Competency assessment ranks high in survey

Providers not documenting competence properly

Meeting the Joint Commission on the Accreditation of Health Care Organizations’ standard for competency assessment of staff was a problem for 14% of ambulatory care organizations and 15% of office-based surgery organizations surveyed in 2004, according to Joint Commission statistics.

"Assessing the competence of a staff member means that the organization has set up a process to make sure the staff member demonstrates his or her ability to do the job and maintains competence over a period of time," says Michael E. Alcenius, MS, PA, associate director in the Standards Interpretation Group of the Joint Commission.

"While many organizations do have some process to assess competency, the process is not always documented properly," he points out. Hospitals were not cited as having compliance problems.

It is important to understand the difference between a performance evaluation and a competency assessment, Alcenius says.

A performance evaluation that is related to pay raises might be a general statement such as "performs clinical duties according to standards set by the organization," he explains.

A competency assessment will include details such as "is able to start IVs" or "clearly explains follow-up care to patients," Alcenius points out.

"Start a competency checklist by looking at the job description and breaking it down into specific skills needed to meet the job responsibilities," he recommends.

There are different components of a competency assessment, but one key element that a surveyor will expect to see is an evaluation of the staff member’s ability to perform his or her tasks for specific populations, Alcenius explains.

"If your same-day surgery program serves primarily geriatric or pediatric patients, the employee must demonstrate a knowledge of the different needs of your particular population," he says. "If you serve a wide range of ages, your employees must be able to demonstrate how to care for pediatric patients, adults, and geriatric patients."

For example, a nurse in a pediatric facility should be able to assess pediatric pain when the patient can’t communicate it, Alcenius says. "If your facility serves a wide range of ages, your employees should be able to explain how a geriatric patient may be positioned differently from a healthy 40-year-old patient in order to ensure comfort."

New hires almost always have some sort of documentation of a competency assessment unless the same-day surgery program is so small that orientation and training is done on an informal basis, he adds.

If this is the case with your program, Alcenius recommends that mentors or staff members providing one-on-one orientation use a checklist based upon the job description to indicate demonstrated competencies.

"You also need to make sure that competence is assessed periodically and not just when the person is first hired," he notes.

A surveyor will check to see that not only are you assessing competency for specific populations based on age, gender, language, or type of care, but also that your competency checklist relates to the person’s job description, Alcenius continues.

The surveyor also will want to see who is responsible for the assessment and what method is used to perform the assessment, such as written test or demonstration, or a combination of different methods, he says.

"You also need to show that you have a process in place to handle situations in which staff members cannot pass the assessment," Alcenius explains. "Your policy must state what corrective action, education, and retesting will occur."

Every outpatient surgery program must show that competency assessments also are performed for contract employees as well, he says.

"Agencies that provide contract employees usually perform the assessments and make the information available to the same-day surgery program," Alcenius says.

"If you regularly use the same employees, you can also perform your own assessment and keep the documentation in your own files," he points out.

At Central Utah Surgical Center in Provo, one of the biggest surprises in their most recent survey was the surveyor’s request to see competency assessments for the nonclinical staff, says Jill Andrews, RN, BSN, CNOR, administrator.

"We’ve always had competency assessments for our clinical staff, but I didn’t realize that our receptionists and billing office personnel needed them as well," she says.

"We’ve assigned team leaders to take the nonclinical job descriptions and develop competency checklists that include items such as answering telephones quickly, posting payments properly, and knowing who to contact for information that they may not have," Andrews notes.

Although there is no specific timeframe set for periodic reviews of competencies, many organizations tie the competency assessment to the annual performance review, according to Alcenius.

"Even if you don’t conduct the assessment annually, you must conduct it before the next accreditation survey or upon any changes in the employee’s job that might require additional or new skills," he says.


For more information about competency assessment, contact:

  • Michael E. Alcenius, MS, PA, Associate Director, Standards Interpretation Group, Joint Commission on the Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5900.
  • Jill Andrews, RN,BSN, CNOR, Administrator, Central Utah Surgical Center, 1067 N. 500 West, Provo, UT 84604. Phone: (801) 374-0354.

For more information about competency assessment requirements:

  • Joint Commission on the Accreditation of Healthcare Organizations. Go to, choose "accredited organizations" from top navigational bar, then click on the type of organization (for example, ambulatory or hospital) standards under which you are accredited. Select "FAQs" on left navigational bar. To submit a specific question not answered by the FAQs, choose "Standards Online Question Submission Form" on the right navigational bar or call (630) 792-5900.
  • Accreditation Association for Ambulatory Health Care. Go to and choose "AAAHC Accreditation Program" on top navigational bar to get general information. For specific questions, contact AAAHC at 3201 Old Glenview Road, Suite 300, Wilmette, IL 60091. Phone: (847) 853-6060. E-mail: