Preparing for Surveys with Competency Assessments

Competency assessments solve a lot of problems for your organization. Depending on what you measure and how, you can ensure your staff is knowledgeable and performs at a high level, with a focus on positive patient outcomes.

And just as importantly, it keeps you in the good graces of the various accrediting bodies out there.

Agencies obviously won’t take your word that everything is going fine. You need consistently measured evidence to show that your organization is adhering to requirements and regulations.

Make competency assessments a core survey focus

Assessing competency is a high priority for any accrediting body. For example, in its hospital Survey Process Guide, the Joint Commission makes it clear that surveyors will review how you measure your staff’s competence and will want access to your educators and HR staff to confirm their findings.

Furthermore, competence and performance are two separate metrics to the Joint Commission.

According to an FAQ, “The competency assessment looks at whether the clinical staff has the skills, knowledge, and abilities to perform the assigned job duties,” whereas, “The performance evaluation looks at how well the clinical staff performs the assigned job responsibilities.”

The Joint Commission expects competency to be documented after staff orientation is complete and at least once every two years thereafter. Of course, other organizations have other requirements. For instance, the Centers for Medicare & Medicaid Services (CMS) have guidance for staff who perform laboratory testing. The

So, documenting your competency assessments is key. Fortunately, tools like Relias can help with that. For instance, we use more than 20 pre-built, validated competency categories that you can plug into your organization for whatever roles you need. We built our tool with compliance audits in mind, making it easy to bring up your evaluations for surveyors in a few clicks.

Remember, personnel evaluations and training are not replacements for documented competency assessments.

Ensure competency assessments are role-based and skill-based

As implied by the CMS CLIA, different roles need to be measured differently, and some of that will fall to the organization level. The Joint Commission agrees: “Because of the complexities of the healthcare environment, organizations are expected to define competencies for those individuals responsible for maintaining a safe physical environment as well as the equipment available for use.”

It will be up to your organization to separate out competencies from normal education or training and then measure them. As an example, the Joint Commission says that basic medication administration may be part of someone’s education. However, programming an infusion pump for intravenous fluid delivery may be an added competency.

Generic annual checklists are on the way out, especially with the Joint Commission switching over to National Performance Goals. Instead, make sure you are focused on patient outcomes.

Competency is ultimately about patient outcomes

At the end of the day, it’s about patient safety.

“Competencies play pivotal roles in ensuring patient safety, quality and continuity of care, and operational efficiency,” according to the Accreditation Commission for Health Care (ACHC). “As a healthcare professional, you have the important responsibility of helping identify and address competence-related issues. Failure to do so can lead to poor patient outcomes and even patient harm.”

The ACHC has eight components that require annual competency assessments.

1. Infection control, including bloodborne and airborne pathogens
2. Quality assessment and performance improvement program
3. Life safety
4. Equipment and device safety
5. Hazardous waste and materials safety
6. Information management, including confidentiality, computer access, and medical records confidentiality
7. Patient rights
8. Restraint use, if applicable to role responsibilities

Are your staff up to date on those? Can you prove it?

Not only may that be required for CMS, but your patients deserve it, too.

Ready to improve your competency assessments?

When people’s lives are in your hands, it makes sense to test how good your hands are. In addition to orientation and training, regular competency assessments are key to keeping your patients safe and your organization out of trouble.

Make sure you have affirmative answers to the following questions:

• Which compliance criteria do you need to maintain?
• How often do you need to demonstrate compliance?
• Do your staff have role-specific competence categories set for them?
• Do your competencies keep patient safety and outcomes in mind?
• Do you have a straightforward way of documenting and showing competence to surveyors?