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Document Title: OR OSL - PCAOwner: Susan J Dempsey Ortega, RN Clinical Nurse SpecDepartment: Operating RoomType: FormRevision Number: 1Document ID: 22709Revision Note:Updated formatting and included universal service-line additions.[Owner changed from Spruce, Kevin to Laing, Brendaby Silva, Natalie on 14-MAY-2018][Owner changed from Laing, Brenda to Dempsey Ortega, Susan J by Silva, Natalie on28-FEB-2019]This document is listed as a link on the document "OR - Trainingand Orientation of Operating Room Staff".Page 11 - 2019/10/22 18:18:13

Orientation Skills/ Competency VerificationSurgical ServicesPatient Care AssistantEmployee Number:Date Completed:Name:Date Original sent to HR:We have a learning organization where the process of self-assessment and continuous improvement is ongoing.This skills list is both a self assessment and a verification of your skills. This determines what you feel you need tolearn in order to do your job!1. Read through the skills checklist2. Under the "Self Evaluation" section, check the appropriate column next to each statement. Sign and date the lastpage when you have completed the "Self Evaluation" column. This column is to be completed by the end of the 2ndday of department orientation.3. Validate that you reviewed the educational material and policy/procedure by placing their initial and date in the"Orientee Validation" column4. The preceptor validates that you have verbalized or observed the skill by placing their initial and date in the"Verbalized and/or Observed the Procedure" column5. The preceptor validates that you have demonstrated the ability to independently perform the skill by placing theirinitial and date in the "Demonstrated Procedure" column.Task/SkillSelf EvaluationAble ptorValidationReviewedEducational Materialand/orPolicy/ProcedureVerbalized and/orObserved theProcedureCorporateCorporate OrientationFirst Day ChecklistsClinical Staff OrientationDepartment OverviewTourDress codeManual locationMeetingsPhoneMailboxLockerKeysBadge AccessParkingCheck My "Timecard"ForumSharePoint Surgical ServicesPneumatic Tube System (PTS)Interpreter UsePage 12 - 2019/10/22 18:18:13DemonstratedProcedure

Orientation Skills/ Competency VerificationSurgical ServicesPatient Care AIRISOR Etiquette/ Customer ServiceResource ManagementOrdering suppliesPatient SafetyBody MechanicsSafe Pt Handling/ Emp. InjuryLatex AllergyUniversal Protocol*SCIP Measures/ NPSGInfection ControlHand washingBody Substance PrecautionsPersonal Protective EquipmentHazardous Waste Disposal(Sharps/ Red Bag)Isolation Precautions (Contact,Respiratory, TB)Exposure Control Plan andfollow-up, (i.e. needle stick)Performance ImprovementUnit Specific Indicators/PIProjectsNotification FormsPatient SatisfactionCustomer ServiceCustomer ComplaintsPatient ProtocolsTechnical Partner (General Information)Unit education/competencies(Code Blue ed.)Call ProcedureRequests for day off, change inschedule and vacationsCPRManual LocationUnit specificPatient CareLippincott Procedures bookHuman ResourcesSafetyInfection controlPage 13 - 2019/10/22 18:18:13

Orientation Skills/ Competency VerificationSurgical ServicesPatient Care AssistantMedical Staff directoryMedical Staff Privilege BinderSS hazardous materials listSS safe practice listJob ly CompetenciesTeam Leader procedureAbsence/attendance reportingSurgical Assistant Didactic TrainingTransportPatient transfer (bed to bed)Positioning/Positioning devicesOR table and attachmentsShave prepsSpecimen handlingSterile techniqueSurgical hand scrubGowning and glovingAutoclave operation andmonitoringSterile supplies: storage, shelflife, and rotationThe Steris SystemLaparoscopy: instrumentation,video equipmentRoom cleaning/turnoverBasic PCA SkillsStockingStock returnsPicking cases routinePostmortem careAssisting with spinal anesthesiaLatex free proceduresBlood transportCustomer relationsPatient confidentialityTransporting patientsChart pack assemblyAddressographing OR recordsBiopsy casesEquipment Care and LocationStorage areasSticker outdatesPage 14 - 2019/10/22 18:18:13

Orientation Skills/ Competency VerificationSurgical ServicesPatient Care AssistantBovieFracture tableOR furnitureMicroscopesPositioning equipmentAnesthesia monitorsAnesthesia machinesInstruments: sterile & nonsterileTourniquetsVideo equipmentPneumo-tanks: changingEquipment failure proceduresX-ray equipmentEmergency EquipmentMalignant hyperthermia cartDifficult airway equipmentPediatric anesthesia equipmentCommunicationMain control deskRNs in area of assignmentShort StayCardiac TeamPhysiciansAreas of Patient TransportCore Competencies*Self Evaluation Completed:Employee SignatureDatePreceptor SignaturePreceptor SignaturePreceptor SignaturePreceptor SignaturePage 15 - 2019/10/22 18:18:13

Document Title: Competency Assessment Validation ProgramOwner: Jon Stabbe, HR Generalist Sr - OD SpecDepartment: Human Resources - EvaluationsType: Policy & ProcedureRevision Number: 6Document ID: 10003Revision Note:Policy due for review. Changed abbreviation DHS (Department of Health Services) to CDPH (California Department ofPublic Health)under policy, section D[Owner changed from Paz, Mary to Stabbe, Jon by Silva, Natalie on 26-APR-2018] br [Added at review/expire: Reviewed by SME. No changes made.] br [Reviewed on 8/23/2018 by Jon Stabbe: NextReview Date is 8/22/2021.]This document is listed as a link on the document "OR - Trainingand Orientation of Operating Room Staff".Page 16 - 2019/10/22 18:18:13

Competency Assessment Validation ProgramPolicy & Procedure NumberPolicy ManualTypeDocument OwnerEffective DateNext Review DateApplication Scope (Applies to)Approved By / Approved DateStatus / Rev #Keywords10003Human Resources - EvaluationsPolicy & ProcedureStabbe, Jon02/13/201508/22/2021All CMC EntitiesPeg Breen, SVP, Human Resources: 02/04/2015 12:00AM PSTCorporate Ops (A): 02/13/2015 12:00AM PSTTim Joslin, CEO: 02/13/2015 12:00AM PSTOfficial (Rev 6)4.06, competency, competencies, validation, validate, BLS, ACLS, orientation,PurposeTo establish the system and process for verifying and validating the skills and abilities of staff to ensure that they arecapable of achieving position specific job requirements and Community Medical Center ("CMC") performancestandards.DefinitionsCompetency: The demonstration of one or more skills based on knowledge derived from education programs andexperience.Competency assessment: The act of evaluating an employee's knowledge and ability to perform a specific procedureor process.The evaluation is to be conducted by someone in a leadership role, a clinical educator and/or a professional peer who exhibits competency in the procedure or process they are evaluating.Process competency assessment: An evaluation of an employee on performing a function which does not require thedemonstration of a technical skill. Appropriate evaluation methods might include, but is not limited to a post test,verbalization, observation, and chart audits.Procedural/technical competency assessment: An evaluation of an employee performing a procedure requiringtechnical skill such as a dressing change, removal of skin staples, or the operation of equipment. Such a competencycan only be validated by direct observation of a demonstration, or through a skills lab demonstration.Orientation Competency Validation: The process of validating an employee's competence at the end of orientation onthe basic procedures and processes required for their unit/service area or department. The Orientation CompetencyValidation form is a tool utilized to document the assessment and is available online. This must be completed during theemployee's initial orientation period, and each time they transfer to a new service area or department.Annual Competency Validation: The annual process of selecting three to five specific competencies for evaluation.Criteria for selection of the specific competencies and the validation process are described in item E below.Performance Criteria: An assessment tool that may be utilized to validate staff competence. Such a document definesspecific criteria necessary to demonstrate competency and must be based on an approved CMC resource.PolicyA. Each employee is to achieve and maintain competence according to his/her role and responsibilities as outlined in theJob Description/Performance Evaluation and unit specific skills checklist.Page 17 - 2019/10/22 18:18:13

Job Description/Performance Evaluation and unit specific skills checklist.B. All departments have a process for determining initial and ongoing staff competence.C. Competency is to be evaluated according to an identified source that represents expert practice, process, orperformance, i.e. Policy and Procedure ("P&P"), Unit/Department P&P, Springhouse Procedure Book or unit specificprocedure textbook (clinical areas), Manufacturer's Instructions, Required Reading, Required Video, Age-SpecificBinder, or National Organization Guidelines such as AORN, APNA, AACN or ASPAN.D. The following must be maintained by employees as applicable to their role (refer to theOrientation of Patient Care Providerspolicy in the Patient Care Policy Manual, theEmployee Educational Training-Mandatory in the Human Resources Policy Manual, and other policies listed below):1. Required licensure for job description/role.2. The skills/competencies required to perform his/her duties in relation to the age-specific patient population intheir area.3. The proper training in the operation and safe use of all equipment in the performance of his/her duties.4. Basic Life Support and Advanced Life Support as required for job role (refer toEmployee Educational Training-Mandatory in the Human Resources Policy Manual).5. Knowledge and skills required to provide a safe and healthful environment (refer toSafety Orientation & Trainingpolicy in the Safety Policy Manual).Child Abuse Reportin6. Knowledge and awareness of CMC policies on gDomestic Violence and Adult Dependent Elder Abuse Reportin,g(Patient Care Policy Manual).7. Knowledge of laws and regulations that pertain to assigned area of care, i.e. TJC, OSHA, Title 22, CDPH,COBRA/EMTALA.8. Knowledge and skills of policies and procedures including:a. Corporate Policies and Procedures, i.e. Administrative/Patient Care/Safetyb. Unit/Service/Area specific Policies and ProceduresE. The following criteria are to be used when selecting the Annual Competencies (per procedure B below) and are to beupdated to reflect current research and regulatory changes.1. Performance Improvement activities2. High risk/high volume/problem prone items/new equipment3. Change in policy/procedure/regulation4. Mandated by regulation5. New technology6. Department's educational needs assessment7. Infection Control reports8. Safety reports9. Risk Management reports10. Strategic Planning initiativesProcedureA. Orientation Competency Validation (Skills List)1. Initiated during the orientation process and completed at Point of Service.2. Maintain the documentation of competency validation, e.g., Orientation Competency Validation (Skills List)verified during Unit Specific orientation in the employee's file at the patient care area or in a CompetencyDocumentation binder. On completion of orientation skills check list, a copy must be sent to Human Resources("HR"). Only the orientation skills check list is to be sent to HR, the supporting documentation and area specificcompetencies are to remain in the patient care area.B. Completion of the Orientation Competency Validation is the responsibility of the person in a supervisory role over thePage 18 - 2019/10/22 18:18:13

B. Completion of the Orientation Competency Validation is the responsibility of the person in a supervisory role over thenew staff member.C. Annual Unit/Service/Area/Department Specific Competencies1. Managers/Clinical Coordinators/Supervisors (or designee) will identify a minimum of three to five annualcompetencies to be demonstrated and documented for each job role. These competencies should include agespecific considerations as appropriate and are to be selected according to the criteria in item E above.2. Managers will determine who can validate the competence of the different categories of employees using thefollowing guidelines:a. Evaluators may include anyone in a leadership role, clinical educators and/or professional peer groupswho exhibit competency in the skill they are evaluating.b. Verification of skills/competencies will include documentation with the name/title/date.Annual Competency Validation Documentatio3. Document the annual verification of staff competence on thenform.a. Indicate the specific titles, dates, and/or editions, as is appropriate, for each of the resources used toassess competence per item C above.b. In order to maintain consistency, if specific performance criteria are developed to be used as acompetency assessment tool, the document will be included with the appropriate P&P or selectedprocedure textbook section.c. Performance Criteria, when developed, are to be approved by the Competency Taskforce. Care must betaken to ensure that consistency of competency assessment and practice are maintained.d. Procedural/Technical Competencies such as venipuncture, dressing changes, and operation ofequipment or machinery can be validated only by demonstration/observation in a clinical setting/workarea, in a skills lab/training setting, or by proficiency testing/quality control.e. Process Competencies such as telephone etiquette, documentation in the clinical record, maintainingequipment logs, financial documentation, and knowledge of mandatory reporting laws can be validatedby demonstration/observation, record/chart review, verbalization, and peer review or post test.Note: The only acceptable method for evaluating a technical skill is by observation of a demonstration.Annual Competency Validation Documentatiof. The manager will send a copy of the completed nform toHR along with the annual Performance Evaluation. The original will be maintained in the manager'sfolder for each employee, or in the Competency binders.g. Upon completion of competency assessment the employee and the evaluator(s) sign the CompetencyValidation form.4. Documentation of annual unit specific competencies will be summarized on the employee's annualperformance evaluation and will be maintained in HR.ReferencesCompetency Assessment: A Practical Guide to TJC Standards, 2001Comprehensive Accreditation Manual for Hospitals, 2001, Management of Human ResourcesReferencesReference TypeTitleNotesDocuments referenced by this documentReferenced DocumentsAnnual Competency Validation DocumentationPage 19 - 2019/10/22 18:18:13

nReferenced DocumentsChild Abuse ReportingReferenced DocumentsDomestic Violence and Adult Dependent Elder Abuse ReportingReferenced DocumentsEmployee Educational Training-MandatoryReferenced DocumentsOrientation of Patient Care ProvidersReferenced DocumentsSafety Orientation & TrainingReferenced DocumentsThe evaluation is to be conducted by someone in a leadership role, a clinical educator and/or a professional peer who exhibits competency in theprocedure or process they are evaluating.Documents which reference this documentReferenced DocumentsLaboratory Personnel PolicyReferenced DocumentsPACU - Training and Orientation of PACU StaffReferenced DocumentsPreoperative & Postoperative CareReferenced DocumentsENDO - Training and Orientation of Endoscopy StaffReferenced DocumentsDiscontinuing Venous & Arterial Sheaths - AdultReferenced DocumentsOrientation Of Patient Care ProvidersReferenced DocumentsPerformance EvaluationReferenced DocumentsMandatory Education RequirementsReferenced DocumentsMandatory Education RequirementsReferenced DocumentsOR - Training and Orientation of Operating Room StaffSource DocumentsAnnual Competency Validation Paper copies of this document may not be current and should not be relied on for official purposes. The current version is inLucidoc athttps://www.lucidoc.com/cgi/doc-gw.pl?ref communitymc:10003.Page 20 - 2019/10/22 18:18:13

Document Title: Employee Educational Training- MandatoryOwner: Jon Stabbe, HR Generalist Sr - OD SpecDepartment: Human Resources - Employee Standards/ExpectationsType: Policy & ProcedureRevision Number: 8Document ID: 10087Revision Note:To comply with SB 1343, Harassment Training Requirements, adding non-supervisory (1 hour) training requirements.Non-supervisory employees are required to completed workplace harassment training within 6 months of hire, andthen every 2 years thereafter. br br Changed policy language to be gender neutral to comply with SB179 GenderRecognition Act.This document is listed as a link on the document "OR - Trainingand Orientation of Operating Room Staff".Page 21 - 2019/10/22 18:18:13

Employee Educational Training- MandatoryPolicy & Procedure NumberPolicy ManualTypeDocument OwnerEffective DateNext Review DateApplication Scope (Applies to)Approved By / Approved DateStatus / Rev #KeywordsI. PURPOSE10087Human Resources - Employee Standards/ExpectationsPolicy & ProcedureStabbe, Jon02/19/201902/18/2022All CMC EntitiesCarla Milton, SVP Human Resources: 01/11/2019 08:42AM PSTCorporate Ops (A): 02/19/2019 09:17AM PSTOfficial (Rev 8)4.07 Training Education MandatoryA. To define the mandatory educational training programs at Community Medical Centers ("CMC") [which are on-linelearning modules delivered using the Healthstream Learning Management System.("HLC")].B. To delineate the defined process for completing the mandatory educational training programs and the consequencesfor failing to comply.C. To be in compliance with regulatory/accrediting agencies' requirements.II. DEFINITIONSA

G. Orient the new employee to the availability and use of on-line training resources, such as: 1. Policies and Procedures - corporate and OR unit-specific 2. Digital training modules (e.g. AORN, T3 by Medcom/Trainex, etc.) 3. Healthstream Learning Center (HLC) modules 4. Lippincott Nursing