Competence and Competency Assessment

We have always known that having competent staff was and remains the backbone to who we are as an organization, and as a provider of care, treatment, and services. Lives depend on competence, not only the lives of our patients, but the lives and livelihoods of those who work with us.

Let’s pause for a moment and think about how important having staff competent in donning and doffing Personal Protective Equipment has been in preventing the spread of Covid-19, how important it has been as we converted anesthesia machines to respirators, converted medical-surgical units to dedicated Covid units or Ventilator management units. Competence was needed and seen in so many other areas besides clinical care, such as Purchasing and Procurement; Bio-Medical Equipment, and Security, for example. We depend on staff competence to permeate our organizations from the basement to the board room, but how do we design a competency assessment program?

When designing or evaluating your program you want to be certain that it addresses the following, in simple terms: Who, What, When, Where and Why.

What Does Competency Mean

Let us first look at what the term competency means. The Joint Commission does not provide a definition within the glossary of their accreditation manual but describes it as “a combination of observable and measurable knowledge, skills, abilities and personal attributes that constitute an employee’s performance”. The Merriam-Webster dictionary provides several definitions:

• the quality or state of having sufficient knowledge, judgment, skill, or strength (as for a duty or in a particular respect)
• legal authority, ability, or admissibility

The American Nurses Association defines it as “an expected level of performance that integrates knowledge, skills, abilities and judgment.” The Cambridge dictionary defines it as “an important skill that is needed to do a job”. Regardless of the definition you select, common to all definitions is the expectation of “demonstrated ability”.

Adopting a definition and embedding it into your policy along with criteria on how you will determine which skills will require “demonstrated ability” is key to having a process that is uniformly implemented across various departments. Competence is separate and distinct from the provision of education and training as these do not require “demonstrated ability”.

When Does Competency Need to Be Assessed

We also need to consider when competency needs to be assessed. The first part of an employee’s employment, post-hire must include an initial assessment of competency. This should occur as a component of the new hires' job specific orientation. The Joint Commission defines Orientation as “a process used to provide initial training and information while assessing the competence of clinical staff relative to job responsibilities and the organization’s mission and goals." Organizations should utilize the same competency assessment tools for each skill regardless of whether the assessment is part of the initial orientation or part of the on-going competency assessment program. Once initial competency has been determined and any required actions taken to establish competence, The Joint Commission standard HR 01.06.01 advises that competency assessments along with evaluations must be conducted at least every 3 years. Be certain to validate your chosen frequency with both federal and individual state requirements as they may define a more stringent timeframe.

When you consider the scope of responsibility of our healthcare team members, outside of initial orientation, it would be impossible to individually assess each person’s ability to perform all of these responsibilities. Organizations must have a means to prioritize those skills that will require a specific focused assessment for competence. This will also help you define  why a competency is required. A solid approach to selecting skills for competence assessment comes from the basic principles of Performance Improvement:

• Low Volume
• High Risk
• Problem Prone

Developing a matrix that reflects this selection process can be a valuable management tool along with a great tool to show to surveyors to substantiate your methodical approach to competence assessment. Utilizing internal sources of data and information can help organizations identify areas where competence may be contributing to under-performance for the organization. Consider data sources such as Incident Reports, Medication Error reports, Medication Safety, Adverse Drug Event and Adverse Event data when establishing or re-evaluating your competency program. Also, keep in mind that when your organization expands into new service lines or new patient procedures, this creates a perfect opportunity to develop a competency assessment specific to the service line or procedure. Often, these new areas involve the use of new equipment, which of course warrants orientation to how to operate and manage the equipment along with an assessment of skills learned.

There are no hard-fast rules as to what individual steps need to be addressed within a competency tool. Your organization will want to define criteria within your policy that will create the foundation of the assessment. Consider criteria such as:

• Any step or procedure that if not performed properly would result in direct patient harm.
• Any step or procedure that is performed solely by one-person and if not performed properly would result in direct patient harm.

When we think about organizations that are journeying to high reliability, these organizations strive to have competence permeate through their organization and so having defined competencies for every role within the organization would be very important. This is a very broad definition who needs to be part of the competency assessment program. For survey purposes, the focus of the competency assessment process lies on those who provide care, treatment, and services to our patients. Keep in mind that, depending upon the resources utilized within your organization, this may include vendors, contracted services, interim staffing, agency staffing and volunteers, depending upon their assigned duties. For instance, organizations that utilize volunteers to feed patients or residents should have a competency for this skill.

Where Should Competency Be Assessed

Finally, we need to focus on the where. This leads us down two paths (1) where should competency be assessed and (2) where should its documentation be housed. Competency is best assessed as part of normal operations. Assigning a competent peer to utilize your competency checklist to observe a peer performing the task is best performed during the performance of the skill. For more complex, perhaps less utilized skills consider using simulation as the framework for assessing skills. Keep in mind that sometimes our competency assessment will measure the person’s ability to apply clinical knowledge in addition to demonstrated ability. For instance, a Registered Nurse would need to possess both clinical knowledge in the criteria used for staging of wounds along with the demonstrated ability of how to properly dress a wound to be responsible for wound care. When employing an agency or interim staff, the agency should be providing your organization a copy of their staff’s competency checklists, but organizations should ensure that they have a means to validate their skills to ensure they are meeting your organization’s expectations and policy requirements. This is often accomplished by having an assigned mentor or trainer perform basic observations of key skills during the initial assigned shift.

Where Should Documentation Be Housed

The documentation of the presence or absence of competence must be housed in a location that is accessible to staff responsible to assign staff duties. Consider persons who would need access to this information such as the staffing office and design your process to place this information at their fingertips. Maintaining evidence of the presence or absence of competence is important for regulatory and legal reasons. While current competency documents need to be readily available for staff assignment purposes, many organizations utilize the Human Resources Department or software systems to permanently archive these documents. Your Competency Assessment Program should address storage locations, how often the tools should be archived and how long those archives will be maintained.

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