Maintaining Compliance with Competency of Employees

A common deficiency that organizations encounter is related to maintaining competency for employees and being able to demonstrate compliance during survey. The HFAP Critical Access Hospital manual includes standards to help organizations achieve, maintain, and effectively evaluate compliance with competency of employees.

05.05.02 Competency

The facility develops policies and procedures identifying those patient care and/or diagnostic procedures that require staff to have evidence of specific competence. Some of these may result in external or internal mechanisms for certification. Maintenance of such competence is considered in the design of these policies and procedures.

Hospital policies must identify required certifications that appropriately align with job responsibilities, such as delineating requirements for employees required to obtain Cardiopulmonary Resuscitation (CPR), Basic Life Support (BLS), or Advanced Cardiac Life Support (ACLS). External certifications may be indicated by subspecialty such as for operating room, emergency room, psychiatric, critical care nursing, etc., or may be technique-specific such as “chemotherapy,” “mammography,” etc. Internal certifications may include processes for minimal sedation, moderate sedation (conscious sedation), deep anesthesia, Monitored Anesthesia Care (MAC), or fetal scalp electrode placement.

05.05.03 Evaluation of competence

Staff are competent in knowledge, skills, and ability to perform their responsibilities. An objective process for assessing and evaluating the competence of all employees is performed at defined intervals. Competency assessment is an ongoing process. The facility will define those competencies to be assessed annually and those competencies to be assessed at shorter, defined time intervals.

Prior to beginning the relationship with the facility, the applicant provides information about education, training, and skills relevant to the desired position. During the initial phase of affiliation with the facility, there is a period of observation and training as needed to document the competencies required. Written criteria are utilized for such evaluations. Such criteria include those noted in the facility and service Quality Assessment Performance Improvement plan. Evaluation is repeated at specified intervals; this may be upon the discretion of the facility but is at least on an annual basis.

ACHC gives facilities the latitude to define via policies and procedures the required competence for specific positions. It is important to remember that EVERY position within the organization must have competency associated. Competency does not apply only to clinical positions. The assessment time intervals should also be defined by the organization.

Successful organizations utilize a multitude of ways of defining competency and time frames for evaluation of competency. Methods of defining competency can be pulled from evidence-based practice with professional organizations, for example, utilizing the Emergency Nurses Association for guidance on imperative topics for education or certifications recommended for staff functioning within Emergency Services.

Organizations have also been successful in using their Quality Assessment Performance Improvement (QAPI) program to define high-risk areas, procedures, or practices that may require additional staff education and training with validation for competence in performance. An example of this process would be that an increase in hospital acquired infections (HAI) could generate a need for education and exhibited competence with housekeeping staff for appropriate cleaning of patient rooms, appropriate delivery of food trays with dietary staff, handwashing with all hospital staff, and other clinical measures with clinical staff coming into direct contact with the patient. These competencies could be added at a more frequent interval until a positive trend with HAI is noted in the organization. Utilizing the QAPI program is a successful way to determine which areas of competence should be of focus. This is also a great example of how implementing value-added competencies for staff results in positive impact for patient outcomes as well as the organization.

It is important to also incorporate unit-specific annual competencies into your competency program. Each department/unit must have annual competencies. This allows organizations to customize education/competency to specific areas of focus that are pertinent to service lines and specialty areas as well. An example may be competency of appropriate handling of sharps disposal. For housekeeping, the focus may be on removal of sharps containers and what to do if a sharp is found in an inappropriate area. The same topic could also be applied to nursing but based on how to handle the sharp from the point of medication administration to the point of disposal in the appropriate sharps container. This is also an example of a recognized competency need based on the QAPI program. Facilities may implement this as part of the patient and staff safety program or due to an increase of needlesticks noted within the facility.

We want ACHC-accredited organizations to determine relevant competencies needed for specific positions to maximize performance of the employees and organization.

Meeting the Challenge

This year's HFAP Quality Review, Meeting the Challenge, examines the most frequent deficiencies cited in 2020 across hospital, clinical laboratory, and ambulatory surgery center surveys. 

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