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The JCAHO Mock Survey Made Simple.

Human resources interview :

preparation for competence assessment process review segment.
This document is included in these guidelines for information purposes only. The hospital is not required to complete any presurvey activities in preparation for the competence assessment process review segment or the Human Resources interview. During the survey, members of the survey team will identify the specific staff whose records will be included in the review.
Background.
The human resources interview is divided into three parts :

  • Interview with hospital staff educators ;

  • Review of staffing information ; and

  • Review of the hospital’s competence assessment process.


The surveyor(s) will address the hospital’s system for :

  • Establishing qualifications required for staff who have specific responsibilities ;

  • Assessing these qualifications based on a review of an individual’s performance evaluation and, as applicable, license/certification ; and

  • Evaluating individual’s performance in the light of defines expectations or responsibilities, as found in a job description, contract, or similar document.


During the human resources interview, surveyor(s) :

  • Meet with staff to assess the hospital’s education programs,

  • Review data with appropriate hospital staff pertinent to staffing ; including aggregate information ; and

  • Review with appropriate staff records pertinent to the hospital’s competence assessment processes.


In addition to the Human Resources Interview, surveyors consider pertinent information from staff interviews conducted throughout the survey when assessing compliance with the human resource standards.
During the human resources interview, surveyor(s) will not address the hospital’s processes for competence assessment for members of the medical staff or for licensed independent practitioners privileged through the medical staff credentials processes. Those processes will be addressed during the medical staff credentials review interview.
Competence assessment process review segment of the human resources interview.
Selection of records/documentation for review.

Each surveyor will identify records for review. The surveyor facilitating the interview will provide you with the “competence assessment process review request form(s)” at the end of the document review session. A few additional names may be identifies later in the survey for inclusion in the review.

The surveyor(s) will list in the competence assessment process review request form the staff for whom the required documentation should be provided. The request may be :

  • By title ;

  • By category of staff (in such cases, you may select a representative of this category ); and

  • By name (the fact that a name is listed should not be construed as a problem with this person ; staff are identifies by name when surveyors have gained some knowledge of their specific responsibilities.


Preparation for the Competence assessment process review.

Hospital preparation for the competence assessment process review begins when the surveyors provide the list of staff records for review at the end of the document review.


  1. For each person on the list, locate the documents that address the following standards :

    1. Job description and/or description of responsibilities (HR. 1);

    2. Verification of current license, registration, or certification, when applicable (HR.2). If not required for the person, for example, a housekeeper, write “NA” in the appropriate column for that person;

    3. Evidence of initial competence (HR. 4) for staff hires after 1/1/93;

    4. Most recent performance evaluation, including the criteria, or skill/competency list(s) used in the review (HR.5). Note : such lists are not required by the Joint Commission, but when used in the organization, should be available to the surveyors; and

    5. Evaluation or age-specific competence for staff who have regular clinical contact with specific patient populations. Examples of patient populations include neonates, pediatric and adolescent patients, and geriatric patients.




  1. The request form has columns numbered from one to six. Having gathered the documents requested, please annotate the request forms as follows :

      1. check the appropriate column on the request form to indicate that information is available relative to a given standard for a given individual on the list;

      2. label the document or other information pertaining to the relevant standard or issue with the number of the appropriate column;

      3. write “NA” when the standard dose not apply to that person; and

      4. when column six is completed by the surveyor, label the specific document which addresses the performance specific skill/competency listed there; otherwise leave column six blank.




  1. During the review of personnel records, the surveyors may request evidence of staff education or training related to improving job performance for specific individuals identified on the competence assessment process review request form.


Additional material for the interview.


  1. Provide material illustrating the establishment of qualifications and responsibilities, and the assessment of competence for the following categories, as applicable to your hospital :

      1. Agency personnel (all categories used);

      2. Per diem staff;

      3. Employees of physicians who assess patient needs, provide patient education, or assist at procedures (unless such individuals are evaluated as a part of the medical staff credentials process ; in which case, these materials should be available at the medical staff credentials interview) ; and

      4. Volunteers.

Note : it is expected that the format of the records addressing the qualifications and competence assessment for these categories will differ from that used for employees of the organization.
Process.

  1. Bring the documents to the room where the review will be held, and :

      • If more than one request sheet is attached, please keep separate stacks of documents for each request sheet so that each surveyor knows which sets or materials he or she requested for review ; and

      • Identify documents related to agency personnel, per diem staff, employees of physicians, and volunteers, as applicable, in a separate place on the table.

  1. Assign at least one, but no more than two, staff to assist each surveyor. Those participating should include representatives from the human resources/personnel department and from nursing, but should be limited to those authorized to have access to all requested information. Because this activity will focus on an in-depth review of employee-specific documentation, it is not useful for those not essential to the process to be present.


Your assistance in responding to this request is appreciated.

Competence assessment process review request form

1999





1

2

3

4

5

6

Name or category or staff15

Job description

HR. 1


Verification of Current license or registration /certification when applicable

HR. 2


Initial assessment of competency including any skill/competency list(s)16

HR. 4


Performance evaluation

HR. 5














Most recent performance evaluation including any skill/competency list(s)17

Age specific competence when appropriate18

Performance specific skill/competency (surveyor use only)


















































































































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