Strong Health Mandatory In-Service Education Program for 2009

University of Rochester Medical Center Strong Memorial Hospital Employees: Each of us is responsible for completing the annual mandatory in-service education regarding internal policies and procedures, Joint Commission and OSHA standards, and other mission-critical information. Each of us is also responsible for passing a competency test to ensure we have retained the information. Please note that there are several changes to this year's process and competency test.

Resource Materials

Materials this year have been split into two separate formats: the Mandatory In-Service Manual and the new Department Resource Guide. The Mandatory In-Service Manual contains the essential information that must be known to provide a safe environment for staff and patients.

The Department Resource Guide is for reference purposes and contains information that may need to be accessed on a periodic basis.

Also included this year for your information is a list of Regulations, Rules and Policies requiring inclusion of the topics in the Mandatory In-Service Education Program.

To access the 2009 material, click on the links below or go to the Blackboard interactive, online program that contains the appropriate topics and tests.

Compliance

All staff members in division 50 (hospital) are required to participate in the 2009 Mandatory In-Service Education Program. University and Medical Center staff members in divisions 10, 40, 60, 90, 91, and 92 who have any type of patient contact or access to patient records or information are also required to pass the appropriate test (with a score of 90%); see below for testing details.

Per Drs. Mayewski and Panzer, physicians are also required to complete the competency test; medical staff privileges for physicians are tied to completion of the competency test.

The deadline for compliance is June 30, 2009.

New Testing Process This Year

The test is now offered in four formats, each one designed for a specific audience. Participants may choose to take the test first and if successful, the accompanying materials do not need to be reviewed. Regardless of which test is required, however, participants are required to pass with a score of at least 90%.

The Four Test Options Are:

1. Test A - For everyone regardless of duties or position; this test will contain all the general topics (e.g., URMC-SMH fire safety, code of ethics).
2. Test B - For everyone who has patient care responsibilities and/or enters a patient room; this test will contain all the topics in test A plus the patient care related topics (e.g., URMC-SMH fire safety, code of ethics, DNR, MOLST).
3. Test C - For everyone who has patient care responsibilities, enters a patient room, and works at HH as well as URMC-SMH; this test will contain all the topics in tests A and B plus the HH addendum. (e.g., URMC-SMH fire safety, code of ethics, DNR, MOLST; HH Conflict of Care procedures, HH fire codes).
4. Test D - For everyone who does not have patient care responsibilities and who also works at HH; this test will contain all the topics in test A plus the HH addendum (e.g, URMC-SMH fire safety, code of ethics; HH Conflict of Care procedures, HH fire codes).

Please follow the process below to ensure Joint Commission compliance.

Department Managers/Supervisors need to choose the appropriate section of materials and one of the fours tests for their staff to take, based on job responsibilities and the parameters listed above.

Process:

1. Faculty, staff, and volunteers need to complete the required competency test (A, B, C, or D) in its entirety. They may take the test before reading the materials, but must pass with a 90%. For Test A, passing is 44 out of 48 points; Test B is 63 out of 70 points; Test C is 72 out of 80 points; and Test D is 53 out of 58 points.
2. If they do not pass the test, they must review the material to ensure full understanding of the topics and then attempt the test again.
3. Upon successful completion with a score of at least 90%, document staff compliance through HRMS. (Contact Annette Schillaci at x5-0326 for questions regarding HRMS access to record compliance.) If the test is taken in Blackboard, compliance will automatically be transferred to HRMS; no department data entry will be required.
4. Please note:
   • When staff members transfer into your department, the previous supervisor should have entered their record of compliance in HRMS. If they are compliant, ask the new staff member for verification of their test compliance to be placed into their new department file.
   • When staff members transfer from your department, please make certain their compliance has been entered into HRMS and provide a verification of their test compliance for them to take to their new supervisor.

Thank you for your leadership in assuring that each staff member reaches Mandatory In-Service compliance for 2009. If you have questions concerning the program, please see contact:

NOTE: The Mandatory In-Service materials are online as Adobe Acrobat files (PDF). You will need the Acrobat Reader to view them (many machines already have the Acrobat Reader installed). This software is available FREE from Adobe. If you click one of the links below and your browser doesn't automatically start up the Acrobat Reader If you click one of the links below and your browser doesn't automatically start up the Acrobat Reader, click here to go to Adobe and get the Acrobat Reader.

Links

• 2009 Mandatory In-Service Education Manual
• 2009 Department Resource Guide
• 2009 Mandatory In-Service Education Competency Tests For Strong Memorial Hospital (select only one test; see parameters above if unclear which to choose):
  • Test A
  • Test A Answer Submission Sheet
    
    
  • Test B
  • Test B Answer Submission Sheet
    
    
  • Test C
  • Test C Answer Submission Sheet
    
    
  • Test D
  • Test D Answer Submission Sheet

Blackboard Interactive 2009 Mandatory In-service Education Programs

To access the URMC-Strong Memorial Hospital interactive, online Blackboard 2009 Mandatory Program, you will need a Blackboard account to log in if you do not already have one. If you do not have a Blackboard account, download these step-by-step instructions to establish a Blackboard account and utilize Blackboard for completion of your 2009 Mandatory In-Service program.

SMH Staff Working at Off-Site or Satellite Locations

Review all relevant sections topics in the 2009 Strong Health Mandatory In-Service Manual and answer all relevant questions in the appropriate 2009 Off-site Location Mandatory Competency Tests below. Additionally, staff working only at off-site or satellite locations, for some questions, will need to substitute site-specific information (example, fire/emergency numbers). However, off-site and satellite staff who also come to SMH need to know the SMH specific information as well as the information for their site and other relevant topics.

• 2009 Off-site Location Mandatory In-Service Education Competency Tests
  • Test A
  • Test A Answer Submission Sheet
    
    
  • Test B
  • Test B Answer Submission Sheet
    
    
  • Test C
  • Test C Answer Submission Sheet
    
    
  • Test D
  • Test D Answer Submission Sheet

Off-site Mandatory Emergency Template for Site-relevant Information

Choose one of the following options:

• Download Word version for editing and printing [56K]
• Download PDF file to print and add completed information later [20K]