The competency assessment and performance review process should be viewed as a positive experience

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1 Overview Competency related to job performance can be defined as the ability, knowledge, credentials, and experience to be deemed well-qualified and able to perform required functions essential for a specific position. A well-written job description is the foundation for this process, followed by an assessment of competency. The competency assessment starts with the review of a potential employee s resume and application, and continues during the applicant s interview process and validation of qualifications and credentials prior to hire. This is the joint responsibility of human resources and the organization s hiring manager(s). Once an employee is hired and meets all initial requirements set forth by the organization, it is critical that a comprehensive orientation be completed, including the essential elements of the facility and the specific area where the employee will work. The next phase of competency assessment should include the use of orientation and skills checklists; policy, procedure, and protocol reviews; and obtaining signed acknowledgements that key regulatory requirements have been reviewed and agreed upon. At this time, any shortcomings should be identified, and an individualized plan with a timeline should be developed to bring performance to an acceptable level before the employee begins working independently. The Joint Commission establishes standards relating to competency and performance. It is important to note that Joint Commission standards require that students and volunteers working in a similar capacity as an employee meet comparable competency requirements as employees. In addition, licensed independent practitioners (LIPs) who are employed need to have an initial competency assessment by the organization. LIPs may also need to go through the medical staff credentialing and clinical privileging process, as delineated by the medical staff bylaws/rules and regulations. As defined by the organization, employees (including students, LIPs, and volunteers) should be required to have periodic performance evaluations to assure ongoing competency. The use of data from monitoring and various methods of feedback reporting should be used as part of this process. In addition, documentation of continuing education activities should include review of new regulations, changes in equipment and drug formulary, policy and procedure revisions, new services or processes implemented, and community needs identified. Staff competency is an essential element of the services being provided by the facility. When a facility markets certain services, the expectation is that the individuals who provide those services are trained and competent. Failure to provide competent staff does not only reflect poorly on the facility s quality it can also make substandard care very difficult to defend. 1

2 The competency assessment and performance review process should be viewed as a positive experience rather than simply another paperwork exercise. Goals should include recognizing excellence and demonstrating the desire to continually improve both individual and organizational performance, thereby enhancing outcomes for residents, clients, or patients. Hiring and Orientation The Human Resources, Leadership, Medical Staff, Waived Testing (Laboratory), and Performance Improvement chapters, and some other standards, of The Joint Commission speak specifically to many hiring, orientation, and competency assessment requirements. These should be reviewed and considered for integration into the organization s structure. Primary source verification (verification of licensure, certification, or registration required to practice a profession) may be a mandatory component per regulation, professional standards, and the organization. Integrating a well-written job description with key elements and competency requirements often facilitates the hiring, orientation, and initial competency assessment, as well as the ongoing evaluation, processes. Clear expectations for each position should be set forth, to assure that all parties understand what will be required prior to each performance review throughout employment. Initial orientation to the organization and area(s) in which the employee will be working should include such things as: Privacy and confidentiality, including federal and state requirements Corporate compliance Employee health screenings and other periodic organizational requirements Infection control, hazardous materials handling, and disposal The competency assessment and performance review process should be viewed as a positive experience Disaster planning, fire prevention, and other environmental and safety matters Resident/employee safety, fire safety, and security Resident satisfaction initiatives Resident rights and abuse prevention Incident reporting Fall and elopement prevention and management Policies, procedures, practice guidelines, and protocols Specialty and subspecialty area requirements that may exceed or differ from those in the general population, including age-specifics, cultural diversity, waived testing, cardiopulmonary resuscitation competencies, etc. High risk/low volume, high risk/high volume problem-prone areas It is important to include all workers whose responsibilities involve comparable job functions, such as students, volunteers, and LIPs, in this process, even though modifications may be needed based upon their specific duties. Training labs, simulation, direct observation, didactic testing, and other creative assessment methods may be used in reviewing competencies, and those assessments should be documented. If any areas of weakness in performance are identified, a plan to improve skills should be developed in collaboration with the employee involved. A minimum level of competency should be defined by the organization that must be achieved by the end of the probationary period. Ongoing educational sessions and organizational requirements should be discussed with new employees regarding the use of any unfamiliar equipment, revised procedures or protocols, changes in resident populations, drugs added to the formulary, changes in scientific knowledge, and performance improvement opportunities identified. 2

3 Periodic Competency and Performance Reviews Following the probationary period competency and performance assessment, each staff member should receive a periodic review of their ongoing competency and performance, to assure that a satisfactory level of knowledge, care, treatment, and/or service continues throughout their employment. The use of skills checklists is an appropriate and simple way to accomplish these reviews. Continuing education efforts should be ongoing relating to new standards, protocols, policies, and procedures relating to high risk areas such as falls, elopement and abuse prevention, wound care, nutrition and hydration, charting and documentation, equipment and drug changes, added programs and resident populations, survey and audit findings, etc. Feedback from data obtained through ongoing monitoring of compliance with policies, protocols, practice guidelines, and core measures should be included in this process. Trends identified from root cause analyses, litigation, study data, complaints, new research, occurrence and regulatory reports, and other quality improvement and risk management activities should be used to identify areas where additional training may be needed. As appropriate to the particular position, areas that should be assessed may include a review/update of topics addressed in initial orientation, as well as: Clinical practice and other service-related skills Critical thinking Interpersonal relationships Achievements toward meeting goals established Demonstrated management and leadership ability Teaching and mentoring of others As job functions may change over time, position descriptions and requirements may need to be updated Maintaining ongoing current licensure(s), certification(s), and competencies that may be required for the position* Current status and relevant type of cardiopulmonary resuscitation (CPR) training* Teamwork Communication skills Ongoing education and improvement in skills Participation in other professional and community-related activities Meeting all ongoing employee health and educational requirements, as defined by the organization, department, specialty, or subspecialty * Note: An electronic database is generally essential for assuring adequate tracking and maintenance of current licensure, certification, CPR, and competency, especially in larger organizations. Whenever areas needing improvement in competency and/or performance are identified, an individualized action plan with a defined completion date is critical for compliance with industry care standards and public expectations. As job functions may change over time, position descriptions and requirements may need to be updated in order to continue to maintain competencies that are current and relevant for use in future performance reviews, and for the hiring of new employees of the same kind. Summary To be in compliance with federal and state regulatory requirements, industry norms, as well as to maintain the community s trust, it is essential that each organization have a well-designed process to assure a high level of employee competence and solid performance. Assuring this on a consistent basis requires continuous monitoring, often by a designated person. This is generally a very time-intensive undertaking which demands an ongoing focus on the overall process and integration across the entire organization. This 3

4 starts with the hiring of each employee and continues through orientation, initial assessment of competency and action plans (as required), completion of probationary evaluation, periodic ongoing performance reviews, and assuring that all organizational and regulatory requirements are met along the continuum. Fragmented processes that are not electronically monitored often result in unanticipated and problematic lapses. Unfortunately, these deficiencies are typically not identified until found by regulatory body surveyors, during root causes analyses of sentinel events, or at the time of investigations in cases in pending litigation. By minimizing deficits in these areas, associated risks and potential financial losses may be mitigated by an organization. The use of the Checklist: Competency Assessment and Performance Review may be of assistance in making improvements related to these functions. This publication is provided for general informational purposes only and does not constitute legal, risk management, or other advice. Readers should consult their own counsel or other advisors for such advice. OneBeacon Professional Insurance, Inc. (OBPI) and Pendulum, LLC, or any consultant or contractor of Pendulum, LLC, assume no responsibility or liability for the discovery or elimination of risks that possibly could cause accidents, injuries, or damages. Compliance with any strategies or opportunities for improvement provided in this publication does not assure elimination of risks or the satisfaction of requirements of applicable law. About the Author Sandra Chellew, MBA, RN, CPHRM, CPHQ, has 30 years of experience in the healthcare industry, giving her a strong background in risk management. From her experience as a Director of Performance Improvement, Risk Manager, and as a Board member and President of VASHRM, Ms. Chellew has a wealth of knowledge in the risk management field. Ms. Chellew is an independent consultant contracted with Pendulum, LLC. This publication is intended for use by current OBPI insured clients. Re-distribution of this material to non-obpi insureds or non-approved producers is not allowed without permission from OBPI. 4

5 CHECKLIST: Competency Assessment and Performance Review Has the executive team: Appointed a person to monitor the entire process throughout the organization to assure consistency? Established expectations for a comprehensive competency and performance review process? Communicated expectations to all managers/ executives? Identified parameters for the person appointed for required monitoring reports relating to the organization s performance of these processes? Has the appointed person established a methodology to work with all managers and executives to implement the framework to assure that the requirements in the competency assessment and performance review process are consistently met throughout the organization? Have key elements and indicators been established for monitoring compliance with the competency assessment and performance evaluation process within areas across the organization? Is the appointed person involved in: Utilizing an electronic database to monitor each employee s compliance with required elements, as defined by his/her job description and the organization, department, specialty, and/or subspecialty? Working in a positive manner with managers and executives to resolve issues and facilitate organizational compliance, as needed? Assuring that all managers comply with assessment requirements, as previously established by the executive team? Monitoring completion of action plans implemented to improve performance when required competency and performance levels have not been found to be satisfactory by the manager, or in compliance with the organization s requirements/expectations? Evaluating and implementing recommendations to improve competency assessment and performance reviews within the organization? Assuring that all competency assessment and performance review tracking data is stored in a central, secure, fireproof file, and that access is limited only to authorized personnel within the organization? Yes No Comments/Action Plan

6 Do managers and executives communicate with the appointed person on significant issues that may arise relating to the organization s comprehensive competency and performance review process? Are key elements and indicators consistently monitored and reported regularly, by defined areas and across the organization, according to the guidelines established by the executive team? Has the organization s competency assessment and performance review process been formally evaluated, with recommendations made for improvements, and reported to the executive team within the past 12 months? Yes No Comments/Action Plan Additional comments: Completed by: Date: Reviewed by: Date: This checklist is not a comprehensive listing of all conditions or situations. This checklist is for general informational purposes only and does not constitute and is not intended to take the place of legal or risk management advice. Parties should contact their own counsel for any such advice.

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