Integrating Quality Improvement into the Human Resources Function

 Integrating Quality Improvement into the Human Resources Function

Week # 7 Notes

• Quality Improvement is integrated within all department of a healthcare organization and vice verse.

• People often say to a Quality Improvement Director, “Why are you involved, this has nothing to do with Quality.  Quality is in almost every function, task and activity that we conduct as part of our everyday lives.

• The Quality Director/Manager plays a vital role in the HR function to ensure a few of the following activities are monitored routinely:

o Initial and annual orientation

o Credentialing of  Licensed Practitioners

o Annual performance evaluations

o Employee training

o Exclusion checks

o Employee file review

• It is essential for the Quality Department to collaborate with HR related to any investigations etc.

• The credentialing area is a major focus of review and the Quality Director sometimes co-chairs the Credentialing Committee. If not, they may conduct periodic audits.

• The completion of initial onboarding for employees, contract staff, volunteers and students is required. Mandatory training topics must be provided based on the organization’s regulatory requirements. Annual training topics are mandated as well. Many organizations are providing e-learning to ensure compliance with training requirements. 

• Annual performance evaluations are a regulatory requirement that requires monitoring.

• Exclusion checks are conducted on hire and on a monthly basis to confirm that employees and Vendors are not Excluded Providers. Screening is typically done against the U.S. Health and Human Services Office of Inspector General's (OIG) List of Excluded Individuals and Entities (LEIE).

• HR departments have a process for the ongoing auditing and monitoring of employee files for documentation specified by regulatory requirements. This can differ for clinical versus non-clinical staff.  The various documents required in employee files include, but are not limited to: Licensure, National Practitioner Databank, Background and Exclusion checks, orientation and annual training, annual health assessment and flu vaccine acceptance or declination.