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Hospital Accreditation

Hospital Accreditation: Determining Staff Competency
Posted by
on 3/6/2018 10:00:00 AM

My father passed away several years ago. He was in and out of the hospital numerous times in the last years of his life. At one point he underwent abdominal surgery for an intussusception and ended up with a colostomy. I remember visiting him in the hospital one day and seeing his nurse come into his room. She changed his colostomy bag and then started to remove his abdominal surgical dressing wearing the same gloves! I’m not kidding. No discarding the gloves (covered with fecal material), no hand hygiene, no donning new gloves… no nothing! I almost came out of my skin, literally screamed at her to stop, and kicked her out of my father’s room.

It’s rare to witness someone that incompetent in their job function; and it’s why assessing staff competency is such an important part of assuring that patients receive safe care. Competency generally means the ability to do something successfully or efficiently. I would add safely as well.

Unfortunately, regulation and accreditation standards give little practical guidance on this subject. My guess is that if you ask ten surveyors what’s considered the best approach to determining staff competency, you’ll likely get ten slightly different answers.

Initial Assessments of Competency
Your hospital has an obligation to assure that staff can perform the full scope of their job function safely. Hence, the initial determination that staff are competent should be thorough. Based on someone’s licensure, education, training, and experience you may be able to accept as self-evident that person’s ability to perform routine low-risk aspects of their job. However, for job duties that carry risk (to patients or to staff), there is an expectation that competency is validated – not assumed.

Many hospitals have 90-day probationary periods which are used to determine if staff are competent. That’s fine, but if it takes longer than 90 days, so be it. There may well be times when – even after 90 days – staff have not performed a job duty sufficiently enough (or not at all) to be sure that they are competent. There is no magic deadline. It’s okay for an initial assessment of competency to take as long as it takes. Staff should not be permitted to independently engage in performing an aspect of their job function until competency has been determined.

New Competencies
At a minimum, staff should have their competency assessed whenever the following occurs:

This last bullet point is one that we often miss. This is a true example. A hospital saw a spike in their ventilator pneumonia rates. Turns out that the ICU had hired a bunch of new grads and they weren’t quite getting the hang of the whole vent bundle thing. A little bit of re-training and everything got back to normal. Lesson… look at staff competency as part of the puzzle when things aren’t going as well as you hope.

Validating Competency
How competency is validated is important. The method must be appropriate to the skill and knowledge needed. Most skills involve some degree of knowledge. Having didactic competencies (on-line learning modules, etc.) work fine for that. But if a skill requires actually having to use your hands, you need to have tactile or demonstrated competencies as well. Would you want a respiratory therapist to stick your radial artery for a blood gas based solely on taking a study module with a post-test? Hopefully not.

A person’s self-assessment of his/her own competency is of very limited value. At best, it may give you an idea of how that person views his/her job abilities. It should never be used as the sole basis to determine competency. Be aware that most supplemental staffing agencies have no ability to validate the competency of the staff they send to you. Those skills checklists are nothing more than self-assessments. Your hospital has a responsibility to at least validate that contract staff can perform high-risk aspects of the job function safely.

Ongoing Competency
Focus on aspects of the person’s job function that are low volume / high-risk. Competency is proficiency borne through repetition. The more often we do something, the better we become at it. Remember the first time you rode a bicycle? Remember how wobbly and unsteady you were. How did you get to the point that you could ride that bike successfully? Simple… practice made perfect! Imagine if your parents instead had put the bike away and you didn’t ride it for a year. Think you’d get on that bike and ride it right out the gate?

An ED nurse asked me once why she had to go through an adult resuscitation competency annually at her hospital. “We code adults all the time”, she said. “If you really want to help us, do mock pediatric codes. I don’t care how long you’ve been an ED nurse. Those still scare us to death”. She understood what competency was all about.

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About the Author

Richard Curtis RN, MS, HACP

Richard (Rick) Curtis is the Chief Executive Officer for CIHQ. Rick is nationally recognized as an expert on the Medicare Conditions of Participation and the CMS Certification & Survey Process. As CEO, he successfully guided CIHQ in becoming the nation's 4th CMS approved deeming authority for acute care hospitals.
Rick's clinical background is in critical care nursing with a focus in cardiovascular and trauma service lines. He has held both clinical and executive management level positions in Quality, Risk, Education, Infection Control, and Regulatory Compliance.
Rick is a regular speaker at numerous state and national conferences on the federal regulations and accreditation standards, and is host of CIHQ's popular monthly webinars addressing key compliance challenges in today's environment.
Rick is nationally certified in healthcare accreditation, and serves as Chair of the Board of Examiners for the Healthcare Accreditation Certification Program (HACP). Rick has a degree in Nursing with a Master's Degree in Health Services Administration.
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