Keep track of staff license renewals, certifications

Use calendars, computerized reminders

SDS Accreditation Update

You know that you have a competent, well-trained staff, but if your documentation doesn’t reflect up-to-date training, certifications, and licenses, you don’t meet accreditation standards. In addition to credentialing standards, staff competency standards also show up in the Joint Commission on Accreditation of Healthcare Organization’s list of standards most often cited as the reason for Type 1 recommendations. Joint Commission’s Standard HR.5, which requires the organization to assess staff members’ ability to perform their job duties, was responsible for 16.1% of Type 1 recommendations during the first six months of 2002.

"Make sure you can document that staff members know how to physically perform their tasks, possess the cognitive skills needed for making decisions in their jobs, and have the interpersonal skills needed to work as a team member, communicate with patients, and interact with physicians," points out Stephen C. Anderson, RN, MBA, a consultant with the Chicago-based Joint Commission Resources. Also, when you are measuring competencies, test the staff member’s competency for all age groups with which they work, Anderson adds. Although the same-day surgery staff plans to simplify the process, Joint Commission surveyors praised the annual competency assessment’s age-related component at The Surgery Center at Nacogdoches (TX).

"We don’t assign age-related competencies throughout the entire competency test, but we have a two-page checklist that measures staff members abilities to provide care to different age groups," says Jeanie Suhor, RN, CNOR, director of the center. [See checklist at Click on "toolbox." Your user name is your subscriber number. Your password is sds (lowercase) plus your subscriber number. The checklist is under "staffing documents."] For example, for infants and toddlers, the center checks to confirm that the nurse provides a safe environment, which includes watching the child at all times, Suhor says. To measure communication skills with infants, toddlers, and young children, we make sure that the staff member smiles and uses a soft and reassuring voice," she adds.

Don’t forget that if you teach a new skill to staff members, you have to document that they performed that skill in their working environment, Anderson says. "If you have a note in a file that an employee was oriented for use of a new laser, the surveyor will ask to see the chart for the patient who was undergoing a procedure with the laser," he says. "It is not acceptable to say that the employee never saw the laser used, just had a demonstration given by a vendor."

Same-day surgery program managers with large staffs may be overwhelmed by the task of making sure employee training and certifications are current, but Christine S. Gallagher, RN, BSN, CNOR, executive director of Salinas (CA) Surgery Center has found a straightforward way to make sure employees know when they need to renew certifications. Tracking required education or certification for staff members is simply a matter of printing out a spreadsheet with all employees’ names and the dates by which they need to complete CPR or other training, Gallagher says. "We post the spreadsheet in our employee lounge, so everyone can keep up with what they need to complete," she says. "The incentive to meet all training and certification requirements is pretty strong. We don’t allow them to work if they haven’t met their requirements."

For staff members with professional licenses, a note is sent to them several weeks before the expiration, says Gallagher. The expiration dates are tracked by computer, she adds. "Often the nurse has already received the new license and has just forgotten to bring it to us," she points out.

Managers at First SurgiCenter in Kearney, NE, have further simplified the process for many certifications. "Regardless of their hire date, all of our staff renew their [basic cardiac life support] and [advanced cardiac life support] certification at the same time each year," says Cheryl Munsinger, RN, BSN, CNOR, director of clinical services at the center. License renewals, which happen throughout the year, are monitored by the office manager, who serves as human resources coordinator. "She checks with employees a few weeks prior to their license expiration date to get a copy of the current one," Munsinger explains.

Track the number of staff who do and don’t meet training and certification requirements in a timely manner, Anderson suggests. Joint Commission Standard HR 4.2 requires the organization to use staff competency data to identify ways to improve education and training, he says. Failure to meet this standard was responsible for more than 12% of Type 1 recommendations for ambulatory care facilities throughout 2001, he adds.

A manager should look at data such as how many staff members complete CPR training on time, says Anderson. If there are large numbers of staff who don’t meet the requirement, identify ways to increase the timeliness of training, and be sure to write up your plan, he suggests. Those ways might include offering CPR classes on-site, after regular work hours, or planning to use PRN staff to cover for staff members to attend classes.

In addition to reviewing your training and educational requirements, be sure to have job descriptions that truly match the employee’s job responsibilities, Anderson points out. "It’s hard to adequately assess someone’s competency if the responsibilities are not clearly defined," he says.