The assurance of patient safety and the provision of high quality of care in the ASC are driving forces behind standards for staff training and competency.
The assurance of patient safety and the provision of high quality of care in Office-Based Surgery are driving forces behind standards for staff training and competency.
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 office-based surgery and update it if your 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:
02.01.07 Staff Training
The organization has a written plan for providing training when necessary and at least annually. Training may address results of competency assessments, quality reviews, peer review, personal requests, new procedures, or techniques, etc.
Organizational training must include:
Ethics and corporate compliance, if applicable.
Patient rights.
Fire safety.
Quality improvement, including adverse events.
Assessment of patient’s risk for self-harm.
Patient confidentiality.
Infection prevention and control, including bloodborne pathogens.
Standard 02.01.08 Staff Training: Identification of Patients at Risk for Harm
Organization staff must be trained to identify environmental safety risks at the time of new employee orientation and annually thereafter.
Organizations must provide the appropriate level of education and training to staff regarding:
The identification of patients at risk of harm to self or others.
The identification of environmental, processes, people, materials, or equipment that pose patient safety risk.
Mitigation strategies. Staff training is provided for:
Direct employees.
Contractors.
Per diem staff.
Other individuals providing clinical care under arrangement.
Organizations have the flexibility to tailor the training to the particular services that staff provide and the patient populations they serve.
Standard 02.01.08 Staff Training: Identification of Patients at Risk for Harm
Organization staff must be trained to identify environmental safety risks at the time of new employee orientation and annually thereafter.
Standard 02.01.10 Assessment of Staff Competency
The office-based surgery provider must have an objective process for assessing the competency of each staff member.
Competency assessment is performed at least annually and at intervals as defined by the organization.
Follow-Up Plan
Once the training and competencies are complete, 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’s 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.
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