Competence: The shot heard round the world’

It’s the one topic that the Joint Commission on Accreditation of Healthcare Organization receives hundreds of phone calls, letters, and e-mails about.

It’s competence — also known as "The shot heard round the world," says Ann Kobs, MS, RN, former director of the department of standards and current sentinel event specialist for the Joint Commission. Competence is covered in the Management of Human Resources section of the standards manual.

What is the biggest misconception? Seventy-five-page checklists are necessary, Kobs says.

"No. 1, long before we said the word competence, didn’t you have a job description?" she asks. "We never asked for checklists. However, if you want to continue checking them, go for it. My question is, why would you bother to check someone who has performed very well on the job all year long, or all two years?"

Perform performance appraisals at intervals, she suggests. "I mean, why would you then put them through a skills lab of putting down an NG tube and taking a blood pressure? If they can’t do that, why are they working?"

You have several options, and one of the options is observation in daily work," Kobs says. "In the absence of error, competence can be assumed. That cuts out all that paperwork."

While not going as far as to say checklists aren’t necessary, Beth Derby, RN, MBA, a surveyor for the Accreditation Association for Ambulatory Health Care (AAAHC) in Skokie, IL, and executive vice president for Health Resources International (HRI) in West Hartford, CT, says the job description can be the same document as the performance review checklist. HRI is involved in the ownership, development, and management of surgery centers in the United States. The company is developing ambulatory projects in many overseas markets.

The job description should be concise, fairly complete, and include age-specific competence requirements where indicated, Derby says. The performance review tool should indicate that the employee was observed and monitored demonstrating competence. Be sure the performance evaluation tool includes specifics, she advises.

If a nurse, for example, is expected to be familiar with many pieces of equipment, the evaluation form might say, "good knowledge of all appropriate equipment."

"If the nurse is required to discharge patients from the postanesthesia care unit, and the patient population includes infants, is that nurse successfully completing her duties, or does she need to have a colleague evaluate all of her pediatric patients? Her supervisor should be aware of the staff nurse’s capabilities and demonstrated competency in caring for the patient population in the facility," Derby says.

This is how evaluation, monitoring, and supervising measures age-specific competency, she says.

Watch out for these areas that can trip you up during surveys, say representatives of the accrediting groups:

Age-specific competence. Between January and June 1998, 23.4% of facilities surveyed received a score of 3, 4, or 5 for HR.5: Staff ability to meet performance expectations.

"People have generated more paper over that than anything I’ve ever seen," Kobs says. "If you have a statement in the job description that says, This employee performs well providing age-specific care to the elderly. Yes or No?’ That’s enough."

Derby says that a lengthy age-specific criteria check sheet is unnecessary. She emphasizes, however, that in a program in which segments of the population have special needs — for example, the elderly or very young — the staff should have documented experience and be able to demonstrate the ability to take care of those patients.

Orientation of new employees. AAAHC suggests that orientation forms usually should be maintained in employee files; however, they can be held by the supervisor to use as a reference when evaluating performance or developing new education programs, Derby says. One of the important factors to consider in orienting staff is to ensure consistency in general knowledge of the facility and its policies and procedures, she says.

The Joint Commission requires orientation documentation for personnel hired after Jan. 1, 1993. The surveyors don’t care where you keep the files, Kobs says. "It’s a matter of whether you can come up with the information when the surveyor says, How [do] you measure competence?’ and We’d like the file of a new staff nurse hired within the past three months.’ Can you go find one?"

Data reported to governing body. Between January and June 1998, 5.3% of facilities being surveyed by the Joint Commission received a score of 3, 4, or 5 for HR 4.3: Aggregate data reported to the governing body.

"HR 4.3 talks about you have to report to the governing body on the human resources that you have," Kobs says. "It appears that even the surveyors don’t read the end of the sentence because it says, for purposes of identifying educational needs.’" That’s the key piece, she maintains. In what areas do you need to plan education? Look at your performance appraisal or your competence model to answer that question.

AAAHC, in its standard on governance, includes characteristics that require the governing board to establish and delegate responsibility for the policies on continuing education of the staff.

Additionally, there is a standard on professional improvement that "strives to improve the professional competence and skill, as well as the quality of performance of the health care practitioner and other professional personnel it employs."

Agency personnel. You must have the same expectations for agency personnel as you have for your own staff, surveyors say.

"And they must be proved competent before they work," Kobs says. "They have to have an orientation and any other requirements you may see fit to put in."