Q&A: Monitoring competency standards compliance

Q: Do you have any suggestions on how I can make sure my staff is fit to perform so that we do not get cited for competencies?

A: Assess hospital orientation programs to ensure that revised practices and accreditation requirements are being incorporated into the basic curriculum. Take a look at your hospital’s training needs—from physicians to the frontline staff—drawing upon the advice of your education staff members. Make sure general orientation for all staff members covers the minimum required elements as well. Sometimes general orientation hasn’t been revised for years.

Look at your department-specific competencies. Have staff members demonstrated that all competencies required for them to work in the department have been completed? Sometimes an opportunity to perform a task isn’t offered during the orientation cycle. The manager does not revisit these orientation forms. As a result, the surveyor cites that organization under human resource competencies as the staff is not competent to perform duties. Typically, you might see this in obstetrics where staff members haven’t rotated through all areas in orientation, or in the ICU where a procedure isn’t performed that often. Make sure you develop a process to close the loop on any omissions in the orientation process.

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