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SOAR with FOUR – Getting Everyone on Board


Getting Everyone on Board: Assuring Education, Competence and Evaluation for Staff, Medical Staff and Contracted Services

OR TeamCompetence is a noun defined by Merriam Webster as the ability to do something well: the quality or state of being competent. In the healthcare field we can extend that to mean that all staff possess required skills, knowledge, qualification, or capacity. Competence is assessed during survey, but foundational practices in this area will also ensure you are meeting applicable laws, regulations and The Joint Commission standards – practices that will ensure that staff are able and equipped to complete their jobs and that patient protection and safety remains paramount.

During Survey

A competence session will be conducted during your survey. This session typically lasts 30-60 minutes and includes staff who have authority to access personnel files, human resources representatives as well as those who provide orientation and education to staff. The purpose of the session is to ensure that all staff are qualified to perform their responsibilities – do they have the qualifications, skills and knowledge to perform? Have they been properly oriented to policies, procedures and practices in the organization? Is there ongoing education to ensure all staff are kept current on new developments and changing job responsibilities? While a portion of the competence session is file review and assessment of orientation and education programs, there is also discussion where the surveyors seek to attain understanding of your internal processes to be sure they are in compliance with law, regulations and standards. (The Joint Commission, 2014, p. 61)

Beyond the Survey: Competence is a State of Protection – for Patients and Staff

Ellen Perry and Darlene Christiansen, Consultants at C&A, refer clients to review The Joint Commission’s Survey Activity Guide for the latest in how to prepare for a competence session. Perry gave an example based on a circumstance when a staff member had been terminated. The termination occurred but because of flaws in the policies and procedures regarding termination, the terminated employee’s access (to the medical record, pharmacy system, etc.) was not immediately revoked. This causes major concerns for the protection of patients. Perry invites you to examine your own policies and procedures regarding termination. “What course of action have you taken? Have you taken all of the steps to safeguard patients and other staff by immediately terminating access for the staff member?” Christiansen elaborated, “This is a critical issue. You don’t typically know it’s a problem, until it happens. However, you can be proactive and as you prepare for survey, investigate how to improve your current practices.”

Four Things You Can Do to Address Competence During Survey and Ongoing:

  • Assemble the team that will be present during a competence session and practice addressing your internal processes and procedures.
  • Organize your files and documents so that they are easily accessible during the session.
  • Review your human resource policies and procedures to verify orientation and termination processes.
  • Document the education programs you provide to staff and demonstrate the results of the educational activities in terms of learning evaluations, demonstrated achievements and enhanced benefits to patients.

In conclusion, think of competence as more than just checking a box off on your survey preparation checklist. Think about how competence is the backbone of an organization. When solid processes, policies and procedures are in place and when the highest caliber of staff are selected, oriented and educated, the organization is positioned to thrive not only during survey, but always.


The Joint Commission’s Survey Activity Guide

Kerrie Bellisario

Author Kerrie Bellisario

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