Program makes assessing competence easier
The administration of Hepburn Medical Center in Ogdensburg, NY, knew that all was not well with its competence assessment. What was done was fragmented and varied from department to department. And some of it may not have been assessment, but was actually education and training. "Nurses might go to a regular education program that was designed and planned by nurses whose goal was to improve quality of care," says Sharon LaDuke, RN, BS, competency coordinator at the hospital. "But while they improved knowledge bases among the staff, they didn’t always assess anything, and the Joint Commission [on Accreditation of Healthcare Organizations] requires that."
LaDuke was charged with the task of bringing the various assessment programs together. The program she created not only adds uniformity to what was a disparate pack of programs, but has also reduced the paperwork and made a single document, the job description, the basis of guiding and documenting all phases of competence assessment required by the Joint Commission. Assess-ments are also reduced to a single piece of paper.
LaDuke says she started by reading all the literature she could about competence assessments. "After the reading, I was convinced we needed a systemwide plan with everyone more or less following the same system. That would allow us to gather and aggregate data."
LaDuke says she hoped to ensure that competencies which were important in multiple departments would follow the same assessment criteria, and also ensure that if one competency area was an issue in multiple departments, managers could identify it easily and create an action plan. One department might call a skill "nutritional monitoring" while another calls it "nutritional management." They might mean the same thing, but are actually very different things. "Without having some uniform skill definitions and performance criteria, we might not be able to address issues that arise from poor nutritional support."
She created a program that hinged on competency-based job descriptions. Every single job, from the CEO to housekeeping, would have a new description. She then set out to sell the idea to managers. "One selling point was that, after some initial effort, there would be less paperwork at the end."
The initial work of revamping job descriptions wasn’t easy. In every case possible, the description was based on standards and guidelines that came from professional organizations and societies. For instance, nursing descriptions were based on information in The Nursing Interventions Classification (NIC)1, developed by the Iowa Intervention Project Research Team at the University of Iowa College of Nursing in Iowa City.
"The only positions I couldn’t find anything for were housekeeping, maintenance, and food service workers," LaDuke recalls. "Even health unit coordinators have an association that has practice guidelines. Referring to them informs you about the basic skills expected of any ward clerk in the country." While managers were encouraged to rewrite the descriptions themselves, LaDuke offered as much assistance as possible, from providing source material to reviewing the job descriptions. She even volunteered to write many of them.
"I proposed a radical change. Some of the things, like performance evaluations at 30, 60, and 90 days with staff rated on a 4-point scale, had been done for years," she says. But because there would be a reduction in work at the end, and since there was top-down support from administration, LaDuke ran into few barriers to her ideas.
The 4-point scale was redefined. Now the levels of performance are:
1. not competent;
3. strong personal performance;
"Although if I had it to do over, I’d only use competent and not competent," she admits. "But the higher levels give staff something to reach for, and the new definitions help managers see that not everyone should get a 4 for everything, or a 2."
LaDuke says she is working on a way to ascertain with data what is working and what isn’t. "I’m not really sure how to measure that. I’d love ideas on that." She will do some user satisfaction surveys to see if people like it, although all the evidence she has so far indicates people do.
Meanwhile, after only nine months of operation, LaDuke has noted plenty of benefits:
• Competence assessments and performance evaluations are reduced to one process and one piece of paper.
• Managers and human resources staff don’t have dozens of checklists for hundreds of employees, which all have to be completed, sorted, tallied, tracked, analyzed, and stored.
• Some staff report they now receive the most objective evaluations/assessments they have ever had.
• Managers report that the increased objectivity that comes from having defined skills and performance criteria makes it easier to write and present evaluations.
• Nurses applying for jobs in specialty areas, after reading job descriptions, have recognized that they may not be ready for such complex practice and have withdrawn applications, preventing self-defeating experiences and waste of hospital resources in an unsuccessful orientation.
• Managers are better able to identify the candidate who is best prepared to assume a position, and who will require the least intensive orientation.
• Nursing preceptors are guided, not by an outdated laundry list of tasks, but by a set of complex patient management skills that have been defined by nursing research. Managers may also gain a more realistic view of the new employee’s readiness to practice independently as orientation draws to a close.
• The competence assessment framework for nursing has been aligned with the documentation framework through the use of the NIC in both processes.
• Competence assessment involves the same set of skills across all phases of assessment, providing consistency and reinforcement.
• Using NIC to define competencies has assisted RNs, managers, and administrators to make the transition from thinking of nursing skills in terms of discrete, psychomotor tasks, to thinking of them in terms of ongoing, complex patient management skills that may very well be invisible to the observer. It has helped validate what nurses actually do, with a heavy emphasis on critical thinking.
Her advice to others is to use an organizationwide assessment model, make sure there is support from above, and don’t forget to sell it from the ground up. She also says that throwing money at seminars on competence assessment doesn’t work very well. "Spend that money to have someone internal dedicated to the task," she says. "And putting it solely on the staff development person’s plate may not work, and probably won’t meet Joint Commission requirements. They clearly state that leadership has to be involved in competence assessment."
[For more information, contact:
• Sharon LaDuke, RN, Competence Coordinator, Hepburn Medical Center, 214 King St., Ogdensburg, NY, 13669. Telephone: (315) 393-3600, ext. 5239. E-mail: firstname.lastname@example.org.
To get more information about this and other innovations in health care, go to www.best4health.org, the site of The Best Practice Network, an organization devoted to promoting information sharing and experience exchange among nurses, physicians, and other health care professionals. For more information on The Best Practice Network, e-mail email@example.com, or call (800) 899-2226.]
1. McCloskey J, Bulechek G, eds. Nursing Interventions Classification (NIC). 2nd ed. Iowa City: Mosby and Core Interventions by Specialty, Iowa Intervention Project Research Team; 1996.