1. Slide 1 FastFacts Feature Presentation November 11, 2013 To dial in, use this phone number and participant code… Phone number: 888-651-5908 Participant code: 182500 To participate via VoIP… You must have a sound card You must have headphones or computer speakers © 2012 The Johns Hopkins University. All rights reserved.

2. Slide 2 Today’s Topic We’ll be taking a look at… Performance Management Policy Revisions: Competency Assessments

3. Slide 3 Today’s Presenter Sharon Kemp Sr. Director of JHHS Compensation Dana Moore Director of Regulatory Affairs

4. Slide 4 Session Segments Presentation Sharon and Dana will address revisions to the Performance Management Policy and the creation of an official Competency Assessment Tool template. During Sharon and Dana’s presentation, your phone will be muted. Q&A After the presentation, we’ll hold a Q&A session. We’ll open up the phone lines, and you’ll be able to ask questions. Sharon and Dana will answer as many of your questions as time allows.

5. Slide 5 Contact Us If you would like to submit a question during the presentation or if you’re having technical difficulties, you can email us at: fastfacts@jhu.edu fastfacts@jhu.edu You can also send us an instant message! GoogleTalk – HopkinsFastFacts@gmail.comHopkinsFastFacts@gmail.com AOL Instant Messenger – HopkinsFastFacts MSN – FastFacts@jhu.edu

6. Slide 6 Survey At the end of this FastFacts session, we’ll ask you to complete a short survey. Your honest comments will help us to enhance and improve future FastFacts sessions.

7. Slide 7 How To View Full Screen Click Here

8. November 11, 2013 8 Performance Management Policy Revisions Competency Assessments Presented by: Sharon Kemp and Dana Moore

9. Competency Assessment Requirement The Joint Commission (TJC) standards dictate that staff competence is assessed and documented annually in accordance with JHHSC/JHH Performance Management policy. Standard # and Text: HR.01.06.01 Staff are competent to perform their responsibilities Element of Performance (EP) # and Text: 5. Competence is initially documented as part of orientation. 6. Staff competence is assessed and documented once every three years, or more frequently as required by hospital policy or in accordance with law and regulation. 8/21/20159

10. Competency Assessment Revision https://hpo.johnshopkins.edu/hopkins/policies/64/220 6/policy_2206.pdf?_=0.281708408807 https://hpo.johnshopkins.edu/hopkins/policies/64/220 6/policy_2206.pdf?_=0.281708408807The Johns Hopkins Hospital (JHH) Performance Management policy (HR004) was reviewed, revised and approved by Human Resources to more clearly define the requirement for annual assessment of competencies at the time of the annual performance evaluation. https://hpo.johnshopkins.edu/hopkins/policies/64/220 6/policy_2206.pdf?_=0.281708408807 https://hpo.johnshopkins.edu/hopkins/policies/64/220 6/policy_2206.pdf?_=0.281708408807 8/21/201510

11. Definition Competency is the application of knowledge and skill in performance. Competency is best assessed via return demonstration and observation. Additional methods include, but are not limited to, simulation, mock reviews, and case studies. Competency is NOT assessed via an education module with a post-test. An education module with a post-test measures knowledge, not competence (or proficiency). One may be very knowledgeable about a skill, but incompetent to actually safely perform that skill. 8/21/201511

12. Upon employment, managers need to meet with all new hires, transfers and those promoted, to review their job descriptions and to inform them of the required education and competencies that must be met during the Initial Assessment period. A list of required education can be found at the following link: http://intranet.insidehopkinsmedicine.org/joint_commission/requi red_education/index.html http://intranet.insidehopkinsmedicine.org/joint_commission/requi red_education/index.html Initial Assessment 8/21/201512

13. Initial Assessment (Continued) The initial assessment period includes a review of the job performance (using the applicable job description) at 90 days. Some nursing orientation periods are > 90 days; if this is the case the review of the job performance is done at the end of orientation. Competency assessment is part of the initial assessment but may be completed prior to the review of the job performance (e.g., for orientations less than 90 days). Competency assessment must be completed prior to employee practicing independently. TJC Standard: HR.01.04.01 Orientation EP # and Text: 2. Key orientation elements are assessed prior to providing care 8/21/201513

14. Initial Assessment (Continued) During the initial assessment, the preferred and most effective way to determine competency is through direct observation of the skill being performed. When an opportunity to observe the skill is not available, mock scenario, or return demonstration may be used. In some situations, a review of clinical documentation in the medical record related to the behavior or skill, if appropriate. 8/21/201514

15. Initial Assessment Methods The method for documenting the initial assessment of competency is as follows: Clinical jobs and Management jobs: Skills Competency Checklist Competency Assessment Tool Template – to be used for initial competency assessment only if no Orientation Skills Competency Checklist is used or if there are additional competencies that require validation. Non-Clinical jobs: Essential Job Functions and Service standards and/or measures marked with an asterisk (*). 8/21/201515

16. Annual Assessment Methods Annual competencies will be documented on the official Competency Assessment Tool template or an equivalent form of documentation. To meet TJC standards, the equivalent form must contain the skills that are required for competency, the method of verification (e.g., observation, simulation, review of work product), an explicit rating (meets vs. does not meet) and include the signature of the assessor and the date assessed. 8/21/201516

17. Annual Assessment Methods Clinical Jobs: Identify a minimum of at least two competencies. Competencies should be reviewed regularly for relevance (i.e., they should not remain the same year after year). Competencies may also differ depending on experience level. Competencies should be determined by low volume, high risk, new procedures/equipment, problem prone areas or as the result of QI activities. For clinicians supervised by a non-clinician (e.g., a manager who also maintains some clinical responsibilities), arrangements must be made to have a qualified person confirm/assess competency. Non-Clinical Jobs: Document annual competencies and essential job functions and service standards on the actual job description. Essential job functions and service standards and/or measures should be marked with an asterisk (*). 8/21/201517

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20. Annual Performance Review Using the Employee File and Education Requirements Grid or the Medical, Resident & Affiliate Staff Education Requirements at the annual performance review, the manager should also audit for timely completion and documentation of applicable competency assessments throughout the intervening year (e.g., when a new skill, new process or new instrument/technology was required). The manager should NOT wait until the annual performance review to first complete certain required competency assessments, but their reflection in the HR file should be audited at the time of the annual performance review. 8/21/201520

21. Resources This new procedure will be effective immediately. Starting December 2, 2013, all clinical employees who have their evaluations processed are required to have documented competencies using the new process. For more information, contact HR Compensation at 443-997-5584. 8/21/201521

22. Slide 22 We’re going to open the phone lines now! There will be a slight pause, and then a recorded voice will provide instructions on how to ask questions over this conference call line. We’ll be answering questions in the order that we receive them. We’ll also be answering the questions that were emailed to us during the presentation. If there’s a question that we can’t answer, we’ll do some research after this session, and then email the answer to all participants. Q&A

23. Slide 23 Thank You! Thank you for participating! We would love to hear from you. Are there certain topics that you would like us to cover in future FastFacts sessions? Would you like to be a FastFacts presenter? Please email us at: fastfacts@jhu.edu

24. Slide 24 Survey Before we close, please take the time to complete a short survey. Your feedback will help us as we plan future FastFacts sessions. Click this link to access the survey… http://connect.johnshopkins.edu/fastfactssurvey/ http://connect.johnshopkins.edu/fastfactssurvey/ Thanks again!