Staff Qualifictions and Competency

Brentwood Hospital 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 and population, 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 mechanism 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

For further information simply call (318) 678-7500 or Toll Free (877) 678-7500. We offer confidential assessments and referrals.