Watch for the curve: Assessing competencies
Watch for the curve: Assessing competencies
Good system meets JCAHO standards
You think your Joint Commission survey is cruising along without a hitch, and then it happens. You run into trouble on staff competencies. Assessing staff competency is one of private duty providers' problem areas when it comes to Joint Commission on Accreditation of Healthcare Organizations (JCAHO) surveys. (See Private Duty Homecare, July, 1997, p. 79, for more on problem areas.)
But even if you are not Joint Commission accredited, you could benefit from accurately assessing staff competency and instituting education programs when needed. (See story on assessing competencies with clinical labs, p. 50.) In this competitive climate, the better care you provide, the better chance you have of maintaining a stable client base.
"Competency evaluations always improve the staff and the care they render," says Donna Franks, RN, MS, CCM, home care consultant at HomeCare Resources Associates in Des Plaines, IL. "It even helps in the marketing of an agency and makes them more competitive in the market. In this way, the agency can demonstrate that they have a highly trained and competent staff to perform services."
JCAHO standard HR.6 requires that organizations assess, maintain, and improve the competency of all care and service staff. (For other Joint Commission standards related to competencies, see story, p. 51.)
Agencies' difficulty with this standard usually arises from an incomplete competency evaluation system or inappropriately qualified competency observers, says Mary Friedman, MS, RN, CRNI, principal of Home Health Systems Inc. in Marietta, GA.
Experts interviewed by PDH offered the following tips to combat these issues:
Identify staff whose competency must be assessed.
Providers must assess the competency of all employees, contractors, and volunteers who directly provide patient care or whose work directly impacts patient care. That includes all professional staff - RNs, LPNs, social workers and physical, occupational, and speech therapists - and any managers who may make visits or perform core competency functions such as education from the office, Friedman says. Agencies with infusion or durable medical equipment services must also assess competencies of positions such as pharmacy technicians and delivery drivers.
Home health aide competency assessment is nothing new to Medicare-certified agencies; it is a long-standing condition of participation.
Private duty providers are responsible for their contractors' competency, both independent individuals and those employed by other companies. Your organization can conduct these assessments itself, hire an outside firm to do so, or rely on the contractor. If you rely on the contractor's evaluation system, make sure it assesses the same skills you defined in your competency set, warns Friedman. And maintain separate files on all individuals providing care under contract to your organization.
Establish position competencies.
The Joint Commission does not dictate qualifications; each organization must determine its own required knowledge and skill set. Core competencies should include frequently performed procedures and know-how needed to care for an agency's general patient population, Friedman says.
Assess only staff who do specialty services
Providers also must develop separate competencies for specialty populations and equipment, such as pediatrics, ventilators, or infusion therapies. Only staff who will service specialty patients must undergo specialty competency assessment, Friedman adds.
Northwest Home Health Agency Inc. in Jasper, GA, combined job descriptions, visit requirements, elements of JCAHO patient rights standards, and specific skills such as Foley catheter insertion to establish position competencies for its largely geriatric patient population, says Kimberly Hendrix, RN, education coordinator. (See sample competency evaluation form, inserted in this issue.)
Identify assessors.
Professional staff with the same or higher licensure status may assess peers' competency. Providers' interpretation of this requirement is sometimes problematic, Freidman says. A common mistake is crossing disciplines. For example, an RN can assess a physical therapist's infection control knowledge and documentation skills but is not qualified to evaluate the practice-specific proficiency.
Some organizations also incorrectly assume that only supervisory or training staff can evaluate competencies. But appropriately qualified peers also may participate, Friedman says. The size of your operations may dictate who you engage as assessors.
For example, with only managers involved, organizations that offer shift care and have a large per diem staff may have difficulty maintaining current assessments. Sizable companies may consider offering a skills day where certain core competencies can be observed in the office, she suggests.
At Northwest Home Health, in-office supervisors conduct ongoing assessments, accompanying staff on visits two days per year. Comprehensive Health Care Services Inc. in Cincinnati accomplishes the task with combined supervisory and staff development personnel.
Determine when competency assessments must be performed.
For example, they are needed in the following instances:
- upon hire;
- after orientation;
- with new services, skills, technologies, and products;
- periodically, at organization-established intervals.
Outline the evaluation process.
The Joint Commission does not define how companies must determine an individual's competency. Common methods include personal interviews, letters of reference, licensure, certification, education, prior work experience, knowledge testing, and self-reporting. Both Northwest Home Health and Comprehensive Home Care Services use those elements. Both organizations tailor orientation to meet new hires' self-reported areas of deficiency, coupled with a skills lab for direct observation and return demonstration of key skills.
Observation waived under certain conditions
Home care companies often employ part- time or per diem staff who also work at hospitals where they exercise clinical skills in daily practice. You can waive direct observation of certain skills for such individuals provided you obtain a copy of a recently completed competency exam conducted by an appropriately qualified employee of that institution, says Friedman.
For example, an RN who also works in the intensive care unit of a local children's hosp- ital unit joins your pediatric continuous care program. You may accept that institution's recent assessment of your new employee's tracheostomy suctioning skills.
Skills not observed during in-office orientation must be field-evaluated before the staff member can perform them in practice. Comprehensive Homecare Services pairs new RNs first with one seasoned case manager for a week and then two or three others over several days, so the trainee "can see different styles and know that there's more than one approach," says Lori McCoy, RN, BSN, OCN, director of nursing.
After orientation, most companies observe competencies at least annually to coincide with staff members' performance evaluations, Freidman says. Northwest Home Health re-assesses new hires' competencies after 90 days and annually, Hendrix adds.
· Report activities to your governing body.
Inform your board and executive management about your competency assessment process at least annually. You may report on information such as the number and results of orientation and ongoing assessments and your staff's overall learning needs and education plans instituted as a result, Friedman says.
Ongoing home care competency assessment is logistically challenging, sources say. "It takes extra time and effort and requires day-to-day time and energy," she adds.
"It is difficult keeping up on a timely basis," says McCoy. "It helps to have one person responsible for the tracking system. It can't be [the senior clinical manager] because that person has too many responsibilities. It should be a staff development or HR [human resources] person." Comprehensive Health Care's staff development coordinator uses software to help track upcoming required assessments.
In spite of its hurdles, sources say competency assessment is an excellent tool private duty providers can use to substantiate quality and differentiate themselves. "It is a good system," McCoy says. "It forces people in the office to get out in the field. It is amazing what you can pick up - both good and bad."
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