PROVING GROUNDS Observe staff competencies real-time in actual clinical settings.

Competencies are the professional attributes that make members of your staff good at what they do — the deft touch that guarantees first-stick success when starting IVs, for example, or knowing precisely how to position patients. But my sense is that most administrators can do a better job of testing staff competencies. Here are 5 tips to follow.

Test and retest competencies. Competencies blend knowledge, attitudes and judgment. They're groups of skills and behaviors that are identified as performance standards for a particular job. The skills and understanding needed to become competent at a job develop over time. A knowledge base is needed, but so is experience in the clinical care environment, because there are limits to what one can learn in the classroom. As a general rule, it takes 2 to 3 years of experience in the same job to function at a competent level. That's why you need to constantly assess the growth of each staff member by testing and retesting competencies in all aspects of her assigned roles, including, among other job-specific focuses, immediate-use sterilization, environmental cleaning, malignant hyperthermia response, universal precautions, patient positioning, IV starts and instrument sterilization.

Establish how you'll evaluate each competency. Base the competencies you assess on individual job descriptions and include lists of mandatory requirements in your facility's policies and procedures. Note which competencies are core requirements and which are job-specific responsibilities. Also establish how often each competency is assessed and which staffing positions are assessed. After establishing how each competency will be evaluated, revisit the standards annually to ensure the processes you're using remain valid and current.

Include competency training during initial orientation and annually thereafter. During orientation, include testing of core competencies related to OSHA regulations, blood-borne pathogens, universal precautions, your facility's exposure control plan, staff and patient ergonomics, and fire safety. Also include training about regulatory compliance pertaining to HIPAA laws, workplace safety and risk management, and computer and keyboarding skills for members of the business office.

Dedicate a day for testing. There are 2 types of competencies: knowledge measured by objective tests or questions — through online learning modules, for example — and skills and behaviors demonstrated and observed. Schedule mandatory competency training or testing on a single day, perhaps on a Saturday when your facility is closed. Alert staff, including per diems, well in advance and make attendance mandatory. All participating staff members must be paid for the day.

First, conduct mandatory in-services on core competencies for the entire staff. Next, break into groups to complete testing on tasks related to specific job descriptions. Experts from within your facility can assist with the training. For example, a CRNA who's particularly adept at starting IVs could teach that skill to the nursing staff. Keep it simple when documenting competencies by using checklists to quickly note if a staff member demonstrates competence or non-competence in a particular task.

There is a drawback to scheduling competency training and testing on a single day, however. It assesses competencies at a single point in time and doesn't provide a full picture of a staff member's performance. In addition, staff members can be coached on the spot, so it might not represent an accurate reflection of their skills. So instead of trying to complete competency testing on a single day, consider setting aside some time to review necessary skills during workdays. Have an experienced staff member who's demonstrated excellence in a task — that CRNA with the knack for starting difficult IVs, for example — observe staff members and sign off that they're doing it correctly. That way, competencies are observed in real-time in actual clinical settings. It's a more accurate assessment of skill levels and it also streamlines the testing process without having to dedicate time to the task during everyone's day off.

Demand accountability. Give staff ownership of the competency assessment process and put the onus on them to fulfill the testing requirements. Establish hard deadlines for completing assessments, and rely on the staff members to complete knowledge-based testing or to set up times to get observed performing specific clinical tasks by the required dates. You also need to determine consequences for noncompliance, including a poor reflection in annual evaluations and perhaps freezes on pay increases. Be religious about demanding that staff complete annual competencies and keep completed test results on file. When accreditation surveyors tour your facility and ask for the paperwork, it needs to be at your fingertips.

Critique and teach. Don't treat competency testing as a rubber-stamp process. If a staff member is deficient in the skills needed to start IVs efficiently and safely, arrange for her to receive extra training from a skilled colleague until she gets up to speed and feels comfortable with the task.

Rising stakes
Testing staff competencies has always been important, but the stakes are rising. A variety of accrediting organizations are calling for increased accountability for the level of care provided in surgical facilities. In addition, CMS is shifting its payment model from fee-for-service reimbursement to paying for quality outcomes. That means the competency of any one person working in your facility can have a significant impact on your organization's reputation and finances. OSM