Competency Assessment Update April 2016 Ceresa Ward

The Joint Commission Standards HR Staff are competent to perform their responsibilities. 1.The hospital defines the competencies it requires of its staff who provide patient care, treatment, or services.

Direct Patient Care Includes, but is not limited to, all registered nurses, licensed practical nurses, unlicensed assistive personnel, allied health professionals, patient transporters, hospitality coordinators, food service workers, custodians, sterile processing technicians, medical laboratory technicians, and security officers.

Issue: Date and Line with Arrow Putting one date on everything and drawing a line with an arrow. Competency checks should indicate assessment on multiple dates by multiple reviewers. NEVER put a date and draw a line with an arrow.

Issue: Need a Qualified Observer Competencies must be signed off by an individual with the educational background, experience, or knowledge related to the skills being reviewed.  Qualified Observer: Must have demonstrated skill mastery and have satisfactorily completed the verification process.  If a qualified observer is not available for a given position on your unit, you should seek assistance from another department or outside the organization as needed.  Must have the same or higher level credentials.

Issue: No credentials Need a qualified observer. With no credentials, we don’t know.

Template to be Revised

“Competency assessment is a fluid, ongoing process.” (p. 13 Wright) “Organizations using systems that merely check and re-check the same list of competencies year after year find their competency assessment process frustrating and meaningless.”

Issue: Ongoing Competence Assessment “ Staff competence is assessed and documented at least once every three years, or more frequently. Don’t just reassess the original new hire competencies. Competencies should be selected from new equipment or processes, high risk, low volume, and time sensitive job duties, and problematic aspects of the job including process improvement initiatives, root cause analysis, or PSN reports

Issue: Not turning Competencies in on time  Due no later than end of probationary period (6 months)  Required for transfers as well as new hires  Reminders are sent to manager and new employee at hire, 90 days, and beginning of 5 th month.  Please scan and submit to Carmen Spurling and Nancy Wittenborn via

Issue: Employee’s Name and EMPLID is Not Documented or Legible

Expectations  Scan and send to Carmen Spurling and Nancy Wittenborn via  Make sure the employee’s name and EMPLID are documented and legible.  Use the approved template found on Navex.  Only qualified observers sign off on competencies.  Make sure to use your credentials when you sign  Do not put a date and draw a line.  Do not sign off on all competencies on the same day.  Competencies will be returned to the unit if do not meet expectations.