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									UTHCPC Policies and Procedures
Organizational Functions - Employee Staffing and Training



                                Chapter 2
                       Employee Staffing and Training

Sections




                         Request to be Excused         Training Credits
                         from Patient Care             Orientation Guidelines
                         Responsibility                New Employee
                         Staffing in Emergency         Orientation
                         Conditions                    Minimum Training
                         Physician On-Call             Requirements
                         Schedule                      Lesson Plan Cover Sheet
                         Holiday Coverage              Code Blue Evaluation
                         Shift Differential            Cardiopulmonary
                         Eligibility                   Resuscitation
                         Overtime                      Certification
                         Jury Duty                     Forensic Staff
                         Temporary Modified            Orientation
                         Duty Assignment
                         Temporary Modified
                         Duty – Non Worker’s
                         Compensation




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            Organizational Functions - Employee Staffing and Training



           Section A
            Staffing

Topics




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Request to be Excused from Patient Care Responsibility

                      Date of Last Revision/Review 07/02/02

Introduction          This topic provides a mechanism for addressing an employee’s request to be excused
                      from patient care responsibilities that conflict with the employee’s cultural or
                      religious beliefs.

Policy                UTHCPC is committed to providing high quality patient care and ensuring that
                      patient care and treatment are not negatively affected or compromised. UTHCPC is
                      dedicated to providing care and treatment to all patients regardless of race, religion,
                      national origin, age, sexual orientation, color, sex, or disability.

Audience              The information in this topic applies to all UTHCPC staff regardless of classification,
                      status, or job title.

Grounds               An employee may request to be excused from participating in an aspect of patient
                      care or treatment due to cultural values, ethics, or religious beliefs. Examples
                      include but are not limited to the following:
                       Escorting a patient to another facility for an abortion
                       Escorting a patient to smoke or transporting tobacco to a patient

Approval              A Supervisor may approve or deny an employee’s request after evaluating whether or
                      not making such accommodations will negatively affect the care of the patient.

Emergencies           UTHCPC expects employees to continue providing the patient care or treatment until
                      the supervisor can make a decision regarding the request, in the event of an
                      emergency.

Request/approval      This table describes the request and approval process:
process
                       Stage                                     Description
                          1       The supervisor attempts to anticipate the environment and areas of patient
                                  care in his/her department.
                          2       The supervisor informs the employee of the anticipated environment and
                                  area of patient care prior to employment.
                                  Note: The supervisor also notifies the employee of changes in these areas
                                  subsequent to employment.
                          3       The employee specifies the following on the Staff Rights Special Request
                                  Form:
                                   The specific patient care or treatment issue
                                   The cultural value, sense of ethics, or religious beliefs in conflict

                                                                                      Continued on next page



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Request to be Excused from Patient Care Responsibility,
Continued

Request/approval      The table describing the request and approval process continues:
process (continued)
                       Stage                                   Description
                         4     The employee submits the UTHCPC Staff Rights Special Request form to
                               his/her immediate supervisor.
                         5     The supervisor reviews the situation.
                               Assistance available: The supervisor may discuss problems with the Ethics
                               Committee.
                         6     The supervisor uses this table to determine what to do with the form:
                                  WHEN the supervisor…           THEN the supervisor notes the…
                                  Approves the request        Approval on the Staff Rights Special
                                                              Request form and reassigns the employee.
                                                              The process is complete.
                                  Denies the request          Reason for denial on the Staff Rights and
                                                              Special Request form and informs the
                                                              employee of his/her decision.

                         7     The employee uses this table to determine what happens next:
                                  WHEN the employee…                         THEN the…
                                  Agrees to accept the        Employee continues to provide patient
                                  supervisor’s decision       care and treatment.
                                  Refuses to provide patient Supervisor instigates disciplinary action.
                                  care and treatment
                                                             May include: Suspension or immediate
                                                             termination of employment.
                                  Decides to appeal the       Employee appeals to the Hospital
                                  supervisor’s decision       Administrator.
                                                              Result: The Administrator makes a final
                                                              determination.



Related standard      JCAHO HR 6.2




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Staffing in Emergency Conditions

                      Date of Last Revision/Review 07/02/02

Introduction          UTHCPC must provide adequate staffing to meet patient care and operational
                      requirements in weather-related and other emergency conditions.

Policy                UTHCPC remains open at all times.
                      Exception: UTHCPC only closes during an emergency evacuation.
                      Note: The closing of other operating units of the UTHSC-H does not automatically
                      result in the closing of offices at UTHCPC.

Employee              UTHCPC expects its employees to report to work, or call in if unable to report to
expectations          work, as scheduled regardless of where employees live, even when UTHSC-H
                      closes.

Authorization to   The following are the only people authorized to suspend any operations when
suspend operations advised of adverse weather conditions or emergencies by the Safety officer:
                       Executive Director
                       Hospital administrator or his/her designee

Calling in            It is the employee’s ultimate responsibility to notify his/her supervisor, or
                      supervisor’s designee, if s/he is unable to report to work as scheduled.
                      Caution: Failure of an employee to call in if unable to report to work is grounds for
                      disciplinary action up to and including termination.

                                          WHEN…                                     THEN…
                      Employees suspect adverse conditions         Employees should call the UTHCPC-
                                                                   specific phone line at 713-741-5001 for a
                      Example: Severe weather
                                                                   pre-recorded message advising them of
                                                                   work attendance status.
                      The Executive Director, Hospital             Administration engages the cascade
                      Administrator, or designee declares a        recall system.
                      formal emergency
                      The employee’s or the hospital’s phone is The employee should make contact as
                      out-of-service                            soon as possible.
                      Employees are housed outside of the          They should contact their supervisor for
                      hospital                                     information about where to report to
                                                                   work if needed.
                      Examples: At OCB or MSI

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Staffing in Emergency Conditions, Continued

Emergency            Employees have the following options for obtaining information about UTHCPC
information          during an emergency:
                        Call the UTHCPC-specific phone line at 713-741-5001 for a pre-recorded message
                        Call his/her supervisor
                        Listen to KTRH radio 740 AM
                        Watch the news on television channels 2, 11, or 13

Essential personnel Essential personnel must report to work during emergency conditions to maintain
                    routine operations.
                     Administration may ask non-essential personnel to come in and cover operations if
                     the hospital is short of essential personnel.

Formal staffing      This table describes how administration appoints essential and non-essential
plan process         personnel:

                         Stage   Person Responsible                        Description
                          1      Department Managers Maintain a formal staffing plan that identifies
                                                     essential and non-essential personnel
                          2      Department Managers Submit formal staffing plans to Directors for
                                                     approval
                          3      Directors              Approve the formal staffing plans
                          4      Directors              Submit approved formal staffing plans to the
                                                        Hospital Administrator
                          5      Department Managers Notify employees of their essential or non-essential
                                                     status if any changes should occur


Compensation         The information in this topic does not affect employee compensation. UTHCPC
                     compensates employees in the same manner as all UT employees.

Related standards    JCAHO HR 2
                     JCAHO LD 2.4




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Physician On-Call Schedule
                      Date of Last Revision/Review 07/02/02

Introduction          An on-call system ensures adequate medical staff availability because patient needs
                      are not limited to traditional business hours.

On-call               The UTHCPC on-call attending physician must be available at all times to do the
responsibilities      following:
                       Walk-ins (responding within 30 minutes of call) see Walk-in Screenings
                       Examine new admissions
                       Respond to the emergency needs of all UTHCPC in-patients between 5 p.m. and 8
                        a.m. on the following days:
                         Monday through Friday
                         Weekends
                         Holidays

On-call period        The on-call schedule designates one-week rotating assignments that start on
                      Mondays and end on Sundays.

On-call schedule      This table describes the process of scheduling physicians for on-call duty:
process
                       Stage                                       Description
                          1       The Department of Psychiatry Chairman’s office produces an on-call
                                  schedule consisting of members of the active medical staff of UTHCPC.
                          2       The Chairman’s office submits the schedule to the UTHCPC Medical
                                  Director’s office.
                          3       The Medical Director’s office distributes copies of the list to the following
                                  areas:
                                   Administration
                                   Admissions
                                   Nursing Administration
                                   Switchboard
                                   Other departments as necessary
                          4       Is the physician able to fulfill his/her scheduled on-call responsibilities?
                                   If yes, s/he does so. The process is complete.
                                   If no, the physician arranges coverage for the assigned time.
                          5       The physician notifies the Chairman’s office and the Medical Director’s
                                  office of the change.
                          6       The Medical Director’s office notifies the appropriate departments of the
                                  change.
                                                                                      Continued on next page



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Physician On-Call Schedule, Continued

Related standards   JCAHO MA 3
                    JCAHO LD 1.3, LD 1.3.4, LD 1.6, and LD 2.3




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Holiday Coverage

                      Date of Last Revision/Review 07/02/02

Introduction          This topic explains what departments must continue to provide services on holidays.

Compensation          Compensation payments follow standard state regulations.

Level of service      This table describes the level of service necessary on the two types of holidays:

                       Type of Holiday                        Description                  Level of Service
                      Core                      Holidays considered so traditional that Minimal
                                                UTHCPC gives staff time off if at all
                                                possible:
                                                 Fourth of July
                                                 Thanksgiving Day
                                                 Christmas Day
                                                 New Year’s Eve
                      Non-core                  Any holiday other than the four core   More staff than core
                                                holidays                               holidays, but less staff
                                                                                       than regular work days


Functional staffing   The department manager of each department that must provide holiday coverage
                      determines the exact holiday staffing necessary to cover the needs of the hospital.
                      Documentation: The department manager documents the specific staffing required in
                      the departmental policy and procedure manual.

Holiday coverage      This table lists which departments must have functional staffing on holidays:

                       Holiday Type                                         Coverage
                      Core                    These departments must continue to provide adequate patient care
                                              and program services regardless of the holiday:
                                               Patient Clinical Programming        Lab
                                               Patient Registration                Linen
                                               Communications                      Nursing
                                               Facilities Management Service       Pharmacy
                                               Food and Nutrition                  Reception Desk
                                               Case Management
                                              Other departments must be available by pager as necessary.
                                              Example: MIS

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Holiday Coverage, Continued

Holiday coverage   The table listing which departments must have functional staffing on holidays
(continued)        continues:

                    Holiday Type                                 Coverage
                   Non-core          The following departments must continue to provide adequate
                                     patient care and program services regardless of the holiday:
                                      Patient Clinical Programming        Linen
                                      Administration                      Patient Account Services
                                      Patient Registration                Medical Staff Support
                                      Cashier                             MIS
                                      Health Information Management  Nursing
                                      Communications                      Nursing Administration
                                      Lab                                 Pharmacy
                                      Facilities Management Services      Performance Improvement
                                      Case Management                     Data Management
                                      Food and Nutrition                  Reception Desk
                                     The following departments must be on site as needed:
                                      Financial Operations              Patient Relations
                                      Library                           Psychology
                                      Support Services                  Safety
                                      Personnel Systems Management  Public Information and
                                                                           Education


Related standard   JCAHO MA 3




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Shift Differential Eligibility

                      Date of Last Review 09/09/04
                      SME: Sherri Orioli
Introduction
                      This topic provides information about shift differential eligibility.

Definition: shift     A bonus provided to classified employees who work shifts that differ distinctly from
differential          the normal workday.
                      Normal workday: 8:00 a.m. to 5:00 p.m.

Legal requirements The law does not require UTHCPC to pay shift differential to non-exempt employees
                   whose shifts differ from the normal workday.

Industry standards UTHCPC follows generally accepted industry standards in providing the shift
                   differential bonus.

Responsibilities      Supervisors have the following responsibilities:
                       Identify the eligibility of the following for shift differential pay:
                        – Shifts
                        – Positions on the said shifts
                       Communicate eligibility decisions to employees
                       Remain consistent in decisions to approve and/or deny shift differential pay

Approval              Supervisors may approve shift differential pay for the following situations, at their
                      own discretion:
                       Positions in departments that require:
                        – Around-the-clock coverage
                        – Consistent late-evening coverage
                       Shifts with 50-percent or more of the scheduled hours between 2:00 p.m. and 8:00
                        a.m.
                       Employees in approved positions asked to work over into another previously-
                        approved shift
                        Rate note: These employee may receive differential for all hours actually worked
                        on that shift.

Reference             Hoops 2.37 Holidays




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Overtime

                      Date of Last Review 09/09/04
                      SME: Sherri Orioli
Introduction
                      UTHCPC may compensate employees for overtime hours worked.

Definition: Day       A day shift is a shift consisting of a standard work week with set hours that fall
shift                 between 7:00 a.m. and 5:00 p.m.

Eligibility           Eligible
                      The following non-exempt employees are eligible for overtime compensation:
                       Classified employees
                       Regular employees with a casual job
                      Ineligible
                      Exempt employees are not eligible for overtime. Supervisors may grant exempt
                      employees compensatory time off, but not necessarily hour-for-hour worked.
                      Exception: Some exempt nursing staff may be eligible for overtime per nursing
                      policy.
                      Reference: See the classified pay plan.

Fair Labor            The Fair Labor Standards Act entitles employees to overtime when they are “suffered
Standards Act         or permitted to work”. Therefore, the working time is compensable if the employer
                      knows or should have known that the employee is working or has worked, whether or
                      not the employer authorized the work.

Preventing            Supervisors should do the following to prevent unauthorized overtime:
unauthorized
                       Ensure that all non-exempt staff members are aware of the policy and procedure
overtime
                        for requesting overtime in advance of the work.
                       Patrol the work area at the end of each shift to ensure that all non-exempt
                        employees have left their work areas. Managers who knowingly allow their non-
                        exempt employees to work past the end of their shift, authorized or not, must
                        legally pay them overtime, or grant compensation time.

Responsibilities for Nursing managers approve overtime for nursing staff.
nursing staff
                     Staffing office codes approved overtime for the nursing staff in the ANSOS
overtime
                     scheduling system.
                                                                                       Continued on next page




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Overtime, Continued

Overtime pay          Pay schedule
                      UTHCPC pays employees for overtime on a semi-monthly basis, based on a properly
                      completed and approved time and attendance form indicating overtime approved in
                      advance.
                      Pay calculation
                      UTHCPC calculates overtime on the employee’s base pay rate. Overtime pay is
                      dispersed with a lapse of one pay period.
                      Paid time-off
                      Managers should not consider paid time off when determining whether the employee
                      meets the 40-hour threshold for overtime pay purposes.
                      Reason: Paid time-off does not represent hours actually worked.
                      Examples of paid time-off: Vacation, personal leave, sick leave, jury duty

Compensatory time Employees must take compensatory time within 12-months following the overtime
                  worked. UTHCPC must pay an employee for the overtime if s/he does not take
                  compensatory time within 12-months.

Overtime rules        UTHCPC assigns each non-exempt employee to one of the following overtime rules:

                       Overtime Rule                                Description
                      40-hour             The Classified employee receives one of the following for all
                                           hours worked in excess of 40 in a work week:
                                            Monetary compensation at one and one-half times their base
                                             hourly rate
                                           – Compensatory time off at one and one-half times the hours
                                             worked
                                          The regular employee with a casual job receives straight hour-
                                           for-hour compensatory pay or time for each hour over 40 in a
                                           work week.
                                         Discussion: The supervisor and employee should discuss the
                                         method of compensation prior to the employee working the
                                         overtime.
                      8/80               The employee receives monetary compensation at one and one-
                                         half times their base hourly rate for the greater of the following
                                         options:
                                          All hours worked in excess of 8 in one day
                                          All hours worked in excess of 80 in a two-week period

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Overtime, Continued

Overtime         This table describes which employees are on each overtime rule plan:
classification
                             Staff                                    Overtime Rule
                 Nursing staff                    8/80
                                                  Exception: Employee and supervisor must sign a
                                                  Letter of Understanding that his/her overtime is paid
                                                  on the 40-hour overtime rule. (Employees who work a
                                                  compressed work week).
                 Nursing department unit          40-hour
                 clerks providing a clerical
                                                  Exception: Employee must sign a letter of
                 function
                                                  understanding that his/her overtime is paid on the 8/80
                                                  overtime rule. (Employees who work a compressed
                                                  work week).
                 Non-nursing employees that 8/80
                 work first and second shifts
                 Non-nursing employees that 40-hour
                 work day shifts

                                                                                  Continued on next page




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Overtime, Continued

Approval process      This table describes the approval process for overtime worked by a non-exempt, non-
                      nursing employee:
                      Caution: Employees cannot work overtime without approval.

                       Stage                                   Description
                         1     The employee uses this table to determine when to contact the department
                               manager:
                                  WHEN the overtime is …                THEN the employee...
                                 Scheduled                      Informs the department manager
                                                                responsible for the departmental budget
                                                                at least 48-hours in advance.
                                 Emergency                      Contacts the department manager for
                                                                verbal approval.
                                 Incidents within the normal    Informs the department manager in
                                 schedule                       advance.
                                 Example: missed meals,
                                 meetings

                         2     The department manager determines how much overtime is essential.
                         3     Department manager uses this table to determine what happens next:
                                  WHEN the compensated is...            THEN the department...
                                 Overtime pay                      Manager completes the Time and
                                                                   Attendance Request form for Non-
                                                                   Exempt Employees for all overtime
                                                                   to be paid.
                                 Comp time                         Maintains a balance of comp time
                                                                   accrued in lieu of overtime pay.

                         4     The department manager submits the form to Personnel Systems
                               Management.
                               Result: The department manager has approved the overtime.


Related standards     JCAHO MA 4
                      UTHSC-H Handbook of Operating Procedures
                      Fair Labor Standards Act (US Code Title 29, Chapter 8)




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Jury Duty

                      Date of Last Review 09/09/04
                      SME: Sherri Orioli
Introduction
                      UTHSC-H believes it is the responsibility and duty of every employee to serve on a
                      jury when summoned.

Compensation          Jury duty is paid leave. The employee’s supervisor ensures that the employee’s salary
                      is not affected by absence for jury duty.

Jury duty            This table describes the jury duty notification process:
notification process
                      Stage     Person Responsible                          Description
                          1       Employee                  Receives notice to report for jury duty.
                          2       Employee                  Notifies his/her supervisor immediately.
                          3       Employee and              Complete the Time and Attendance Request form.
                                  Supervisor
                          4       Employee and              Submit the Time and Attendance Request form to
                                  Supervisor                Personnel Systems Management with the
                                                            following:
                                                             Weekly punch details
                                                             Copy of the summons
                          5       Supervisor                Arranges the schedule to ensure coverage while the
                                                            employee is off.
                          6       Employee                  Informs supervisor of time expected away from the
                                                            workplace.
                          7       Employee                  Submits documentation provided by the court to
                                                            his/her supervisor when s/he returns to work.


Related standards     JCAHO GO 2
                      JCAHO MA 1
                      Civic Duty Leave HOOP 2.39D




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Temporary Modified Duty Assignment

                      Date of Last Review 09/09/04
                      SME: Sherri Orioli
Introduction
                      The University of Texas at Houston Harris County Psychiatric Center (UTHCPC)
                      strives to accommodate employees who have been temporarily restricted from
                      performing their regularly assigned duties.
                      This procedure only covers employees who have sustained an accidental injury or
                      occupational illness while performing duties within the course and scope of their
                      employment or appointment.

Overview              Employees who sustain an injury or illness while performing assigned job duties
                      should immediately report the injury or illness to their immediate supervisor in
                      compliance with policy Workers’ Compensation Insurance 2.17D.

                      The policies below are to be followed after an injury/illness incurred resolves
                      sufficiently for the employee to return to work on a modified basis:
                       Assist employees to the extent possible by temporarily modifying work assignment
                        or duties
                       Arrange for a temporary modified duty assignment, not to exceed six calendar
                        months
                       Medical re-evaluation by the employee’s health care provider must be performed at
                        a minimum of every 2 weeks at the expense of the Worker’s Compensation
                        Insurance Carrier, as provided by that program
                       Employee must participate fully in her/his recovery by keeping all physician and
                        physical therapy appointments
                       Failure of the employee to keep physician and physical therapy appointments
                        impede the continuation of temporary modified duty assignments
                       The employee must notify her/his supervisor and the Employee Health Case
                        Manager of all doctor appointments
                       Physical Therapy appointments should be scheduled after working hours if at all
                        possible
                       At each visit with the employee’s health care provider, restrictions must be
                        reviewed for modification, renewal or elimination and an updated TWCC 73 must
                        be sent to the Workers Compensation Insurance Carrier and UTHCPC’s Employee
                        Health Case Manager
                                                                                      Continued on next page




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Temporary Modified Duty Assignment, Continued

Evaluation by a   The employee visits a health care provider for care relating to the injury/illness as
health care       follows:
provider

                   Step                                         Action
                     1      The attending health care provider determines any temporary work
                            restrictions to be applied to the employee’s work duties.
                     2      The attending health care provider documents any findings in writing on
                            form TWCC 73 and sends the form to:
                            Employee Health Case Manager
                            UT-Harris County Psychiatric Center
                            2800 South MacGregor Way, Room 1D01
                            Houston, Texas 77021
                     3      Upon receipt of the documentation from the healthcare provider the
                            UTHCPC Employee Health Case Manager:
                             Reviews the TWCC 73
                             Contacts the employee’s health care provider clarifying any restrictions
                             Provides information to the physician regarding UTHCPC return-to-
                              work procedures


Employee health   The UTHCPC Employee Health Case Manager coordinates the temporary modified
case manager      duty assignment as follows:


                   Step                                         Action
                     1      Contacts the employee’s supervisor to schedule a meeting to discuss:
                             Employee’s restrictions
                             Practicality and feasibility of modifying the employee’s current job
                              function
                             Identifying an assignment within other hospital departments

                                                                                  Continued on next page




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Temporary Modified Duty Assignment, Continued

Employee health       The UTHCPC Employee Health Case Manager coordinates the temporary modified
case manager          duty assignment as follows (continued):
(continued)

                       Step                                        Action
                         2     Use this table to determine the results of the supervisor’s response
                                         If the supervisor...          Then the Employee Health Case
                                                                                 Manager...
                                 Agrees to place the employee in a     Informs Personnel Systems
                                 temporary modified duty                Management (PSM) of the
                                 assignment within her/his              agreement
                                 department                            Requests that PSM:
                                                                        – Perform a salary work-up
                                                                        – Prepare a Letter for Bona Fide
                                                                          Job Offer

                                 Determines there is not placement     Requests that PSM locate a
                                 for the employee in her/his            temporary modified duty
                                 department                             assignment in a different
                                                                        department within the hospital
                                                                       If a department is located, the
                                                                        Health Care Case Manager
                                                                        contacts the department
                                                                        manager to:
                                                                        – Discuss the employee’s
                                                                           restrictions
                                                                        – Ensure that the department
                                                                           can accommodate the work
                                                                           limitations

                         3     Use this table to determine funding for the temporary modified duty
                               assignment
                                                 If...                              Then...
                                 The employee is assigned to the      The employee’s supervisor and
                                 same department                      Personnel Systems Management
                                                                      determine funding availability
                                 The employee is assigned to a        Personnel Systems Management
                                 different department                 and the department manager
                                                                      determine funding availability


                                                                                    Continued on next page



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Temporary Modified Duty Assignment, Continued

Employee health   The UTHCPC Employee Health Case Manager coordinates the temporary modified
case manager      duty assignment as follows (continued):
(continued)

                   Step                                       Action
                     4     The Employee Health Case Manager sends a copy of the bona fide offer
                           letter to the Workers Compensation Insurance Carrier to be reviewed prior
                           to the job offer.
                     5     The bona fide offer letter is given to the employee during the meeting with
                           her/his supervisor and the Employee Health Case Manager. See section on
                           “Bona Fide Offer Letter” below.


Bona fide offer   The following is the process for making the employee a bona fide offer of temporary
letter            modified employment:


                   Step                                       Action
                     1     The employee, Employee Health Case Manager, and the employee’s
                           supervisor meet to:
                            Discuss the physical and time requirements
                            Ensure the temporary position is in keeping with the employee’s
                             restrictions which are valid for the stated period not to exceed 6 calendar
                             months
                            Review the offer letter which the employee and supervisor sign in
                             agreement
                     2     The employee’s supervisor:
                            Sends a copy of the letter to PSM and the Employee Health Case
                             Manager
                            Initiates a personnel action form as appropriate
                     3     If an employee accepts the offer, then loses time without a doctor’s note,
                           the employee’s lost time is considered unauthorized.
                     4     If the employee does not present in person, the letter is sent by certified
                           mail to the employee with the stipulation that they must reply within 5 days
                           from the date of the letter.
                     5     If no reply is received from the employee in 5 days, the department
                           considers this a refusal of the temporary modified duty assignment offer.

                                                                                Continued on next page




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Temporary Modified Duty Assignment, Continued

Bona fide offer       The following is the process for making the employee a bona fide offer of temporary
letter (continued)    modified employment (continued):


                       Step                                       Action
                         6     If the employee refuses the offer:
                                It may be grounds for termination
                                Workers Compensation Commission Insurance Carrier may reduce or
                                  suspend temporary income benefits


Return to full-duty   The employee must send a work release from her/his physician to the Employee
policies              Health Case Manager 1 day prior to returning to work. Other policies are as follows:


                       Step                                       Action
                         1     The employee will return to a position comparable in pay and benefits
                         2     If the employee refuses to return to regular duties in response to a written,
                               bona fide offer of employment sent via certified mail, the employee is
                               terminated from UTHCPC employment.
                               Reference: Texas Revised Civil Statues Annotated, Article 8308


Extended/             The table below shows what happens when an employee is unable to return to full
Permanent             work duties after being on a modified duty assignment:
disability

                       Step                                       Action
                         1     Extended or permanent disability may be necessary if:
                                The employee is not released by her/his attending health care provider to
                                 return to regular duties after six calendar months or
                                The employee or employee’s supervisor no longer believes it is practical
                                 or feasible to continue the temporary modified duty assignment
                         2     UTHCPC makes reasonable accommodations to:
                                Continue the individual’s employment at UTHCPC or
                                Place the employee, if eligible, on long-term disability per UT procedure
                                 on Disability 2.18C
                         3     Decisions regarding extended or permanent disability are made on a case-
                               by-case basis in accordance with applicable state and federal laws and
                               regulations.

                                                                                     Continued on next page



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Temporary Modified Duty Assignment, Continued

Related standards   Temporary Modified Duty Assignments HR HOOPS 2.39A.1
                    Workers' Compensation Insurance HOOPS 2.17D
                    Family and Medical Leave, section on "Serious Health Condition" HOOPS 2.40C
                    TX Labor Code Chapter 503
                    TX Workers' Compensation Commission Rule 129.6




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Temporary Modified Duty – Non Worker’s Compensation

                      Date of Last Review 09/09/04
                      SME: Sherri Orioli
Introduction
                      The University of Texas at Houston Harris County Psychiatric Center (UTHCPC)
                      strives to accommodate employees who have been temporarily restricted from
                      performing their regularly assigned duties or are unable to perform essential aspects
                      of their regularly assigned duties.

                      This procedure only covers employees who have sustained a personal accidental
                      injury or illness totally unrelated to any injury or illness incurred while performing
                      duties within the course and scope of their employment or appointment.

Overview              The policies below are to be followed after a personal injury/illness incurred resolves
                      sufficiently for the employee to return to work on a modified basis:
                       Assist employees to the extent possible by temporarily modifying work assignment
                        or duties
                       Arrange for a temporary work assignment, not to exceed 90 calendar days
                       Medical re-evaluation by the employee’s health care provider must be performed at
                        each 30 days at the expense of the employee

Evaluation by         The employee visits a health care provider (with their job description) for care
health care           relating to the injury/illness as follows:
provider
                        Step                                         Action
                          1       The attending health care provider determines any temporary work
                                  restrictions to be applied to the employee’s work duties after review of the
                                  job description.
                          2       The attending health care provider documents any findings in writing
                                  describing any job restrictions or physical limitations.
                          3       The employee provides these documents to their manager to review.

                                                                                       Continued on next page




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Temporary Modified Duty – Non Worker’s Compensation,
Continued

Supervisor duties   Upon receipt of the documentation from the healthcare provider, the supervisor
                    proceeds as follows:


                     Step                                       Action
                       1     Reviews the employee’s restrictions and then determines the practicality
                             and feasibility of modifying the employee’s current job function.
                       2     Confers with Personnel Systems Management (PSM) Director and
                             managers with open positions to determine a need for personnel within the
                             hospital.
                       3     Use this table to determine the results of the supervisor’s response:
                                    If the         Then the Supervisor’s Department Manager...
                                 Supervisor...
                               Agrees to         Works with the Director of PSM to locate a
                               modify the         temporary modified duty assignment in a different
                               employee’s         department within the hospital
                               current position  If a department is located, the manager of the
                               within her/his     department accepting the employee for temporary
                               department         assignment develops a job to meet the restrictions
                                                  or physical limitations established by the physician
                                                 Modifies the employee’s job description as needed
                                                  to meet the restrictions or physical limitations
                                                  established by the physician
                                                 Works with Human Resources to determine the
                                                  appropriate job classification and salary
                                                 Prepares a Letter for Bona fide Job Offer
                                                 Reviews the medical re-evaluation received from
                                                  the employee’s health care provider each 30 days
                                                  to determine if the temporary assignment should
                                                  continue
                               Determines      See Extended/Permanent Disability
                               there is not
                               placement for
                               the employee in
                               UTHCPC


                                                                                  Continued on next page




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Temporary Modified Duty – Non Worker’s Compensation,
Continued

Return to full duty   The employee must provide a Certification of Fitness for Duty form from her/his
                      physician to the Supervisor one (1) day prior to returning to work. The employee
                      will return to a position comparable in pay and benefits.

Extended/             The table below shows what happens when an employee is unable to return to full
Permanent             work duties after being on a modified duty assignment:
disability

                       Step                                      Action
                         1     Extended or permanent disability may be necessary if:
                                The employee is not released by her/his attending health care provider to
                                 return to regular duties after 90 calendar days or
                                The employee or employee’s supervisor no longer believes it is practical
                                 or feasible to continue the temporary modified duty assignment
                         2     UTHCPC makes reasonable accommodations to:
                                Continue the individual’s employment at UTHCPC or
                                Exhaust all benefits available to the employee (FMLA, sick leave,
                                 vacation, holiday, sick leave pool)
                                Grant the employee a leave of absence without pay as long as the
                                 department is not negatively impacted operationally
                                Refer the employee to the Benefits department, if eligible, to explore
                                 benefits options
                         3     Once all reasonable accommodations are explored and exhausted, and the
                               employee is still unable to return to work without restrictions, the
                               employee is separated from university employment.


Related standard      Family and Medical Leave HOOP 2.40C, section on “Serious Health Condition”
                      JCAHO HR 1




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Training                           UTHCPC Policies and Procedures
            Organizational Functions - Employee Staffing and Training



           Section B
           Training

Topics




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Training Credits

                      Date of Last Revision/Review 07/02/02

Introduction          This topic provides general information about training credits.

Goal                  UTHCPC’s goal is to provide training required by statute or accreditation standards.

Definitions           Training
                      UTHCPC defines training as a structured educational experience with predetermined
                      objectives related to job performance or personal growth.
                      Continuing Education Units (CEUs)
                      A recognized standard for training credits. UTHCPC affirms the value of such a
                      measure and actively participates in CEU programs.

CEU credit            The following information is about CEU credits:
                       Each professional body has separate requirements and paperwork for granting CEU
                        credits.
                       Notify Hospital-Wide Education at least four weeks in advance if you want to offer
                        CEU credit for a unit-based or department specific in-service.

CEU                   This table lists the documentation of CEU credits:
documentation
                            CEUs earned…                                     Recorded in the…
                      At UTHCPC                          Individual training transcript
                      Elsewhere                          Individual training transcript if it is related to your job at
                                                         UTHCPC and you provide appropriate documentation
                                                         (i.e. certificate)


Outside training      Employees may choose to take outside training to increase their knowledge and
                      skills.
                      Note: Employees cannot substitute outside training for New Employee Orientation
                      or Crisis Management requirements.
                                                                                              Continued on next page




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Training Credits, Continued

Record maintenance This table describes how training records are maintained and verified:
and verification
                   Stage    Person Responsible                         Description
                        1      Hospital-Wide        Maintains all official training records by class and
                               Education department by individual transcript
                        2      Hospital-Wide        Prints and distributes individual transcripts to
                               Education department department managers
                        3      Manager or designee    Ensures that each employee is in compliance with
                                                      the Minimum Training Requirements and/or
                                                      educational training
                        4      Manager or designee    Registers employees for training classes as
                                                      necessary
                        5      Manager or designee    Maintains individual transcripts in the
                                                      departmental personnel file for reference
                        6      Employee               Contacts the Hospital-Wide Education office for
                                                      additional transcripts as desired


Form                 Job-Related Training and Education: Employee Request Form

Related standards    JCAHO HR 3.1 and 4.2




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Orientation Guidelines

                      Date of Last Revision/Review 07/02/02

Introduction          This topic provides general information about orientation.

Orientation           This table lists information about the types of orientation administration requires for
requirements          people functioning in different capacities:

                           Person                 Orientation Type                  Comments
                      UTHCPC staff          New employee orientation Conducted by:
                                                                      UT-Houston
                                                                      Hospital-Wide Education
                                                                       department
                                                                      Designated department preceptors
                                                                      Reference: See New Employee
                                                                      Orientation.
                       Contract staff One of the following           Examples:
                       Per diem       according to the contract       Pharmacy staff conduct their own
                                       terms:                           orientation
                       Casual staff
                                        New employee                  Food and Nutrition and
                                         orientation                    Housekeeping staff conduct their
                                        Orientation provided by        own orientation
                                         contract agency               Assigned department staff complete
                                                                        department-specific orientation
                      Volunteers            Volunteer orientation     Conducted by: Volunteer Coordinator
                                                                      Time requirement: Orientation prior
                                                                      to assignment

                                                                                     Continued on next page




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Orientation Guidelines, Continued

Orientation         The table lists information about the types of orientation administration requires for
requirements (cont) people functioning in different capacities continues:

                           Person           Orientation Type                      Comments
                      Students          Two-hour orientation         Content: Introduction to the following
                                                                     information:
                                                                      UTHCPC mission statement,
                                                                       philosophy, and organization
                                                                       structure
                                                                      Patient rights
                                                                      Basic self-defense
                                                                      Policies and procedures regarding
                                                                       student activities
                      First year        3-day, (24-hours of          Content: Extensive information about
                      residents         orientation)                 the following information:
                                                                      Verbal intervention skills
                                                                      Self-defense
                                                                      Unit safety
                                                                     Conducted by:
                                                                      UTHCPC subject matter experts
                                                                      Mental Sciences Institute (MSI)
                                                                       Residency Training program


Training records      The Hospital-Wide Education department maintains all employee training records.

Related standards     JCAHO HR 1 and 2




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New Employee Orientation

                      Date of Last Revision/Review 07/02/02

Introduction          This topic provides information about new employee orientation.

Arranging for new     The staff recruiter or designee contacts Hospital-Wide Education to arrange for
employee              orientation of new employees.
orientation
Duration              New employee orientation lasts throughout the 120-day probationary period.

Phases                This table describes the phases of new employee orientation:

                         Phase          Introduction to…                        Description
                          One          University of          General overview of the following:
                                       Texas-Houston           UT system
                                                               Safety lectures
                                                               Benefit options
                          Two          UTHCPC                 The Hospital-Wide Education department and
                                                              content experts provide the following
                                                              information:
                                                               UTHCPC mission, vision, and value statements
                                                               Payroll/compensation
                                                               CPR (direct care staff)
                                                               Organizational structure of the facility
                                                               Patients and pathology
                                                               Infection control
                                                               Fire safety
                                                               Hazardous materials
                                                               Patient rights
                                                               Ethics
                                                               Crisis management
                                                               Policies and procedures
                                                               Performance improvement
                                                              Duration: 28-hours

                                                                                       Continued on next page




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New Employee Orientation, Continued

Phases (continued)   This table describes the phases of new employee orientation (continued):


                       Phase       Introduction to…                       Description
                        Three     Department or unit Supervisor introduces employees to their specific
                                                     unit/department
                                                       Note: May include the following depending on
                                                       individual needs:
                                                        Additional classroom training
                                                        Formal and informal on-the-job training
                                                        Competency testing
                                                       Duration: Several days to several months.




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Minimum Training Requirements

                      Date of Last Revision/Review 07/02/02

Introduction          UTHCPC requires all employees to maintain annual minimum training requirements
                      (MTRs) to ensure that the hospital functions at its highest level.

Requirement           All staff members must meet the MTRs, or mandated core courses, for UTHCPC to
                      consider them competent in their positions.
                      Including: Contract and per diem employees

Definitions           This table explains terms in this topic:

                                   Term                                           Definition
                      Competency based                    Training directly related to job performance
                      training
                                                          Note: Most training is competency-based
                      Direct care staff                   Staff whose primary responsibility is for the daily care of
                                                          patients on or about the patient care units
                                                          Examples: Nurses, hospital aides, social workers, case
                                                          managers, therapists, counselors
                      Indirect care staff                 Staff whose work responsibilities may take them on or
                                                          about the patient care units, but are not directly
                                                          responsible for daily patient care
                                                          Examples: Administrative staff, clerical support staff,
                                                          non-clinical management staff
                      MTR (minimum training               Core competencies required by UTHCPC policy
                      requirement)
                                                          See Minimum Training Reference Guide
                      Training                            Structured educational experience with a predetermined
                                                          objective related to job performance or personal growth

                                                                                            Continued on next page




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Minimum Training Requirements, Continued

Responsibilities    This table lists MTR responsibilities:

                      Person/Department                              Responsibility
                    Hospital-Wide               Determines what MTRs to implement using data from
                    Education department         the following sources:
                                                 – Group management meetings to discuss competency
                                                   issues
                                                 – Supervisory review of performance appraisals and
                                                   development plans
                                                 – Performance improvement data
                                                 – Regulatory and other external requirements
                                                 – Formal and informal staff feedback
                                                 – Recommendations from hospital committees
                                                   Examples: Safety and infection control
                                                Updates MTRs annually
                    Administration             Reviews and approves MTRs
                    Department Managers         Assign employees as either direct or indirect care
                                                Communicate training requirements to employees
                                                Ensure that employees demonstrate competency in all
                                                 required core areas
                                                Determine the job-specific training their staff require


References          Competency Requirements

                    Minimum Training Reference Guide

                    Licensure and Certification

Related standards   JCAHO HR 1 and 2




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Organizational Functions - Employee Staffing and Training


Lesson Plan Cover Sheet

                      Date of Last Revision/Review 07/02/02

Introduction          Lesson Plan Cover Sheets provide a means of assessing what learning is intended and
                      accomplished.
                      Purpose: To maintain a high level of quality in accordance with adult education
                      principles.

Function              The Lesson Plan Cover Sheet form documents training conducted at UTHCPC.

When to use           Complete the form and submit it to Hospital-Wide Education after conducting the in-
                      service.

Completing the        This table describes what information to record in the Lesson Plan Cover Sheet form
form                  fields:

                                Field                 Information to Include                 Notes
                      Course title                 MTR listing of your in-       Examples:
                                                   service                        Safety
                                                                                  Infection Control
                                                                                  Unit-Based In-service
                      Lesson title                 Title of this particular      Examples:
                                                   training                       Use of Fire Extinguishers
                                                                                  Reading TB Tests
                                                                                  The Role of Child Protective
                                                                                   Services in Pediatric
                                                                                   Psychiatry
                      Total time                   Number of classroom hours Are Continuing Education
                                                   this training takes to conduct Units (CEUs) available?
                      Date                         Dates you plan to conduct     NA
                                                   the training
                      Times to be taught           Clock hours during which      NA
                                                   you plan to conduct this
                                                   training
                      Target population            People you anticipate being   Examples:
                                                   in the training                Case managers
                                                                                  All unit staff
                                                                                  Registered nurses
                      Number of                    Range of participants you     Examples: Up to 30 or 5-6
                      participants                 expect in each training
                                                   session

                                                                                        Continued on next page
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Lesson Plan Cover Sheet, Continued

Completing the     The table describing what information to record in the Lesson Plan Cover Sheet form
form (continued)   fields continues:

                          Field            Information to Include                    Notes
                   Space requirements    Amount of classroom space      Examples:
                                         needed                          Tables and chairs
                                                                         Chairs only
                                                                         Room to break into
                                                                          discussion groups
                   On job performance    Final job-improvement        Be concrete
                   goal                  outcome expected as a result
                                         of this training
                   Learning objectives   What participants will be       Use behavioral terms
                                         capable of after this training   Examples: Explain,
                                                                          recognize, list, perform
                                                                         Avoid words that are not
                                                                          measurable
                                                                          Examples: Know or
                                                                          understand
                   Evaluation            List how you plan to           Examples:
                   procedures            measure whether                 Written quiz
                                         participants achieve the
                                         performance objectives for      Class participation
                                         the class                       Skills test
                   Instructional method Primary teaching method         Examples: Lecture or
                                        you plan to use                 discussion
                   Materials             Any props for the instructor   Attach a copy of these
                                         to use                         materials
                                                                        Examples: Handouts or
                                                                        overheads
                   Equipment and         Audiovisual equipment          Check all that apply
                   supplies needed


Related standard   JCAHO HR 4.2




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Organizational Functions - Employee Staffing and Training


Code Blue Evaluation

                      Date of Last Revision/Review 04/01/03

Policy                Code blue drills are designed to prepare staff in responding to medical emergencies
                      as a part of the staff competency curriculum.

Safety Committee      The Safety Committee is responsible for the following:
responsibilities
                       Overseeing completion of code blue drills
                       Establishing frequency and areas to be tested as part of its annual plan of action
                        Note: Frequency of drills is 2 times per year

Nursing/Safety        The Safety Officer is responsible for scheduling and facilitating a random code blue
Officer               drill in collaboration with Nursing and Hospital-Wide Education.
responsibilities
Required              The drill is designed to test staff competency on the following:
competencies
                       Recognition of acute medical crisis
                       Proper use/application of medical equipment
                        Examples: O2 tank, EKG machine, ambu-bag, automated external defibrillator
                        (AED)
                       Adherence to policy/procedure regarding management of acute medical
                        emergencies
                        Example: Notification/documentation
                       Proper CPR procedures

Review team           The nursing Safety Committee representative or designee requests a representative
members               from nursing, medical staff, hospital-wide education and safety to form a review
                      team.

Evaluation process    This table describes how the review team evaluates the drill:

                       Stage                                  Description: The review team…
                          1       During the drill the Nursing Supervisor, manager or designee observes staff
                                  and records the observation on the Code Blue Evaluation form.
                          2       During an actual code or medical emergency the Nursing Supervisor or
                                  designee also completes the Code Blue Evaluation form. This evaluation is
                                  credited as part of staff training.

                                                                                        Continued on next page




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Code Blue Evaluation, Continued

Evaluation process   This table describes how the review team evaluates the drill (continued):
(continued)

                      Stage                        Description: The review team…
                        3      Reviews the completed drill form, analyzes observations, and prepares a
                               performance analysis report.
                        4      Forwards the report to Nursing Administration, Safety Committee, and
                               other appropriate departments for review and action as needed.


Related standards    JCAHO HR 2, HR 4.2




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Organizational Functions - Employee Staffing and Training


Cardiopulmonary Resuscitation Certification

                      Date of Last Revision/Review 07/02/02

Introduction          Personnel responding to emergencies in the work place are trained in the following
                      techniques:
                       Proper training in cardiopulmonary resuscitation (CPR)
                       Use of automated external defibrillator (AED)
                       Relief of foreign-body airway obstruction

Who requires          All direct care staff must have a current certification in CPR. See Minimum Training
certification?        Requirements for definition of direct care staff.

When to re-certify    CPR certification is a part of orientation for direct care staff who are responsible for
                      obtaining re-certification every two years.

How to obtain         Employees may be re-certified as follows:
certification
                       By completing one of the regularly scheduled CPR classes provided by the
                        Hospital-Wide Education department
                       By completing Red Cross or American Heart Association training in CPR
                        Note: Employees must show the agency completion card as proof of training

Related standard      JCAHO HR 1-4




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Forensic Staff Orientation

               Date of Last Revision/Review 9/19/03

Introduction   UT-Harris County Psychiatric Center serves voluntarily and involuntarily committed
               patients. To clarify the role of forensic staff at HCPC, specific guidelines have been
               established to orient and educate to responsibilities related to patient care.

Policy         It is UTHCPC policy to orient forensic staff, Security/UT Police, to their role in
               hospital procedures that may involve them while they are in this facility.

Types of       Forensic staff are oriented to the following procedures:
procedures
involved

                Types of Procedures                                         Includes
               Emergency                         Disaster
                                                 Fire (Code Red)
                                                 Hospital internal emergencies
                                                  – Cardiopulmonary arrest (Code Blue)
                                                  – Security alert
                                                  – Special team

               Patient                          Clinical restraint and seclusion:
                                                UTHCPC does not expect forensic staff to assist with
                                                special teams, clinical restraint, or seclusion
               Routine                           Patient confidentiality
                                                 Orientation to locations in the facility
                                                 Number of visitors allowed in patient room/treatment
                                                  area

                                                                                       Continued on next page




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Forensic Staff Orientation, Continued

Orientation           General orientation is conducted by the Hospital-Wide Education department.
                      Department-specific orientation is provided by Facilities Management. See table
                      below:


                       Person/Department                              Responsibility
                      Hospital-Wide             Provides general orientation to new officers from the
                      Education department       Security/UT Police office which includes
                                                 – Fire safety
                                                 – Hazardous materials and waste management
                                                 – Patient rights
                                                 – Seclusion/restraint
                                                 – Patient management training
                                                Receives a list of new officers to attend orientation from
                                                 UT Police
                      Facilities Management     Department-specific orientation includes:
                      Manager/designee           – Review of policies related to their job assignment
                                                 – Location of disaster plan and responsibilities during
                                                   internal and external disasters
                                                 – Facility operations during a Code Blue emergency
                                                 – Forensic staff role
                                                 – Limited tour of areas in the facility that forensic staff
                                                   may need to access
                                                 – Procedures regarding visitor control
                                                 – Other issues as appropriate at the discretion of the
                                                   individual responsible for orientation


Annual inservicing    On an annual basis, Hospital-Wide Education provides inservicing/information to
                      Security/UT Police as follows:
                       Emergency communications
                       How to call a Special Team, or a Code Blue
                       Seclusion/restraint procedures (only UTHCPC staff respond to these)
                       Fire evacuation

Related standard      JCAHO HR 4.1




Printed: 08/08/12                                                                                          2-41

								
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