36C24419R0074-036.pdf

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER

Erie, Pennsylvania

Medical Center Memorandum No. 00Q-002 January 13, 2017

ENVIRONMENT OF CARE ORIENTATION, ANNUAL TRAINING, AND

EDUCATION

I. PURPOSE: To establish policy and procedures for the development, administration and evaluation of the Environment of Care (EOC) orientation, annual training and continuing education program. This program is designed to maintain and improve the knowledge and skills of all personnel. It is based on performance expectations that take into consideration the knowledge, skills and behaviors appropriate to the individual’s job responsibilities as well as those needed to maintain and/or improve job

II. POLICY: Employees will be properly oriented and trained to function safely, efficiently and effectively in their individual positions and as a team member working to improve quality service.

The goal of this program is to assure the safety and health of personnel by setting and enforcing standards, providing training and education as well as encouraging continual improvement and awareness of their work environment.

III. RESPONSIBILITY:

A. The Medical Center Director has overall responsibility for EOC training and education.

B. The EOC Committee will ensure that annual training and education on the EOC

Management Program is provided for all employees.

C. Supervisors and Managers are responsible for:

1. Monitoring and documenting policy compliance and effectiveness within their area(s), and to alert employees of the requirements for training and development.

2. Ensuring employee attendance at medical center New Employee

Orientation conducted by Human Resources (HR) and completion of orientation by volunteers.

3. Conducting area specific New Employee Orientation within 60 days of a new employee reporting for duty. New Employee Orientation will include:

MCM 00Q-002, Environment of Care Orientation, Annual Training, and Education

a. The medical center’s mission, vision and goals, governance, policies and procedures.

b. Department/Program/Office policies and procedures.

c. The medical center’s EOC Management Program and the employee’s responsibilities.

d. The medical center and Department/Program/Office-level performance improvement plan and activities, and the individual’s role in the plan and activities.

4. Ensuring the completion of annual continuing education and training on the following:

a. The Safety Management Plan

b. The Security Management Plan

c. The Hazardous Materials & Wastes Management Plan

d. The Emergency Operations Plan

e. The Fire Safety Management Plan

f. The Medical Equipment Management Plan

5. Confirming training documentation. All training, including contractor and vendor provided training must be documented. Contact Human Resources for information on proper documentation.

D. Human Resources (HR) is responsible for:

1. Establishing and maintaining processes to document the training and education courses completed by employees.

2. Working with supervisors, as appropriate, to plan training and development programs designed to rectify identified deficiencies with regard to the EOC Management Program.

3. Submitting a semi-annual report of EOC training to the EOC Committee.

E. The Voluntary Officer is responsible for:

1. Orientation of EOC plans for all volunteers.

2. Recording and maintaining educational records for volunteers.

3. An annual voluntary self-assessment of educational needs, including EOC plans.

IV. PROCEDURES:

A. New Employee Orientation and annual continuing education will be conducted on all EOC plans.

B. The effectiveness of training/employee knowledge will be evaluated as part of the

Administrative Rounds process. Findings will be reported quarterly to the EOC

Committee by the Safety Manager.

V. REFERENCES:

A. The Joint Commission Comprehensive Accreditation Manuals for Hospitals, Home Care, Behavioral Health, and Laboratory & Point-of-Care Testing, (current editions)

B. VA Directive 7700, Occupational Safety and Health, dated February 11, 2009

C. VHA Handbook 7701.01, Occupational Safety and Health (OSH) Program

Procedures, dated August 24, 2010

VI. FOLLOW UP RESPONSIBILITY: Medical Center Director, Supervisors and

Managers

VII. REPORTING REQUIREMENTS:

A. Semi-annual report by HR to the EOC Committee (Section III, D, 3)

B. Quarterly Administrative Rounds report to the EOC Committee (Section IV, B)

VIII. RESCISSION: MCM 00Q-002, Environment of Care Orientation, Annual Training, and Education, dated January 21, 2014 (Note: See Attachment for revisions made to this

MCM).

(Original Signed 1/13/17)

John A. Gennaro

Medical Center Director

Attachment: EOC MCM Revision History

ATTACHMENT

EOC MCM REVISION HISTORY

1/12/17 EOC Triennial review: Verified and revised references, Added

Attachment, MCM Revision History. No other changes required.