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FastFactsFeature Presentation

November 11, 2013

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Today’s TopicWe’ll be taking a look at…

Performance Management Policy Revisions:

Competency Assessments

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Today’s PresenterSharon KempSr. Director of JHHS Compensation

Dana MooreDirector of Regulatory Affairs

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Session SegmentsPresentation

Sharon and Dana will address revisions to the Performance Management Policy and the creation of an official Competency Assessment Tool template.During Sharon and Dana’s presentation, your phone will be muted.

Q&AAfter the presentation, we’ll hold a Q&A session. We’ll open up the phone lines, and you’ll be able to ask questions. Sharon and Dana will answer as many of your questions as time allows.

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November 11, 2013

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Performance Management Policy Revisions

Competency Assessments

Presented by: Sharon Kemp and Dana Moore

Competency Assessment RequirementThe Joint Commission (TJC) standards dictate that staff competence is assessed and documented annually in accordance with JHHSC/JHH Performance Management policy.

Standard # and Text:

HR.01.06.01 Staff are competent to perform their responsibilities

 

Element of Performance (EP) # and Text:

5. Competence is initially documented as part of orientation.

6. Staff competence is assessed and documented once every three years, or more frequently as required by hospital policy or in accordance with law and regulation.

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Competency Assessment Revision

• The Johns Hopkins Hospital (JHH) Performance Management policy (HR004) was reviewed, revised and approved by Human Resources to more clearly define the requirement for annual assessment of competencies at the time of the annual performance evaluation. https://hpo.johnshopkins.edu/hopkins/policies/64/220https://hpo.johnshopkins.edu/hopkins/policies/64/2206/policy_2206.pdf?_=0.281708408807 6/policy_2206.pdf?_=0.281708408807

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Definition

• Competency is the application of knowledge and skill in performance. Competency is best assessed via return demonstration and observation. Additional methods include, but are not limited to, simulation, mock reviews,  and case studies.  

• Competency is NOT assessed via an education module with a post-test. An education module with a post-test measures knowledge, not competence (or proficiency). One may be very knowledgeable about a skill, but incompetent to actually safely perform that skill.

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• Upon employment, managers need to meet with all new hires, transfers and those promoted, to review their job descriptions and to inform them of the required education and competencies that must be met during the Initial Assessment period.

• A list of required education can be found at the following link: http://intranet.insidehopkinsmedicine.org/joint_commission/required_education/index.html

Initial Assessment

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Initial Assessment (Continued)

• The initial assessment period includes a review of the job performance (using the applicable job description) at 90 days. Some nursing orientation periods are > 90 days; if this is the case the review of the job performance is done at the end of orientation.

• Competency assessment is part of the initial assessment but may be completed prior to the review of the job performance (e.g., for orientations less than 90 days).

• Competency assessment must be completed prior to employee practicing independently.

TJC Standard: HR.01.04.01 Orientation

  EP # and Text:

  2. Key orientation elements are assessed prior to providing care

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Initial Assessment (Continued)

During the initial assessment, the preferred and most effective way to determine competency is through direct observation of the skill being performed. When an opportunity to observe the skill is not available, mock scenario, or return demonstration may be used. In some situations, a review of clinical documentation in the medical record related to the behavior or skill, if appropriate.

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Initial Assessment Methods

The method for documenting the initial assessment of competency is as follows:

Clinical jobs and Management jobs:

•Skills Competency Checklist

•Competency Assessment Tool Template – to be used for initial competency assessment only if no Orientation Skills Competency Checklist is used or if there are additional competencies that require validation.

Non-Clinical jobs:

•Essential Job Functions and Service standards and/or measures marked with an asterisk (*).

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Annual Assessment Methods

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Annual Assessment Methods

Clinical Jobs: •Identify a minimum of at least two competencies. Competencies should be reviewed regularly for relevance (i.e., they should not remain the same year after year). Competencies may also differ depending on experience level.

•Competencies should be determined by low volume, high risk, new procedures/equipment, problem prone areas or as the result of QI activities.

•For clinicians supervised by a non-clinician (e.g., a manager who also maintains some clinical responsibilities), arrangements must be made to have a qualified person confirm/assess competency.

Non-Clinical Jobs: •Document annual competencies and essential job functions and service standards on the actual job description. Essential job functions and service standards and/or measures should be marked with an asterisk (*). •

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Annual Performance Review

• Using the Employee File and Education Requirements Grid or the Medical, Resident & Affiliate Staff Education Requirements at the annual performance review, the manager should also audit for timely completion and documentation of applicable competency assessments throughout the intervening year (e.g., when a new skill, new process or new instrument/technology was required).

• The manager should NOT wait until the annual performance review to first complete certain required competency assessments, but their reflection in the HR file should be audited at the time of the annual performance review.

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Resources

This new procedure will be effective immediately. Starting December 2 , 2013, all clinical employees who have their evaluations processed are required to have documented competencies using the new process.

For more information, contact HR Compensation at

443-997-5584.

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Q&A

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