The Importance of Competency Assessment and Performance Reviews

Sandra Chellew, MBA, RN, CPHRM, CPHQ

12.2017

Competency assessment begins at the time of the initial review of a candidate’s application and resume. It continues throughout the interview process and the validation of qualifications and credentials prior to hire. This is a joint responsibility of human resources and the organization’s hiring manager(s).

OVERVIEW

Competency in job performance can be defined as the ability, knowledge, credentials, and experience required in order to be considered qualified and able to perform essential job functions for a specific position. A well-written job description is the foundation for this process. An assessment of an applicant’s critical thinking skills, prior work experiences and education, interpersonal communications, and positive professional references will assist in evaluating baseline competency requirements.

After an applicant has met all initial organizational requirements and is hired, a comprehensive orientation needs to be completed and documented. The Joint Commission and other regulatory agencies have established certain standards relating to initial and ongoing competency. Also, students and volunteers working in a similar capacity as an employee must meet comparable competency requirements. Employed licensed independent practitioners (LIPs) need to have an initial competency assessment by the organization and may also need to go through the medical staff credentialing and clinical privileging process, as required by the medical staff bylaws/rules and regulations.

When a facility markets quality patient/resident care and services, the community’s expectation is that the staff and LIPs are well-trained and competent. Failure of an organization to provide competent staff can reflect poorly on their management and the overall quality of care. It can also make substandard care very difficult to defend.

The Human Resources, Leadership, Medical Staff, Waived Testing (Laboratory), Performance Improvement, and other Joint Commission standards address many hiring, orientation, and competency assessment requirements. These should be incorporated into the organization’s policies. Primary source verification of licensure, certification, and/ or registration required to practice may be a mandatory component of hiring and/or privileging, per regulations and professional standards. This type of effort maximizes an organization’s chances of assuring the authenticity of these documents.

Carefully written job descriptions, which delineate key elements of education, experience, and competency, can facilitate the hiring, orientation, initial assessment, and the periodic evaluation processes. Expectations should be clearly stated for each position to assure that each worker has a comprehensive understanding of exactly what types of performance will be required throughout employment.

Orientation should include a review of important facility-wide policies and procedures along with the expectations of the corporate compliance and safety programs. In addition, more detailed information needs to be shared related to the employee’s specific role and the area where the employee will work. This may include an orientation and skills checklist to assess initial competence and understanding of critical departmental policies, procedures, and protocols. Any areas of weakness should be identified and a plan for improvement developed, along with a timeline, so that an acceptable level of performance can be achieved before the employee begins working independently. In addition, signed acknowledgments should be obtained indicating that key regulatory requirements have been discussed and agreed upon by the new hire.

HIRING AND ORIENTATION

INITIAL ORIENTATION SHOULD INCLUDE, AT A MINIMUM:

NOTE: It is important to include all of those whose responsibilities involve comparable functions, such as students, volunteers, contractors, and LIPs in these efforts, even though tailoring may be needed based upon their particular roles.

Documented creative approaches, such as the use of training labs, simulation, direct observations, and didactic testing, are encouraged in performing competency assessments. Minimum competency and performance requirements to be achieved by the end of the probationary period need be clearly defined.

• Privacy and confidentiality, including federal and state requirements• Corporate compliance training• Employee/LIP/contractor/student/volunteer health screenings and other

health-related organizational requirements• Infection prevention and control, antibiotic stewardship1, isolation protocols,

and hazardous materials handling and disposal, as appropriate• Emergency management, including disaster planning, fire safety, other environmental

and safety matters, and availability of current Material Safety Data Sheets (MSDS) • Patient/resident/employee safety and security, including active shooter training

and workplace violence• Patient/resident and staff/LIP satisfaction initiatives• Patient/resident rights, and abuse prevention and reporting• Occurrence/incident reporting, including “near misses”• Fall and elopement prevention• Policies, procedures, professional best practice guidelines, and protocols • Specialty area requirements that may exceed or differ from those in the general

population, including age-specifics, cultural diversity, waived testing, advanced cardiopulmonary resuscitation competencies, etc.

1 Antimicrobial Stewardship Standards – M.M.09.01.01, The Joint Commission, Oakbrook Terrace, IL, 60181, April 27, 2017. http://www.jointcommission.org

PERIODIC COMPETENCY AND PERFORMANCE REVIEWS

After orientation and the probationary period are completed satisfactorily, each employee/LIP should receive a periodic evaluation of their competency and performance. This is important in order to assure that the level of knowledge, patient/resident care, and service continues to meet the organization’s expectations throughout employment. Skills checklists are a positive and simple way to accomplish and document these competency assessments.

Employees, contractors, students, LIPs, and volunteers are required to have periodic performance evaluations to assure ongoing competency, as specified by the organization. Given the rapidly changing science, standards, and best practices in health care, annual reviews are recommended. Accrediting agencies, such as The Joint Commission, require at least annual educational updates on certain topics. Data from monitoring of performance, including occurrence reporting, should be utilized as part of this process. Continuing education efforts are needed to address new standards of care, and revisions or additions to treatment protocols, policies, and procedures, especially those that relate to high risk topics.

EXAMPLES MAY INCLUDE:• Fall prevention• Infection prevention and control • Elopement• Abuse• Wound care• Nutrition and hydration • Documentation• Equipment and drug changes• New programs and/or patient populations• Survey and audit findings

Trends identified from any root-cause analyses, litigation, new research, satisfaction feedback, occurrence and regulatory reports, and other performance improvement/risk management activities should be utilized to identify areas where additional education for staff/LIPs may be warranted.

DEPENDING UPON AN EMPLOYEE’S JOB DUTIES, AREAS TO BE EVALUATED MAY INCLUDE A PERIODIC REVIEW/UPDATE OF TOPICS ADDRESSED IN INITIAL ORIENTATION, AS WELL AS:

NOTE: An electronic database is most effective in assuring adequate tracking and maintenance of current licensure, certification, registration, CPR requirements, and competency, and employee health requirements. Manual documentation often results in lapses in meeting these obligations.

Anytime areas of competency and/or performance are found to need improvement, an individualized educational action plan, with a defined completion and re-evaluation date, should be implemented. This follow-up is critical for maintaining compliance with professional care standards and to meet the public expectations.

Position descriptions and requirements need to be reviewed and updated periodically, including whenever duties change, in order to promote the ongoing maintenance of current competencies with relevant performance reviews, and to use in recruiting and hiring future employees.

• Professional practice and other service-related skills• Critical thinking• Interpersonal communications• Progress toward meeting personal and organizational goals and objectives• Effective management and leadership techniques, as appropriate• Responsibility for meeting all employee health and professional continuing

education requirements, as required• Educating and mentoring of other team members• Assuring that ongoing current licensure(s), certification(s), registrations, and

skills are maintained, as may be required, including basic and/or advanced types of cardiopulmonary resuscitation (CPR) training

• Participation in other professional and community-related activities that may be deemed necessary by the organization

It is essential that each organization have a well-designed process to assure an ongoing high level of employee competence and performance. Assuring this on a consistent basis requires frequent monitoring, typically by a designated person utilizing a computerized process. To maintain compliance with accreditation and regulatory requirements, this can be a very time consuming process, which requires a continuing managerial focus across the entire organization. It includes the hiring of each new employee, orientation, the initial evaluation of skills and knowledge, developing and monitoring any action plans needed to improve, and completion of a probationary evaluation. The process continues throughout the course of employment with ongoing continuing education and periodic performance reviews, assuring that all organizational and regulatory requirements are met. The competency assessment and performance review process should be viewed as a positive experience rather than just a paperwork exercise.

Fragmented processes that are not meticulously monitored frequently result in unanticipated and problematic lapses. Unfortunately, these issues are often not identified until they are cited by accreditation or regulatory surveyors, during root-cause analyses of adverse events, or when investigations occur in cases in pending or actual litigation. A well-managed ongoing comprehensive performance review and competency assessment program can help mitigate the associated risks, potential financial losses, and the adverse impacts that any lapses in such efforts can have on an organization’s reputation.

SUMMARY

REFERENCES:

Chellew, Sandra, Competency Assessment and Performance Reviews, Pendulum, LLC, Albuquerque, NM, 2016.

Antimicrobial Stewardship Standards – M.M.09.01.01, The Joint Commission, Oakbrook Terrace, IL, 60181, April 27, 2017. http://www.jointcommission.org

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