Chapter 1 – Health Care Governance and Administration

Policy

• California Correctional Health Care Services (CCHCS) shall provide all Dietary Services staff including, but not limited to, Food Administrator II, Food Administrator I, Registered Dietitian, Correctional Facility, Supervising Correctional Cook, and Correctional Supervising Cook who provide clinical or support type of services in licensed health care facilities within California Department of Corrections and Rehabilitation (CDCR) institutions with relevant and job-specific orientation and training (onboarding). Clinical competency assessments shall also be provided for applicable clinical job classifications.  This policy shall not be construed as altering existing laws and regulations governing civil service probationary periods or any applicable bargaining unit contract provisions.

Purpose

• To establish a comprehensive and standardized onboarding and competency assessment process for Dietary Services staff that:

• Promotes consistency and standardization among all institutions statewide regarding minimum onboarding expectations for new Dietary Services staff.

• Supports newly appointed Dietary Services staff with relevant orientation and training by experienced subject matter experts (SMEs) during the probationary period.

• Facilitates adherence to applicable scope and standards of practice, clinical guidelines, and CCHCS, CDCR standards.

• Promotes job satisfaction while enhancing Dietary Services staff effectiveness, efficiency, competence, and knowledge.

Responsibility

• Statewide

  • The Statewide Chief of Dietary Services is responsible for planning, implementing, and evaluating this policy and procedure on an as-needed basis.

• Regional

  • The Regional Health Care Executives are responsible for the application of this policy at the subset of institutions within their assigned region.

• Institution

  • The Chief Executive Officer, or designee, is responsible for the implementation, monitoring, and evaluation of this policy.

  • The Chief Support Executive or the Correctional Health Services Administrator and the institution Food Administrator are responsible for the local application of this policy and procedure, and the supervision of orientation, training, probationary and professional evaluations, and competency assessments for Dietary Services staff.

    • The Chief Support Executive or the Correctional Health Services Administrator and the institution Food Administrator shall coordinate with headquarters and the regional health care office on these tasks.

    • The Chief Support Executive or the Correctional Health Services Administrator and the institution Food Administrator shall defer to an appropriate clinical SME for the validation component and subject matter expertise of these tasks if they do not have the required clinical expertise and experience to perform them.

Procedure

• Orientation and On-the-Job Support during the Probationary Period

  • The direct supervisor and applicable SMEs shall use the appropriate Dietary Services Onboarding and Competency Assessment Checklist to ensure each newly hired staff completes the appropriate checklist during the first 90 calendar days of hire. (The checklists are located within the Dietary Services Portal under the Professional Workforce heading.

    • During the staff’s first two weeks of hire, it is expected the staff’s supervisor or SME shall complete items under the “Orientation to the Institution and Dietary Department” section of the checklist, which includes, but is not limited to:

      • Facility tour and introduction to Executive staff.

      • Completion of Human Resources and Information Technology departments mandated forms.

      • Overview of the institution’s or work location’s missions and physical layout.

      • Overview of the new staff’s workspace.

      • Issuance of the new staff’s identification card and other essential work items.

    • Onboarding of the new staff that is institution or work location-based shall address the designated topics specified in the Dietary Services Onboarding and Competency Assessment Checklist.

    • CDCR Non-Custody New Employee Orientation, as applicable to the staff’s assigned work location, is to be completed by all staff within the six-month or twelve-month probationary period. This training is composed of classroom and computer-based modules. The classroom portion is provided by the institution’s In-Service Training Office.

    • Dietary Services staff shall complete Electronic Health Record System (EHRS) training and competency assessment. Training shall include completion of CCHCS Learning Management System EHRS Modules consistent with the staff’s duty statement.
      

    • Dietary Services staff shall complete orientation and mentoring as identified in the Dietary Services Staff Onboarding and Competency Assessment Checklist.

  • Staff beginning independent work shall have access to Dietary Services staff with similar job duties for questions and assistance.

  • Within 90 calendar days after the new staff hire date, the direct supervisor shall ensure completion of the Dietary Services Onboarding and Competency Assessment Checklist and shall review, sign, and maintain the completed forms in the supervisory file of the staff being assessed. If the new dietary staff member is delayed in completing the Dietary Services Onboarding and Competency Assessment Checklist, the direct supervisor may provide additional time on a case-by-case basis to complete the onboarding process and the checklists as soon as possible after the 90 calendar days.

• Probationary and Professional Performance Evaluations

  • For staff who have a one-year probationary period:

    • The 12-month STD 636 may be completed as soon as 11 months but no later than 12 months after the hire date.

    • Interim STD 636s may be completed as needed between probationary periods, to assess professional performance and clinical competency.

  • For staff who have a six-month probationary period:

    • The six-month STD 636 may be completed as soon as five months but no later than six months after the hire date.

    • Interim STD 636s may be completed as needed between probationary periods, to assess professional performance and clinical competency.

  • Prior to the end of the probationary period, the direct supervisor shall review the probationary evaluations and other clinical and performance observations such as competency assessments in order to make a recommendation regarding permanent civil service employment.

• Determination of Permanent Civil Service Status

  • After completion of the second STD 636, but no later than one month prior to the end of probation, the direct supervisor shall review the findings and recommendations contained in the probationary evaluations and other documented professional observations in order to make a recommendation about whether to grant permanent civil service status.

  • If there are concerns regarding the performance of the probationary staff, the direct supervisor shall immediately notify their supervisor and the Health Care Employee Relations Officer.

  • A recommendation to reject the staff during the probationary period may occur any time during the probationary period if the previous STD 636, professional practice evaluations, competency assessments, or other documented performance observations show significant concerns regarding the staff’s performance or conduct.

• Re-orientation of Dietary Services staff (Re-entry Training)

  • For Dietary Services staff who are out of the office for an extended period but did not separate from service with CDCR (e.g., long term sick):

    • If staff has been out for six months or less, the following is required:

      • There must be documentation of prior completion of the Dietary Services Staff Onboarding and Competency Assessment Checklist.

      • Staff shall review all classes, updates, and mandatory training missed.

      • A competency assessment shall be completed for the areas in which staff will be working.

    • If staff has been out for six months to one year, the following is required:

      • There must be documentation of prior completion of the Dietary Services Staff Onboarding and Competency Checklist.

      • Staff shall review all classes, updates, and mandatory training missed, including CDCR Non-Custody Annual Block Training and In-Service Training.

      • A competency assessment shall be completed for the areas in which staff will be working.

    • Staff who are out more than one year shall complete the onboarding process in its entirety upon return.

  • Staff who separate from the Department and then return to state service, regardless of the length of time, shall be required to complete the onboarding process in its entirety.

• Transferring Between Institutions without a Break in Service or Performing Duties at More Than One Institution

  • The direct supervisor is responsible for ensuring that all Dietary Services staff working at that institution are competent to perform all the duties of the position for which the Dietary Services staff has been hired.

  • The direct supervisor may develop an abbreviated Dietary Services Staff Onboarding and Competency Assessment Checklist for the staff sharing assignments between multiple institutions.

  • Proof of completion of the onboarding process, clinical competencies, and professional performance shall be maintained at each CDCR location. This does not absolve the direct supervisor at each CDCR location from ensuring that annual performance evaluations are conducted or that dietary staff is competent to perform the duties required in their position.

• Clinical Competency Assessment

  • Program Development

    • Clinical competencies shall be developed by CCHCS headquarters Dietary Services based upon internal and external requirements. Dietary Services leadership shall review and update all clinical competencies developed by Dietary Services, as needed.

  • Competency Components

    • Registered Dietitians (RDs)

    • The California Commission on Dietetic Registration sets forth duties all RDs, regardless of role, population, or specialty, are expected to perform competently. The components of competency include, but are not limited to:

      • Nutrition Screening: The RD performs or obtains and reviews nutrition screening data.

      • Nutrition Assessment: The RD performs via in-person or telemedicine a nutritional assessment and documents the results of the assessment in EHRS.

      • Nutrition Diagnosis: The RD determines current nutrition diagnosis(es).

      • Nutrition Intervention or Plan of Care: The RD determines or recommends a nutrition prescription and initiates interventions. When applicable, the RD adheres to established and approved disease or condition-specific protocol orders from the referring health care practitioner.

      • Nutrition Monitoring and Evaluation: The RD determines and documents the outcome of interventions reflecting input from all sources to recognize primary care team member contributions, the patient experience, and quality outcomes.

      • Discharge Planning and Transitions of Care: The RD coordinates and communicates the nutrition plan of care for patient discharge or transitions of care, or both.

  • Competency Assessment Frequency

    • A competency assessment shall be conducted every six months within the first year of hire. After the first year, a competency assessment shall be completed, at a minimum, on an annual basis for the evaluation of the staff member’s professional performance and clinical competency.

      • The staff member’s direct supervisor shall review the dietary staff member’s duty statement with the staff. This review shall be acknowledged by the staff’s signature on the duty statement. The signed duty statement shall be retained in the supervisor’s staff member file.

    • A competency assessment may also be conducted on an as needed basis for the following reasons:

      • Change in staff member job duties;

      • Quality improvement initiatives;

      • Performance evaluation;

      • Performance Improvement Plan; or

      • New policies and procedures

    • Competency assessment results shall be part of a staff member’s probationary and professional practice evaluation and performance appraisals.

    • Informal, or practice competency assessments may be administered under the direction of Dietary Services leadership as an internal audit to ensure staff members can achieve sufficient competency levels to meet Department and clinical standards. The methodology, scoring, and remediation efforts of these informal assessments shall be established by the Statewide Chief of Dietary Services.

  • Competency Assessment Methodology

    • Competency assessment methods used to measure the individual abilities for specific competency standards include, but are not limited to:

      • Tests

      • Observation

      • Case studies

      • Mock events

      • Quality improvement monitors

    • Some competencies may require a combination of assessment methods. The Statewide Chief of Dietary Services shall determine the particular methodology, scoring, and remediation efforts for the Department’s Dietary Services clinical competencies.

    • Competency assessment forms, checklists, and background materials can be found on Lifeline Dietary Services Resources.

  • Documentation and Tracking

    • A record of Dietary Services staff member’s competency assessments shall be maintained in the following files: their supervisory, the designated regional health care office, and headquarters Dietary Services.

      • Identifying Patient Health Information shall be removed or blacked out to safeguard patient privacy when applicable.

Policy

• California Correctional Health Care Services (CCHCS) shall provide all newly appointed civil service laboratory services staff, including, but not limited to Laboratory Assistants, Senior Laboratory Assistants, Clinical Laboratory Technologists (CLT), Senior Clinical Laboratory Technologists, and Supervising Clinical Laboratory Technologists who provide clinical and/or support services in California Department of Corrections and Rehabilitation (CDCR) institutions with relevant and job-specific orientation and training (Laboratory Services Staff Onboarding) during the probationary period.  This policy shall not be construed as altering existing laws and regulations governing civil service probationary periods or the provisions of any applicable bargaining unit contract.

The CCHCS Laboratory Services shall maintain a Laboratory Services staff competency program to ensure:

• Standard laboratory practice is consistent with the laboratory process and practice established by the Clinical Laboratory Improvement Amendment, California Department of Health, Clinical Laboratory Standards Institute (CLSI), and certification agencies.

• Department Laboratory Services staff demonstrate the knowledge, skills, and abilities required to achieve an appropriate level of competency and perform within their scope of practice.

• Laboratory Services staff complies with CCHCS and CDCR policies and procedures, federal and state laws and regulations, and nationally accepted laboratory standards.

• The competency program includes:

  • Educational programs;

  • Competency validation; and

  • Documentation and tracking of the validation results.

• Competency validation is the evaluation of staff competencies by a subject matter expert (SME) and occurs on a continuum.  This continuum shall include assessment of competencies during the hiring process, during the orientation period, annually, and throughout employment as the requirements of the job and needs of the organization change.

Purpose

• To establish a comprehensive and standardized onboarding process for new civil service Laboratory Services staff that:

  • Promotes consistency and standardization among all institutions statewide regarding minimum onboarding expectations for new laboratory services staff.

  • Supports newly appointed Laboratory Services staff with relevant orientation and training by experienced SMEs during the probationary period.

  • Facilities adherence to applicable scopes of practice, standards of practice, applicable clinical guidelines, and CCHCS/CDCR standards.

  • Promotes job satisfaction while enhancing Laboratory Services staff effectiveness, efficiency, and knowledge.

• To provide guidelines for the competency and ongoing assessment of Laboratory Services staff.

Responsibility

• Statewide

  • The Statewide Chief of Laboratory Services is responsible for implementation, evaluation, and planning related to this policy and procedure.

• Regional

  • The Regional Health Care Executives are responsible for the application of this policy at the subset of institutions within their assigned region.

  • The Senior CLT with regional responsibilities are responsible for:

    • Coordination with regional and local administration for the local application of this policy and procedure.

    • Application of this policy and procedure at the subset of institutions within their assigned region.

    • Validation and subject matter expertise of the clinical components related to this policy’s onboarding requirements, competency requirements, and ongoing education for all Laboratory Services staff.

    • Maintenance of a competency & education tracking system.

• Institution

  • The Chief Support Executive and/or Correctional Health Care Services Administrator I/II are responsible for the local application of this policy and procedure, and the supervision of onboarding, training, and competency requirements for all Laboratory Services staff.

    • The Chief Support Executive and/or Correctional Health Care Services Administrator I/II shall coordinate with the Senior CLT with regional responsibilities on these tasks.

    • The Chief Support Executive and/or Correctional Health Care Services Administrator I/II shall defer to the Senior CLT with regional responsibilities for the validation component and subject matter expertise of these tasks if they do not have the required clinical expertise and experience to perform them.

  • Laboratory Services staff are responsible for completing all standardized onboarding requirements if they are new to civil service, and all assigned training and competency within the required competency testing frequency.

Procedure

• Orientation and On-the-Job Support During the Probationary Period

  • The direct supervisor and applicable SMEs shall use the New Employee Orientation Checklist and the appropriate Competency checklist to ensure each newly hired staff completes the applicable checklists and orientations during the first 90 calendar days of hire.  (The checklist can be found under the Laboratory Services Resources Lifeline page under the “Other” tab.)

    • During the staff’s first two weeks of hire, the staff’s supervisor or SME shall complete items under the “New Employee Orientation Checklist” and complement with the following:

      • Facility tour and introduction to executive staff;

      • Completion of Human Resources and Information Technology departments mandated forms;

      • Overview of the institution’s or work location’s missions and physical layout;

      • Overview of the new staff’s workspace; and

      • Issuance of the new staff’s identification card and other essential work items.

    • Institution or work location-based onboarding shall address the designated topics specified in the Laboratory Services New Employee Orientation Checklist.

    • CDCR Non-Custody New Employee Orientation, as applicable to the staff’s assigned work location, is to be completed by all staff within the six-month or twelve-month probationary period.  This training is composed of classroom and computer-based modules.  The classroom portion is provided by the institution’s In-Service Training Office.

    • Laboratory Services staff shall complete Electronic Health Record System (EHRS) training and competency validation including completion of CCHCS Learning Management System EHRS Modules consistent with the staff’s duty statement.

    • Laboratory Services staff shall complete orientation and mentoring of specific tasks identified in the appropriate Laboratory Services Onboarding and Competency Assessment Checklist based on job title, and the Urine Drug Screening (UDS) specimen collection process utilizing the UDS Onboarding and Competency Assessment Checklist.

  • Staff beginning independent work shall have access to the Laboratory Services staff with similar job duties for questions and assistance.

  • Within 90 calendar days after the new staff hire date, the direct supervisor shall ensure completion of the Laboratory Services New Employee Orientation Checklist and Competency Assessment Checklists and shall review, sign, and maintain the completed forms in the staff’s supervisory file.  If the new Laboratory Services staff member is delayed in completing the Laboratory Services New Employee Orientation Checklist and Competency Assessment Checklist, the direct supervisor may provide additional time on a case-by-case basis to complete the onboarding process and the checklists as soon as possible after the 90 calendar days.

• Probationary and Professional Performance Evaluations

  • For staff who have a one-year probationary period:

    • In accordance with civil service laws and regulations, the direct supervisor shall complete, at minimum, an STD 636, Report of Performance for Probationary Employee at four months, eight months, and 12 months after hire to assess professional performance and clinical competency.

    • The 12-month STD 636 may be completed as soon as 11 months but no later than 12 months after the hire date.

    • Interim STD 636s may be completed as needed to assess professional performance and clinical competency.

  • For staff who have a six-month probationary period:

    • In accordance with civil service laws and regulations, the direct supervisor shall complete, at minimum, an STD 636 at two months, four months, and six months after hire to assess professional performance and clinical competency.

    • The six-month STD 636 may be completed as soon as five months but no later than six months after the hire date.

    • Interim STD 636s may be completed as needed to assess professional performance and clinical competency.

  • Two to four weeks before the end of the probationary period, the direct supervisor shall review the probationary evaluations and other clinical and performance observations to make a recommendation regarding permanent civil service employment.

  • After the probationary period ends, the direct supervisor shall complete, at minimum, an annual evaluation of the staff’s professional performance and clinical competency.  In addition, on an annual basis, the direct supervisor shall review the Laboratory Services staff member’s duty statement with the staff.  This shall be acknowledged by the signature of the staff on the duty statement which shall be retained in the staff’s supervisory file.

• Determination of Permanent Civil Service Status

  • After completion of the second STD 636, but no later than one month before the end of the probation, the direct supervisor shall review the findings and recommendations contained in the probationary evaluations and other documented professional observations to make a recommendation about whether to grant permanent civil service status.

  • If there are concerns regarding the performance of the probationary staff, the direct supervisor shall immediately notify their supervisor and the Health Care Employee Relations Officer as soon as issues are identified.

  • A recommendation to reject the staff during the probationary period may occur any time during the probationary period if the previous STD 636s, professional practice evaluations, competency validations, or other documented performance observations show significant concerns regarding the staff’s performance or conduct.

• Re-orientation of Laboratory Services staff (Re-entry Training)

  • For Laboratory Services staff who are out of work but did not separate from service with CDCR (e.g., long-term sick):

    • If staff have been out for six months or less, the following is required:

      • There must be documentation of the previous completion of the Laboratory Services Staff New Employee Orientation Checklist and Competency Assessment Checklists.

      • Staff must review all classes, updates, and mandatory training missed.

      • Validation of competencies shall be completed for the tasks in which staff will be completing.

    • If staff have been out for six months to 12 months, the following is required:

      • There must be documentation of the previous completion of the Laboratory Services New Employee Orientation Checklist and Competency Assessment Checklists.

      • Staff must review all classes, updates, and mandatory trainings missed, including CDCR Non-Custody Annual Block Training and In-Service Training.

      • Validation of competencies shall be completed for the areas in which staff will be working.

    • Staff who are out more than one year shall complete the onboarding process in its entirety upon return.

  • Staff who separate from the Department and then return to state service, regardless of the length of time, shall be required to complete the onboarding process in its entirety.

• Transferring Between Institutions without a Break in Service or Performing Duties at More Than One Institution

  • The direct supervisor is responsible to ensure that all Laboratory Services staff working at that institution are competent to perform all the duties of the position for which the Laboratory Services staff has been hired.

  • The direct supervisor may develop an abbreviated Laboratory Services Staff Onboarding and Competency Assessment Checklist for Laboratory Services staff sharing assignments between multiple institutions.

  • Proof of completion of the onboarding process, clinical competencies, and professional performance shall be maintained at each CDCR location.  This does not absolve the direct supervisor at each CDCR location from ensuring that annual performance evaluations are conducted, or Laboratory Services staff are competent to perform the duties required in their position.

• Ongoing Education and Competency

  • Program Development

    • Educational trainings and competencies shall be developed by CCHCS headquarters (HQ) Laboratory Services based upon internal and/or external requirements. Laboratory Services leadership shall review and update all laboratory educational training and competencies developed by Laboratory Services, as needed.

  • Competency Components

    • Laboratory Assistants (LA)

      • The California Public Health Department, Laboratory Field Services Division, sets forth the duties that all laboratory personnel, regardless of role, population, or specialty, are expected to perform competently.  The components of competency include, but are not limited to:

      • Venipuncture Specimen Collection: The LA performs venipuncture consistently following CLSI standards for specimen collection through venipuncture.

      • UDS Specimen Collection: The LA follows the special handling collection requirements for UDS as contained in policy.

      • Specimen Collection for “Miscellaneous” Specimens: The LA follows the CLSI and reference laboratory collection standards for “miscellaneous” specimens.

      • Infection Control: The LA follows all Department infection control policies and uses correct personal protective equipment while performing all duties.

      • Specimen processing for blood samples: The LA understands and follows all recommended sample processing requirements listed for every laboratory test collected.

      • UDS Specimen Processing: The LA follows the CCHCS UDS special handling collection and processing requirements in policy.

      • Specimen Processing for “Miscellaneous” Specimens: The LA understands and follows all recommended sample processing for “miscellaneous” specimens.

      • EHRS Documentation: The LA completes all EHRS documentation correctly and thoroughly.

      • Adverse Outcomes/Patient Safety during Collection Procedures: The LA understands the potential for adverse outcomes when performing a venipuncture and knows how to instruct the patient on post-venipuncture care.

    • Clinical Laboratory Technologists (CLT)

      • Education and training shall be provided within the CLT scope of practice and shall be expected to perform competently.  The components of competency include, but are not limited to:

      • Venipuncture Specimen Collection: The CLT understands the correct procedure for venipuncture stated in the CLSI standards for venipuncture specimen collection.

      • UDS Specimen Collection: The CLT understands the policy and procedure for UDS collections.

      • Specimen Collection for “Miscellaneous” Specimen: The CLT understands the CLSI and reference laboratory collection standards for “miscellaneous” specimens.

      • Infection Control: The CLT follows all Department infection control policies and uses correct personal protective equipment while performing all duties.

      • Specimen Processing for Blood Samples: The CLT understands all recommended sample processing requirements listed for every laboratory test collected.

      • UDS Specimen Processing: The CLT follows and understands the CCHCS special handling processing requirements for UDS specimens.

      • Specimen Processing for “Miscellaneous” Specimens: The CLT understands all recommended sample processing for “miscellaneous” specimens.

      • EHRS Documentation: The CLT completes all electronic health record documentation correctly and thoroughly.  The CLT demonstrates the ability to perform health records audits for policy compliance.  The CLT demonstrates the ability to troubleshoot interface errors by applying critical thinking and problem-solving.

      • Adverse Outcomes/Patient Safety during Collection Procedures: The CLT understands the potential for adverse outcomes when performing a venipuncture and knows how to instruct the patient on post-venipuncture care.

      • Teaching and Competency Assessment: The CLT utilizes the best practice tools for teaching and providing instruction to other Laboratory Services staff.

      • Quality Control Practices: The CLT understands quality control practices and can apply continuous quality improvement measures.

  • Validation Frequency

    • Education and competency validation is conducted every six months within the first year of hire; after the first year, validation may occur annually or as needed based upon:

      • Quality improvement;

      • Performance evaluation;

      • Performance Improvement Plan; or

      • New policies and procedures

    • Competency validation results shall be part of a staff’s performance appraisals.

  • Validator Competency

    • Laboratory Services staff must demonstrate competency before teaching educational trainings and validating the competency of other Laboratory Services staff.  Methods to acquire knowledge and/or skills include, but are not limited to:

    • Continuing education programs

    • Review of policies and procedures

    • In-service education

    • Training-for-trainers

    • Simulation exercises

    • Observation/demonstration

  • Competency Validation Methods

    • Competency validation methods used to measure the abilities of an individual for a specific competency standard include, but are not limited to:

      • Tests

      • Observation

      • Case studies

      • Mock events

      • Quality improvement monitors

    • Some competencies may require a combination of validation methods.  The Laboratory Services leadership shall determine the validation methods for each competency developed by HQ Laboratory Services.

    • Competency Assessment forms can be found on Lifeline Laboratory Services Resources.

  • Documentation and Tracking

    • A record of Laboratory Services staff member’s competency assessments shall be maintained in their supervisory file, as well as in the competency & education tracking system maintained by the Regional Senior CLT.

Policy

• California Correctional Health Care Services (CCHCS) shall provide all newly appointed civil service Medical Imaging Services staff, including, but not limited to, Radiologic Technologists (RT) and Senior Radiologic Technologists (SRT) who provide clinical services in California Department of Corrections and Rehabilitation (CDCR) institutions, with relevant and job-specific orientation and training (Medical Imaging Services Staff Onboarding) during the probationary period. This policy shall not be construed as altering existing laws and regulations governing civil service probationary periods or any applicable bargaining unit contract provisions.

Purpose

• To establish a comprehensive and standardized onboarding and competency assessment process for new civil service Medical Imaging Services staff that:

• Promotes consistency and standardization among all institutions statewide regarding minimum onboarding expectations for new Medical Imaging Services staff.

• Supports newly appointed Medical Imaging Services staff with relevant orientation and training by experienced subject matter experts (SMEs) during the probationary period.

• Facilitates adherence to applicable scopes of practice, standards of practice, applicable clinical guidelines, and CCHCS/CDCR standards.

• Promotes job satisfaction while enhancing Medical Imaging Services staff effectiveness, efficiency, competence, and knowledge.

Responsibility

• Statewide

  • The Statewide Chief of Medical Imaging Services is responsible for the implementation, evaluation, and planning related to this policy and procedure.

• Regional

  • The Regional Healthcare Executives are responsible for the application of this policy and procedure at the subset of institutions within their assigned region.

• Institution

  • The Chief Support Executive is responsible for the local application of this policy and procedure.

  • The Correctional Health Care Services Administrator I/II or SRT is responsible for supervising the completion of the onboarding requirements for all Medical Imaging Services staff.

Procedure

• Orientation and On-the-Job Support during the Probationary Period

  • The direct supervisor and applicable SMEs shall use the applicable Medical Imaging Services Onboarding and Competency Assessment Checklist found under the Medical Imaging Services Resources Lifeline page under the RIS/PACS/EHRS tab to ensure each newly hired staff completes the appropriate checklist during the first 90 calendar days of hire.

    • During the staff’s first two weeks of hire, the staff’s supervisor shall complete the following items:

      • Facility tour and introduction to executive staff.

      • Completion of Human Resources and Information Technology department’s mandated forms.

      • Overview of the institution’s or work location’s missions and physical layout.

      • Overview of the new staff’s workspace.

      • Issuance of the new staff’s identification card and other essential work items.

    • Onboarding of the new staff that is institution or work location-based shall address the designated topics specified in the Medical Imaging Services Onboarding and Competency Assessment Checklist.

    • CDCR Non-Custody New Employee Orientation, as applicable to the staff’s assigned work location, to be completed by all staff within the six-month or twelve-month probationary period.  This training is composed of classroom and computer-based modules.  The classroom portion is provided by the institution’s In-Service Training Office.

    • Medical Imaging Services staff shall complete Electronic Health Record System (EHRS) training and competency validation. Training shall include completion of CCHCS Learning Management System EHRS Modules consistent with the staff’s duty statement.

  • Medical Imaging Services staff shall complete orientation and mentoring by Medical Imaging Services staff performing specific tasks identified in the Medical Imaging Services staff Onboarding and Competency Assessment Checklist.

  • Staff beginning independent work shall have access to Medical Imaging staff with similar job duties for questions and assistance.

  • Within 90 calendar days after the new staff hire date, the direct supervisor shall ensure completion of the Medical Imaging Services Onboarding and Competency Assessment Checklist and shall review, sign, and maintain the completed forms in the supervisory file of the staff being assessed.  If the new Medical Imaging staff member is delayed in completing the Medical Imaging Services Onboarding and Competency Assessment Checklist, the direct supervisor may provide additional time on a case-by-case basis to complete the onboarding process and the checklists as soon as possible after the 90 calendar days.

  • A copy of the signed Onboarding and Competency Assessment Checklist shall be emailed to the following email address: medicalimagingservices@cdcr.ca.gov.

• Probationary and Professional Performance Evaluations

  • For staff who have a one-year probationary period:
    In accordance with civil service laws and regulations, the direct supervisor shall complete, at minimum, a STD 636, Report of Performance for Probationary Employee at four months, eight months, and 12 months after hire to assess professional performance and clinical competency.

    • The 12-month STD 636 may be completed as soon as 11 months but no later than 12 months after the hire date.

    • Interim STD 636s may be completed as needed between probationary periods, to assess professional performance and clinical competency.

  • For staff who have a six-month probationary period:
    In accordance with civil service laws and regulations, the direct supervisor shall complete, at minimum, a STD 636 at two months, four months, and six months after hire to assess professional performance and clinical competency.

    • The six-month STD 636 may be completed as soon as five months but no later than six months after the hire date.

    • Interim STD 636s may be completed as needed between probationary periods, to assess professional performance and clinical competency.

  • Two to four weeks prior to the end of the probationary period, the direct supervisor shall review the probationary evaluations and other clinical and performance observations to make a recommendation regarding permanent civil service employment.

  • After the probationary period ends, the direct supervisor shall complete a competency assessment whenever job duties change, or at a minimum, on an annual basis to evaluate the staff’s professional performance and clinical competency.  In addition, on an annual basis, the direct supervisor shall review the Medical Imaging Services staff member’s duty statement with the staff.  This review shall be acknowledged by the staff’s signature on the duty statement.  The signed duty statement shall be retained in the staff’s supervisory file.

• Determination of Permanent Civil Service Status

  • After completion of the second STD 636, but no later than one month prior to the end of probation, the direct supervisor shall review the findings and recommendations contained in the probationary evaluations and other documented professional observations to make a recommendation about whether to grant permanent civil service status.

  • If there are concerns regarding the performance of the probationary staff, the direct supervisor shall immediately notify their supervisor and the Health Care Employee Relations Officer.

  • A recommendation to reject the staff during the probationary period may occur any time during the probationary period if the previous probationary reports (STD 636), professional practice evaluations, competency validations, or other documented performance observations show significant concerns regarding the staff’s performance or conduct.

• Re-orientation of Medical Imaging Services staff (Re-entry Training)

  • For Medical Imaging Services staff who are out of the office on an extended basis but did not separate from service with CDCR (e.g., long term sick):

    • If staff have been out for six months or less, the following is required:

      • There must be documentation of prior completion of the Medical Imaging Services Staff Onboarding and Competency Assessment Checklist.

      • Staff must review all classes, updates, and mandatory training missed including the CDCR Non-Custody Annual Block Training and In-Service Training

      • Validation of competencies shall be completed for the areas in which staff will be working.

    • If staff have been out for six months to one year, the following is required:

      • There must be documentation of prior completion of the Medical Imaging Services Staff Onboarding and Competency Checklist.

      • Staff must review all classes, updates, and mandatory trainings missed including CDCR Non-Custody Annual Block Training and In-Service Training.

      • Validation of competencies shall be completed for the areas in which staff will be working.

    • Staff who are out more than one year shall complete the onboarding process in its entirety upon return.

  • Staff who separate from the Department and then return to state service, regardless of the length of time, shall be required to complete the onboarding process in its entirety.

• Transferring Between Institutions without a Break in Service or Performing Duties at More Than One Institution

  • The direct supervisor is responsible to ensure that all Medical Imaging Services staff working at the institution are competent to perform all the duties of the position for which the Medical Imaging Services staff has been hired.

  • The direct supervisor may develop an abbreviated Medical Imaging Services Staff Onboarding and Competency Assessment Checklist for the staff sharing assignments between multiple institutions.

  • Proof of completion of the onboarding process, clinical competencies, and professional performance shall be maintained at each CDCR location.  This does not absolve the direct supervisor at each CDCR location from ensuring that annual performance evaluations are conducted or that Medical Imaging staff are competent to perform the duties required in their position.