeds criteria, 4=frequently exceeds), and lines on which the manager can write the score that the employee earned for each competency.

2. We are using these JD/PE's as a pre-employment competence assessment tool, and as our orientation curriculum/competence assessment tool as well.  Therefore - voila! the exact same competencies through every phase of competence assessment.

3. each of the Responsibilities in these JD/PE's corresponds to one of the Domains in the NIC taxonomy. Each of the Standards corresponds to an Intervention in the NIC taxonomy. NIC does not replace the nursing process or NANDA diagnoses - it is a toolbox of interventions.

4. each Intervention qualifies as a competency because it is broken down into performance criteria. The manager and the staff can review, learn and discuss those criteria by reading each chosen Intervention in the NIC book.  If you don't have the book, these job descriptions will be meaningless for you because you won't know what the performance criteria are. The book is Nursing Interventions Classification, edited by J. McCloskey and G. Bulechek, 2nd ed, 1996, Mosby, approx $40. If you have a book or any other tool, like a policy or instruction manual, that lists performance criteria, you do not need a checklist.

5. another important tool is the monograph entitled "Core Interventions by Specialty" (approx $10), which contains lists of NIC Interventions (competencies, remember) chosen by many professional nursing specialty organizations as being representative of the practice of their members.

6. the Intervention/competencies (called Standards in our JD/PE) that appear in each of our JD/PE's are based on these Core Interventions by Specialty. Therefore, we know these JD/PE's are based on current research (NIC) and current practice guidelines (the specialty organizations). We are using NIC as a standardized language throughout our organization to promote unity, support cross training, reduce floating anxiety, improve patient assignment choices, provide a framework for education, as our documentation standard (NIC lends itself well to a computerized documentation system), etc.

7. since each "standard" in the job description is a competency by virtue of the fact that it has been identified by professional nursing societies, and its performance criteria have been defined by a research group, when I use the job description to document someone's performance eval, I am at the same time documenting their competence in each of the skills. I don't use checklists. The performance criteria are either listed in NIC, or they are contained in a policy, procedure, user's manual, guideline, chart, whatever.

8. remember that just because a  job description contains 50 competencies (skills - not checklists!), that does not mean you have to test everybody on every one every year. Single out 3-6 of the competencies for assessment. Use your common sense and knowledge of trends in your unit and in your profession to choose which competencies to assess. Tailor the process to each nurse individually, just as nurses are expected to tailor their care to individual patients.

9. Employees of long standing that have always been considered competent are STILL considered competent. In the absence of error, you may assume competence - as long as the employee is actually using the skill. Criteria for choosing competencies to assess include complexity and volume, feedback from all sources, developments in the profession/healthcare system/technology/knowledge, etc.

10. Methods for assessment, from best to worst, are direct observation during daily work (best method, not disruptive to staff and can delegated); performance testing in a simulation (better than a written test but not proof of on-the-job performance); written test in which the employee must construct a response (better than a multiple-choice test but of questionnable relevance to job performance); and a multiple-choice test (poor). Attending inservices, while important, does not demonstrate or assess competence.

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Download the above article in Word95 format zipped in a self extracting file:   HR0070.exe
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GENERAL POSITION INFORMATION

Position Title: Director, Quality and Accreditation, Market Service Area

Reports to: Vice President, Quality and Accreditation

Department (and location): YOUR HOSPITAL Support Services Center

General Purpose Statement: Responsibilities for preparation and coordination across the continuum for regulatory compliance in the Market Service Area: accredited hospitals, home health care, physician office practices and long term care. Work directly with organizational quality directors to coordinate quality improvement programs.

ESSENTIAL DUTIES AND RESPONSIBILITIES

GENERAL

1. Coordinates, through organizational Quality Directors, educational activities regarding regulatory standards.

2. Provides expertise in standards and advocacy with regulatory agencies.

3. Provides focused surveys, mock surveys and unannounced surveys to assess state of readiness for surveys, focusing upon continual preparation.

4. Coordinates Denver Market Service Area regulatory surveys.

5. Prepares reports to YOUR HOSPITAL Senior Vice Presidents, Boards and Administrators regarding status of compliance and recommendations for corrections of identified deficiencies.

6.    Work in collaboration with SSMSA Director, Quality and Accreditation to coordinate activities, focus efforts and provide consistency.

7. Oversees data repository for Quality Profile and required JCAHO external database. Coordinates external contracted JCAHO services.

8. Provides on-site consultation to individual entities to assure that data is being used in quality improvement and risk management initiatives.

9. Provides expertise in development of organization dashboard, facility dashboards, and service line dashboards.

10. Provides comparative data for company, and a resource for benchmarks and best practices.

LEADERSHIP, KNOWLEDGE AND SKILL REQUIREMENTS

1. Participates as requested as a team player in facility and system-wide quality initiatives and programs.

2. Develops and maintains good working relationships with YOUR HOSPITAL Health management, employees, and other constituencies.

3. Uses various communication techniques on a regular basis, to exchange all information necessary and applicable in order to efficiently and effectively fulfill duties.

4. Participates as a team player in promoting a positive image of YOUR HOSPITAL Health and its affiliates.

5. Expertise in JCAHO and HCFA standards and surveying methods.

6. Public speaking, consultative and intrapersonal skills.

7. Sense of humor.

8. Computer skills, knowledge of software including Access, Excel and Word.

9. Understanding of the corporate and healthcare environment.

10. Performs other duties as necessary and/or as assigned.

MINIMUM QUALIFICATIONS

A. Education and Licensure: Bachelors degree in medical field (nursing, medical technology, health information management). Advanced degree and CPHQ preferred.

B. Experience: Four to six (4-6) years experience in management in healthcare environment with three (3) years in quality management.

C. Specialized Knowledge:

a) Excellent communication, problem-solving, statistical and analytical abilities

b) Strong PC skills and knowledge

c) Strong presentation and delivery skills

d)     Previous experience with JCAHO preparation, coordination, education and surveys for hospitals, physician office practices and home health care

e) Previous consulting experience preferred.

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View  or Download these documents in Adobe Acrobat Reader Format:   HR008O.pdf
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