JOB DESCRIPTIONS and PERFORMANCE EVALUATIONS

Transcription

1 JOB DESCRIPTIONS and PERFORMANCE EVALUATIONS 1. Identify the functions necessary to operate your Facility. 2. Review the job descriptions and verify that the identified essential functions are assigned to at least one staff member. 3. The job descriptions for the Facility Director, Clinical Manager, and Office Manager represent the essential managerial functions of the Facility. Review these job descriptions carefully. If not using the job titles of Facility Director, Clinical Manager, and Office Manager, identify the titles to be used and modify documents as needed to reflect the job titles. 4. Select the job titles and/or job descriptions that best represent the needed staff functions in your Facility (if necessary, more than one set of essential functions may be assigned to one staff member). 5. Create an organizational chart delineating the hierarchy and reporting processes in your Facility. A sample of an organizational chart follows. Governance Facility Medical, i.e., Clinical Manager Office Manager Administrative Staff Nurse Surgical Assistant(s) Billing Coordinator Insurance Coordinator Medical Records Clerk Telephone Operator Post-Surgery Counselor Job Descriptions & Performance Evaluations (1 of 6)

2 6. Assign responsibility for Environment of Care and add the following statement to the job summary: Responsible for management of all aspects of the Environment of Care. Also add the following to the Essential Functions and Objectives and to the Performance Evaluation (adjust the numbering as required for the job description). 1. Designs and organizes a safe, accessible, effective and efficient Environment of Care consistent with the mission and services of the Facility and pertinent laws and regulations Implements and manages safety and security plan Implements and manages OSHA hazardous communication plan Implements and manages emergency preparedness plan; determines that fire and disaster drills are conducted and documented in a timely manner Implements equipment and utilities management system. 7. Assign responsibility for Infection Control and add the following to the Essential Functions and Objectives and Performance Evaluation (adjust the numbering as required for the job description). 1. Implements processes for the surveillance, prevention, and control of infections Coordinates processes to collect and monitor data related to infection control Initiates investigations when data identify problems or undesirable trends Takes steps to identify any common factors of infections Develops and implements processes to prevent the transmission of infection in staff and patients (e.g., TB, HBV, handling of soiled linen, cleaning protocols, sterilization processes and quality controls) Develops and implements methods to control infections (e.g., employee health status, staff illnesses) Develops and implements methods for external reporting of mandatory requirements as defined by the Public Health Service Implements processes to provide adequate data analysis, interpretation, and presentation. 8. Assign responsibility for OSHA and add the following to the Essential Functions and Objectives and Performance Evaluation (adjust the numbering as required for the job description). 1. Manages a comprehensive occupational safety and health program Reviews occupational safety and health principles, standards, laws, rules and regulations and recommends action to achieve compliance with requirements Participates in the development of OSHA-related policies and procedures, orientation programs for new employees, and continuing education programs for employees Manages an ongoing process to collect, document, and evaluate information about potential hazards to employee safety Participates in hazard surveillance and incident reporting on a regular basis and audits employee activity for compliance with the OSHA-related employee safety plan Investigates, with the designated Risk Manager, all incidents that involve occupational illness or injury, submits necessary reports to state agencies, and maintains the OSHA 200 Log as required by federal regulations In cooperation with the Safety Coordinator, analyzes employee safety plan, recommends policy and procedure revisions and safety measures, prepares reports for presentation to the Quality Management Committee, and implements changes as directed by the Quality Management Committee Maintains adequate supplies and availability of personal protective equipment (PPE), engineering and workplace controls and reviews location and use of personal protective equipment (PPE) with employees. Job Descriptions & Performance Evaluations (2 of 6)

3 9. Assign responsibility for Quality Management and add the following to the Essential Functions and Objectives and Performance Evaluation (adjust the numbering as required for the job description). 1. Develops and maintains an effective, comprehensive performance improvement program Establishes standards and criteria for the program, develops recordkeeping and reporting functions, maintains appropriate files, enforces quality management policies, and provides quality management information as necessary Reviews and assists in establishing indicators and trains Facility staff about the indicators used in assessment Establishes systems to collect and aggregate data and to continually assess performance improvement processes and activities; initiates in-services for all Facility staff regarding the quality management process and data collection and use Assists employees in identifying aspects of care that are high volume, high risk, and problemprone Assists in determining performance measures and reviews checklists for deviations from predetermined standards Maintains on-going status of quality management activities; current, follow-up and resolution Evaluates program and recommends revisions to the Quality Management Committee Develops agendas for Quality Management Committee meetings, identifying issues that need immediate action and issues that need additional information before presentation to the Committee Submits timely, accurate reports to the Quality Management Committee and Governance. 10. Assign responsibility for Risk Management and add the following to the Essential Functions and Objectives and Performance Evaluation (adjust the numbering as required for the job description). 1. Coordinates and maintains effective programs for identification and assessment of loss potential Monitors inspection and reporting system to investigate and evaluate conditions conducive to loss Assists employees in identifying and correcting environmental conditions and work practices that could result in injuries or claims Monitors reporting system to collect, investigate, and evaluate variances from approved policies and procedures that could result in claims Investigates every allegation of sexual misconduct occurring on the premises made against a staff member and reports every allegation of sexual misconduct to the Facility Director Collects and organizes data to document patterns of actual or potential exposure to medical liability Reviews construction or renovation plans for exposure to risk Coordinates with legal counsel in advising employees and professional staff in sensitive situations involving actual or potential claims Monitors and coordinates the efforts of insurance company investigators to analyze and report incidents and losses according to Facility, insurance company, and state government policies, rules and regulations Researches, negotiates and implements loss funding and risk financing mechanisms, including commercial insurance, self-insurance and alternate mechanisms. Job Descriptions & Performance Evaluations (3 of 6)

4 11. Assign responsibility for Safety and Security and add the following to the Essential Functions and Objectives and Performance Evaluation (adjust the numbering as required for the job description). 1. Develops a comprehensive safety and security management program Reviews safety and security management principles, standards, laws, rules and regulations Recommends action to achieve compliance with safety and security management requirements and, in conjunction with the designated Risk Manager, develops safety and security policies and procedures and education and orientation programs Maintains equipment owner's manuals, monitors status of warranty information, maintains records of product safety recalls, removes designated products from service, and responds to recall notices as required Manages ongoing process to collect and evaluate information about hazards and safety practices to identify safety management issues throughout the Facility Regularly participates in hazard surveillance and incident reporting and documents inspections, performed at least semiannually, to identify environmental hazards and unsafe practices In conjunction with the designated Risk Manager, investigates all incidents involving property damage or occupational illness or injury Audits Facility and personnel for compliance with safety policies and procedures Maintains records of reported safety violations, hazards, policy and procedure noncompliance, and results of investigations. 12. Using the established hierarchy (as shown on your organizational chart), insert the job titles on the following lines of each job description Reports to and Supervises. 13. Print the job descriptions selected and/or modified for use in your Facility and present them to governance for review and approval. Governance review and approval of the job descriptions should be documented in the governance meeting minutes. 14. Modify the performance evaluations to match the job descriptions. 15. Review the job description with the employee and answer all questions about the specific functions and responsibilities. When the review is completed, obtain the employee s signature on the job description and place it in the staff member s file. 16. After a designated time period, each employee performs a job analysis to verify that the actual job functions and responsibilities are accurately portrayed in each job description. Modify the job descriptions based on the findings of the job analysis and modify the performance evaluations to reflect changes in the job descriptions. Review job descriptions regularly, not less than every three years. 17. Provide information to the employees about performance outcomes at least annually. Employees may request this information any time a question arises about the management s expectations of the employee s job responsibilities and/or performance or about how the job performance is being perceived. 18. Conduct performance evaluations to review the progress in meeting expected outcomes in job performance. Meet privately with each employee to review and discuss the performance evaluation. Discuss only the performance being evaluated with the employee. Both the employee and the supervisor sign that the performance evaluation has been reviewed and discussed. The employee s signature does not imply acceptance of the supervisor s evaluation. 19. Document all evaluations in writing and retain in the employee s personnel file. Job Descriptions & Performance Evaluations (4 of 6)

5 JOB ANALYSIS Job Identification Title Code Written By Location Status Date Written Approved By Title of Immediate Supervisor Job Summary (A brief statement describing the general nature of the job.) Relationships Reports to Works with inside the Facility Works with outside the Facility Supervises Authority (Define the authority this position has for decision-making, financial/budget issues and direct supervision.) Working Conditions (Describe adverse conditions such as noise, heat and other potential hazards.) Job Specifications (List required education, experience and skills necessary to perform the job.) Knowledge (List facts and principles with which the employee must be familiar to perform the job.) Skills (List skills needed to perform the job, e.g., computer or equipment operation.) Abilities (List abilities needed to perform the job, e.g. math, reasoning, problem-solving, interpersonal communication.) Job Descriptions & Performance Evaluations (5 of 6)

6 Physical Activities (Briefly list physical requirements needed to perform the job.) Special Environmental Conditions (Describe special conditions, e.g., duties performed under water) Typical Work Incidents (Briefly describe events that happen during a normal working day.) Responsibilities and Duties (List what the employee does when performing the job.) Attach additional sheets if needed. Job Descriptions & Performance Evaluations (6 of 6)