A brief history
Ambulatory surgery administrators must develop realistic and effective competency programs and ensure that staff competency is documented. Competency is defined by a variety of sources. The Cambridge International Dictionary of English defines competency as "the ability to do something well." The online Merriam Webster Dictionary defines competency as, "The quality of being adequately or well qualified physically and intellectually." Competency in the nursing context is defined as the professional attributes of an individual in a particular practice setting that blend knowledge, skills, attitudes and judgment.[1]

The American Nurses Association's Code for Nurses (1985) states, "The profession of nursing is obligated to provide adequate and competent nursing care. Therefore, it is the personal responsibility of each nurse to maintain competency in practice."[1] Additionally, the ANA states, "Nurse Practice Acts hold nurses accountable for their practice based on their education and experience."

Therefore, nurses in all practice settings are personally responsible for their competence and for its documentation within their practice environment. While the individual nurse is responsible for maintaining continuing competence, it is the responsibility of the profession, regulatory bodies and workplaces to provide the framework and an environment that is conducive to allowing the individual nurse to succeed.

The Pew Commission, created by the Pew Charitable Trusts and active from 1989 to 1999, developed recommendations for change in the education of healthcare professionals and made suggestions for new educational policies that hold true today. In 1995, the Pew Commission proposed the following nurse education recommendation: "States should require each board (of nursing) to develop, implement and evaluate continuing competency requirements to assure the continuing competence of regulated health care professionals."[1] Furthermore, the commission said that the purposes of ensuring continuing competence are the protection of the public and advancement of the profession through the professional development of nurses.

The foundation for development of nursing competency programs was laid in our history, particularly the 1980s and 1990s, and it continues to evolve as changes in our regulatory requirements and environments change. For instance, we now include and emphasize infection control, corporate compliance, patient safety and disaster planning more than ever before. A competency program is a living document and should be evaluated annually to ensure that it remains current. The public has a right to expect competence from all healthcare providers, including the nurses who care for them. Nurses must be involved in development of the tools and documentation of that competence.

Components of a competency program
Basic nursing competency is initially documented at licensure and is considered ongoing, unless behavior demonstrates otherwise. After licensure, a variety of continuing education opportunities contribute to nursing competency. More advanced nursing competency can be documented by advanced degrees or certifications, such as the Certification for Professional Achievement in Perioperative Nursing Practice (CNOR). Indirectly, nursing competency is demonstrated via facility accreditation, since all accrediting bodies have requirements for documentation of the staff's clinical competency.[1]

A successful competency program begins during new hire orientation, is assessed at least annually and is job-specific. It will be incorporated into an organization's cross-training program and will also be included as part of an employee's annual performance appraisal. There is no better motivation to complete competency documentation than to make it a required element of the performance appraisal process.

The competency program should be driven by the organization's mission statement. To help ensure its success, the program must be realistic, designed around the needs of the environment and certainly must be cost effective. The program cannot be one that is created and forgotten, but must instead be an integral part of the facility's daily activity. When integrated with the total ongoing education program of the facility, the competency program acts as a catalyst for the identification of new educational needs and also assists the administrator in developing and updating the competency program itself.

Primary reasons for developing competency programs in a clinical practice setting are the concerns for patient safety and the provision of a high quality of care. The development of a competency program requires the identification of standards that relate to the work to be done. Professional organizations like the Association of periOperative Nurses (AORN)[2] and the American Society of periAnesthesia Nurses (ASPAN)3 develop standards based on current research in their field and often coordinate their work with other associated industry organizations.

Facility administrators then develop orientation, educational programs and policies around those standards in an attempt to assure the highest possible quality of care. An active competency program assists the facility in meeting accreditation requirements, but from a more practical viewpoint, it ensures that a level of continuity in staff performance expectations is developed. An effective program is fully integrated with annual employee performance appraisals so staff understand the expectations established for their professional performance.

The competency program should include a core competency or a job-specific competency. Core competencies are shared by all nurses in this practice setting and may be required by regulatory and accrediting bodies, or by the organization itself. Job-specific competencies are required elements of a specific job or position within the facility.

Another area for competency consideration is your facility's risk management program. Issues to regulate may be identified as an educational need of the staff as a whole, or of a specific group. A risk management competency can center on a general concern that should be addressed, or it may be related to a new regulation, standard or guideline published for the industry. Development of a risk management competency measurement may also be driven by an adverse event or a near-miss incident at your center.

The orientation portion of the competency program should include the following.

I. Core Competencies
These competencies are universal to clinical and non-clinical staff in a surgery center or HOPD.

• Human resources. Upon hire, each employee is required to document that they have read the facility's employee handbook, which describes the expectations of their actions and performance as an employee of the organization. This usually includes issues related to staffing and scheduling, employee benefits, paid time off, insurance, payroll and a discussion of the disciplinary process. Job descriptions outline the expectations for each position within the center. Retraining or education is required if a significant change to the policies occurs.
• Mandatory in-service. Measured upon hire and annually thereafter. This category includes specific training required by regulatory or accrediting bodies. Examples are training for OSHA handling of hazardous chemicals; blood borne pathogens; universal precautions and the exposure control plan for Hepatitis B and C and tuberculosis; electrical safety; fire safety and ergonomics.
• Regulatory compliance. Measured upon hire and annually thereafter. Covers corporate compliance, including a hotline or a "safe" method for reporting suspected abuse, HIPAA training on privacy and security policies and required patient forms.
• Workplace safety and risk management. Measured upon hire and annually thereafter. These topics are related to safety and risk management, including diversity and cultural competency, sexual harassment in the workplace, violence in the workplace and disaster plans - both internal (facility) and external (community) - including plans for bioterrorism4 and pandemic.

"Culture is defined as the integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values and institutions of a racial, ethnic, religious or social group."[5] Cultural competency is defined as the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of services and thereby produce better outcomes.[6] Diversity is valuing, accepting and respecting differences both between and within cultures.

While these elements are newer components of a competency program, it is important that healthcare providers recognize differences in how the cultures they serve, and the people they work with, perceive healthcare and that adaptations are developed in the way service is provided so that it reflects an understanding of those differences. Understanding of cultural differences should affect every level of service delivery and should be reflected in attitudes, policies and services. As increases in cultural diversity are seen in the population of patients cared for in the ambulatory setting, research has demonstrated that "providing culturally competent care" increases patient satisfaction and promotes evidence based practice.[7]

Sexual harassment has been known to be so pervasive in the surgery environment that it has become accepted as normal behavior. An unspoken expectation exists that staff participate in, or at least tolerate, the behavior in order to be accepted. Sexual harassment is not acceptable and should not be tolerated. It is important that administrators have policies in place and include this topic in orientation and annual in-service programs.

It is important to enforce the expectation that sexual harassment is not to be tolerated by any employee, credentialed professional or contracted employee. This topic has recently become a risk management issue. Training videos and educational programs are available through professional organizations.

Violence in the workplace is another new addition to competency programs, but also a risk management topic of importance. Employees must understand policies for the restriction of guns and other weapons from the workplace. Employees should also know how to approach and calm a violent patient, employee or visitor. If possible, provide professional training. In many communities, the local police department will provide this training upon request.

In the past, it was accepted that surgery centers did not participate in external or community disasters. This is no longer true. Accrediting organizations prefer to see a policy that addresses appropriate ways a facility can assist the community and acute care providers in the event of an emergency.

There are a multitude of educational programs available on these topics from a variety of sources.

Informatics. Assessed upon interview, hire or change of job responsibility. Computer and keyboarding skills have become commonplace; however, there are still a few potential employees who do not possess this competency. Depending upon the organization's and the employee's job responsibilities, varying degrees of competency are required.

Business office personnel require a higher degree of competency. Nurses need to acquire keyboarding skills, if they do not already possess them, as electronic medical and health records are adopted by a growing number of centers. Each position's job description should detail the required level of informatics skills, including keyboarding, information systems, electronic medical records and proficiency in Word, Excel, Adobe Acrobat, PowerPoint, calendar and e-mail programs. Tests are available to assess that employees meet the level of competency required.

II. Position- or Job-specific Competencies
These competencies are specific to the position an employee has been hired to perform.

• Policy. All employees, clinical or non-clinical, must read policies relating to specific job performances. Some administrative policies are core to all jobs, while other positions have policies and procedures unique to their responsibilities. Employees must document that they have read these policies to serve as an attestation of competency in policy.

New policies should be included in the ongoing education program of the facility, with documentation of each employee affected by the policy. A required reading binder and sign-off sheet is useful for this purpose, allowing part-time or PRN employees who may not otherwise be able to attend a staff meeting to read and sign off on each policy.

Listing all employees and highlighting the names of those who need to read and sign off on the policies makes it easy to identify those who have met, and those who have not met, the requirements. Collect the required reading items regularly to assure compliance and place them in the facility's in-service file. Also update the competency on policy list for each job description annually and include the list in the center's yearly competency documentation.

• Equipment. All employees, clinical and non-clinical, must receive training on all equipment they will be responsible for using in the performance of their job. A list of required equipment for each job description should be developed and regularly maintained. An employee should sign off on each piece of listed equipment, serving as an attestation that they are competent to use the equipment.

Whenever new equipment is brought into the workplace, a mandatory in-service should be provided and documented for each employee who will use the piece, even if the equipment is in the facility for a trial. An annual update of equipment competency for each job description is recommended.

• Medication administration. All nursing staff that administers medications, including IV starts, should be tested on medication administration policies and the medications appropriate to their specific job responsibilities. It is possible that medications kept in the facility or on the formulary may change throughout the year. It is important to maintain good communication with staff whenever a change is made to different medications or different brands of the same medications, including generics.

Documentation of this communication in a staff meeting or in a communications notebook is recommended. Include stock and narcotic storage information, medication administration orders and IV medications. A test, developed by the nursing staff on the above topics and updated annually, is a good way to document this competency. It is always a good idea to review the "5 Steps of Medication Administration," even if just to reinforce that employees know and follow the center's medication administration policies.

Age-specific competency. An educational program with testing should be documented on hire with an abbreviated annual review of the age categories served by the facility. All age groups should be addressed: infancy, toddler, preschool, adolescent, young adult, middle adult and older adult. Both chronological and functional age should be considered when caring for patients. Consideration should be given to how staff communicate, providing a safe environment and whether appropriate equipment is available.[8]

• Unit- or position-specific clinical competencies. In this category, high-risk/low volume, low-risk/high volume and problem-prone areas are addressed.

High-risk/low-volume competencies may include code blue, malignant hyperthermia, anaphylactic shock, laparoscopic procedures that open to laparotomy, patient transfer and positive biological.

High-volume/low-risk competencies include glucose testing, urine pregnancy testing, hemocue, IV starts and any other tasks you feel appropriate to your specific practice setting.

Problem-prone areas include quality or risk issues based on organization-specific experiences, including errors or near-misses in infection control, patient transfers, medication errors and wrong-site surgery. These topics may be a temporary part of the organization's competency program until the quality committee determines that behaviors have been changed, that policies and procedures are being followed and that quality or risk issues have been corrected.

• Position-specific competencies. In this category, the specifics of the position description at the task level should be addressed. This competency should only be needed at orientation, and the employee must document this competency when signing off on the center's orientation program. Annual performance appraisals serve to document ongoing competency. The following outline is an example of departments or units and the associated positions in a surgery center.

Administration/management
Business office

• Registration
• Billing & A/R
• Accounts Payable
• Facility Maintenance
• Surgery Nurses
• Scrub Technologists
• Instrument Technicians
• Housekeeping
• Clinical & Support Staff
• Maintenance
• Pre-op, PACU, Phase II Nurses

Clinical clerical positions

• Scheduling
• Materials Management

The administrator is responsible for providing an environment conducive to employees demonstrating competency in their specific practice settings. The administrator is also responsible for cultivating and maintaining the competency program for the organization by performing research to identify the appropriate standards of care, identifying staff to participate in the development of the program and assisting staff to identify appropriate unit- or position-specific competencies to be included in the program. Administrators should provide leadership to the task force that will develop and maintain the program.

The best way to create a successful, living competency program is to involve the facility's staff in the development and ongoing maintenance of the program. Make the documentation package available to the staff in clinical areas and recruit staff to lead various parts of the program. Perhaps one nurse is willing to organize and oversee the employees' documentation files. Other nurses may be interested in taking responsibility for various parts of the program, specific areas for testing or other forms of documenting competency.

Once the program is designed and the tests are written, the employees must be educated about the workings and expectations of the program. It then becomes the responsibility of the nurse or non-clinical employee to meet the requirements of the organization and to document the required competencies annually after the initial orientation period. The administrator must provide an atmosphere that allows employees to meet the requirements by providing opportunities for education and testing to the staff, including time and resources to do so.

Writing competency documentation involves determining the method of testing to be used for each of the competencies identified. Examples include an educational program with a written test, a verbal description or demonstration of the competency, observed performance of a task in the course of work or attestation of competency.

It is important to determine the frequency of testing for each competency based on the degree of risk associated with that competency. Finally, it is also important to coordinate competencies between departments so that work is not duplicated and competencies that affect multiple nursing units can be written in a shared way that meets the needs of all involved.

After implementation, the program will be most successful if it is integrated with the annual performance appraisal. Requiring employees to present required paperwork at the time of the performance appraisal provides a powerful incentive to ensure staff takes responsibility for documenting their competency. The practice also provides a checks and balance system to assure that time and education sessions are provided by management in order to meet this expectation. Below is a document that can be used to organize an employee's performance appraisal and annual competency documentation.

Carol S. Kleinman, PhD, RN, CNAA, defined management and administration competencies by surveying both groups to determine how each group perceived the other's responsibilities and competencies.[9] The competencies listed below are based on a possible score of 100 and were identified and rated by each group; the ratings represent the degree of importance each group assigned to the competencies for each management level (Nurse Manager=NM; Nurse Executive=NE).

The nurse manager had titles such as clinical manager, clinical director, clinical coordinator, nurse manager or team leader. The nurse executive role holds titles such as administrator, executive director, chief nursing officer or surgery department manager/director.

Nurse Manager Competencies represents how the nurse managers and nurse executives rated their perception of the competencies of the nurse manager position. Nurse Executive Competencies represents how the nurse executives and nurse managers rated their perception of the competencies of the nurse executive.

Resources on nurse administrator and manager competencies are difficult to find in literature. The Foundation for Ambulatory Surgery in America certified administrator surgery center (CASC) exam tests for administrator competencies identified by the industry during development of the credential in 2002. Those competencies also define the content of the CASC exam.[10]

An additional source is The Nursing Leadership Institute Competency Model, where interviews with 120 nurse managers identified Nursing Leadership Competencies as personal mastery, financial management, human resource management, interpersonal effectiveness, caring and systems thinking.[11]

Satisfying results
Development of a competency program is both challenging and rewarding. There is a wonderful feeling of accomplishment and collaboration between the management team and staff when the process is completed. Keeping staff involved in maintaining the program throughout the years will make the process easier for both management and staff, will give staff a sense of ownership in the process and will accomplish the original purpose of the program, which is to ensure that facilities provide competent, high quality patient care.