Did You Know?

Staff training and competency assessment should begin during new hire orientation and then be assessed at least annually. It is also important to ensure that training and competency requirements are job-specific.

In the perioperative setting, employee roles are diverse. When developing your program, consider designing it around the scope and needs of the Ambulatory Surgery Center and update it if the organization’s activities and/or staff roles change. The program should act as a catalyst for identifying new educational needs and quality initiatives. A thorough staff training and competency program helps foster growth and aligns with annual performance evaluations.

The Standards

The following ACHC standards apply to staff training and competency assessment:

02.01.05 Orientation Plan

The organization must have a written orientation plan that orients the new employee to the organization and the specific duties they will perform. Organizational training must include:

• Ethics and corporate compliance.
• Patient rights.
• Fire safety.
• Quality improvement.
• Patient confidentiality.
• Infection control, including bloodborne pathogens.
• Handling of hazardous waste.

02.01.06 Annual Staff Training

• The organization must develop a plan to provide continuous on-the-job training.
• The written training plan is supported with lesson plans.
• The organization conducts annual staff training.
• Annual training reviews the seven requirements of orientation. (See standard 02.01.05 above.)

02.01.08 Assessment of Staff Competency

• The ASC must have an objective process for assessing the competency of each provider of service. Competency assessment is performed at least annually and at intervals as defined by the ASC.

Follow-Up Plan

Once the training and competency assessments are complete, the organization should follow up as needed with individual staff members to develop successful skills and behaviors while encouraging a culture of safety.

Tips for Compliance

• Review your policies on initial and annual training and competency assessment to ensure they are capturing all aspects of the staff’s job descriptions and responsibilities.
• When creating the competency checklist, consider how addressing each item on the list will be accomplished by staff, specific to the task they will be performing.
• When improvement opportunities within an organization are identified through quality tracking and trending, consider the staff training that is needed and incorporate it into annual training and/or competencies.
• If a staff member is being cross-trained in more than one role, ensure they are receiving a competency for each.
• Consider that competencies can be evaluated through skills fairs, demonstrations, and fun games with staff.
• Develop a system with the checklist to track staff members’ training and competencies.
• Ensure the competency documentation is dated and signed.
• Adjust as needed to capture new learning requirements.
• Be aware that if the Registered Nurse is administering moderate sedation, there must be additional documented training and competency for this task (Standard 11.01.05).
• Document staff training on quality assurance and performance improvement (QAPI) initiatives in their personnel files.
• Review state regulations to ensure compliance.
• Remember that the training and competency of any one person working in the organization can have a negative or positive impact on the whole organization.

Here to Help

To download the most recent ACHC Accreditation Standards, log in to your customer portal account. If you have questions, please contact your Account Advisor or email us at customerservice@achc.org.