Sync template from atomicqms-style deployment

SOPs/SOP-003-Training.md

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+# Standard Operating Procedure: Training and Competence
+
+| Document ID | SOP-003 |
+|-------------|---------|
+| Title | Training and Competence - NICU/PICU |
+| Revision | 1.0 |
+| Effective Date | [DATE] |
+| Author | [AUTHOR] |
+| Approved By | [APPROVER] |
+| Department | Nursing Education / Quality |
+
+---
+
+## 1. Purpose
+
+To ensure personnel caring for critically ill neonates and children are competent based on appropriate education, training, skills, and experience.
+
+## 2. Scope
+
+This procedure applies to:
+- All NICU/PICU clinical staff (nurses, physicians, NPs, PAs, RTs)
+- Support staff (pharmacists, social workers, child life specialists)
+- Contract and temporary personnel
+- Students and trainees
+
+## 3. Responsibilities
+
+### 3.1 Unit Leadership/Managers
+- Identify training needs for NICU/PICU personnel
+- Ensure training is completed before independent practice
+- Evaluate competence of personnel
+- Maintain department training records
+
+### 3.2 Nursing Education
+- Coordinate NICU/PICU orientation programs
+- Maintain central training database
+- Track training compliance
+- Archive training records
+
+### 3.3 Quality Assurance
+- Develop QMS-related training
+- Approve clinical training curricula
+- Audit training compliance
+
+### 3.4 Clinical Staff
+- Complete assigned training on time
+- Maintain current certifications (NRP, PALS, ACLS)
+- Report training needs to supervisor
+- Participate in annual competency validation
+
+## 4. Required Certifications
+
+### 4.1 NICU Staff
+- Neonatal Resuscitation Program (NRP) - every 2 years
+- STABLE Program (post-resuscitation care)
+- Electronic Fetal Monitoring (OB/NICU)
+
+### 4.2 PICU Staff
+- Pediatric Advanced Life Support (PALS) - every 2 years
+- Advanced Cardiovascular Life Support (ACLS) if applicable
+
+### 4.3 All ICU Staff
+- Critical care orientation
+- High-risk medication administration
+- Ventilator management competency
+- Central line care
+- Sedation assessment
+- Pain assessment tools
+
+## 5. Procedure
+
+### 5.1 Training Needs Assessment
+
+1. Identify competence requirements for each role
+2. Document requirements in job descriptions
+3. Assess current competence of personnel
+4. Identify training gaps
+5. Consider regulatory and accreditation requirements
+
+### 5.2 New Employee Orientation
+
+All new NICU/PICU staff shall complete:
+
+1. **General Orientation** (1-2 days)
+   - Hospital policies
+   - Safety and emergency procedures
+   - Quality system overview
+
+2. **Unit Orientation** (4-12 weeks depending on role)
+   - Unit tour and equipment
+   - Documentation systems
+   - Communication protocols
+   - Family-centered care principles
+
+3. **Clinical Competencies** (validated during orientation)
+   - Patient assessment
+   - Medication administration
+   - Respiratory support
+   - IV access and management
+   - Emergency response
+
+4. **Required Certifications**
+   - NRP or PALS (must be current before start)
+   - Unit-specific competencies
+
+### 5.3 Annual Competency Validation
+
+All staff shall demonstrate competency annually in:
+1. Code/emergency response
+2. High-alert medication administration
+3. Sedation scoring
+4. Pain assessment
+5. Equipment operation (vents, infusion pumps)
+6. Documentation requirements
+7. Infection prevention practices
+
+### 5.4 Training Documentation
+
+Training records shall include:
+- Employee name and ID
+- Training title and date
+- Trainer name and qualifications
+- Assessment results (minimum 80% passing for written tests)
+- Practical demonstration verification
+- Signatures
+
+### 5.5 Retraining Requirements
+
+Retraining is required when:
+- Significant protocol revisions occur
+- Performance deficiencies identified
+- Extended absence from unit (>6 months)
+- New equipment or technology introduced
+- Sentinel event or serious safety concern
+
+### 5.6 Preceptor Qualification
+
+Preceptors must:
+- Have minimum 1 year ICU experience
+- Complete preceptor training program
+- Demonstrate teaching ability
+- Maintain current certifications
+
+## 6. Training Records Retention
+
+- Training records maintained for duration of employment
+- Records retained 7 years after employee departure
+- Records available for Joint Commission and regulatory inspection
+
+## 7. Related Documents
+
+- FRM-004 Training Record Form
+- FRM-005 Clinical Competency Checklist
+- Job Descriptions
+- Preceptor Manual
+
+---
+
+## Revision History
+
+| Rev | Date | Description | Author |
+|-----|------|-------------|--------|
+| 1.0 | [DATE] | Initial release | [AUTHOR] |