Staff Qualifications and Competency
Alliance Health Center actively maintains
ongoing processes to assure that only qualified and competent staff provide
patient care or support services.
Credentialing
Facility employees are credentialed through an
internal mechanism supervised by the director of human resources. Each employee
performs his duties according to a criteria-based job description that reflects
patient age, population, and specific needs, and defines required qualifications
and competency standards. A performance appraisal is conducted for each employee
upon completion of the probationary period and at least annually thereafter.
Clinical staff are also required to complete a competency assessment and orientation
upon hire and annually thereafter in selected areas to assure that ongoing competency
requirements are met.
Credentialing for members of the medical staff
and affiliate staff is provided through the medical staff credentialing and
privileging process for appointment as previously noted. This process is defined
in the medical staff credentialing plan and medical service bylaws.
Evaluation
Monitoring and evaluation of the effectiveness
of patient care and support services are maintained on an ongoing basis through
a well-defined program for improving organizational performance. The program
emphasizes the analysis of the appropriateness of care, evaluation of problems
and concerns identified, as well as opportunities for improvement of services
and patient care. These activities provide mechanisms to effectively assure
a comparable level of care for all patients.
This plan for provision of patient care is reviewed
and revised as necessary, but not less than annually. The following elements
are taken into consideration in conducting the annual review:
- The facility's mission
- Strategic and budget-planning process
- Findings from performance improvement, risk
management, utilization review and other evaluation activities
- Changes in inpatient care needs/community
needs
- Patient requirements and implications for
staffing
- Relevant information from staffing variance
reports
- Adequacy of staff recruitment and development
activities
Findings from the annual review will be reported
to the quality council, medical executive committee and board of trustees.
General Staffing
Staffing patterns are determined by a combination
of employees per occupied bed ratio (inpatient), attendance expectations (PHP),
and a patient acuity system, with consideration given to individual patient
needs in each program. A core staff level is determined for each inpatient unit
consisting of a charge nurse, mental health technician, social workers and activity
therapist. Each addictive disease program also has a chemical dependency counselor.
Core staffing for outpatient services will be determined based on the scope
of services offered, attendance and program size.
Nursing Staffing
Nursing care is prescribed, delegated and coordinated
by registered nurses. Members of the nursing staff include registered nurses,
licensed practical/vocational nurses and mental health technicians. Assignments
for nursing care are made according to programmatic and patient acuity needs
as defined in the hospital plan for nursing care.
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