This Policy Applies to All Acute Care Departments Employing Clinical Associates

This Policy Applies to All Acute Care Departments Employing Clinical Associates

POLICY TITLE: Clinical Competency, Orientation, and Education
DEPARTMENT:Human Resources / ORIGINATION DATE:10/01/2012
CATEGORY: Education-Training / EFFECTIVE DATE:

SCOPE

This policy applies to all acute care departments employing clinical associates.

PURPOSE

To describe the process for competency assessment, orientation, and education for clinical acute care associates. The competency assessment process includes identification, maintenance, and enhancement of clinical competency. Orientation processes describe all elements of how new clinical staff are introduced to key elements in their role necessary for success. Education processes encompass all planned formal and informal activities designed to develop, maintain, and advance the knowledge, skills, abilities, and practice of the patient care services associates.

STATEMENT OF POLICY

1.Verification of staff qualifications: all applicants will be assessed upon hire via review/verification and documentation of licensure and certifications, educational credentials, work experience, and reference checks as well as personal interviews, criminal background checks, health screening, and other human resource requirements as required by the job responsibilities, law, and regulation.

2.How staff function within the organization: staff who provide patient care, treatment, and services practice within the scope of their license, certification, or registration and as required by law and regulation.

3.Education is founded on a competency-based model and recognizes that the clinical associate is:

a.Personally accountable for maintenance and advancement of their knowledge, skills, abilities and practice level.

b.Responsible and accountable for identifying their education needs.

c.Involved in the defining of patient care delivery standards.

d.Involved with the assessment and/or planning of organization/department/unit-based educational opportunities using the results of quality improvement monitoring and the needs of the patient population served by the clinical unit.

4.Orientation for clinical associates includes the following elements. Completion of this orientation is documented.

a.Key safety content including, but not limited to, specific process and procedures related to the care, treatment, and services; the environment of care; and infection control.

b.Hospital wide and unit specific policies and procedures.

c.Specific job duties, including infection prevention, control/assessment/management of pain.

d.Sensitivity to cultural diversity based on job duties and responsibilities.

e.Patient rights, including ethical aspects of care, treatment, and services; and the process used to address ethical issues based on their job duties and responsibilities.

5. Associates engage in ongoing education and training to maintain or increase their competency. Staff participation is documented. Topics include:

a.Education/training whenever staff responsibilities change.

b.Education/training specific to the needs of the population served by the hospital.

c.Team communication, collaboration, and coordination of care.

d.Reporting of unanticipated adverse events.

e.Fall reduction activities

f.Identification of early warning signs of a change in patient condition and how to respond to a deteriorating patient, including how and when to contact responsible clinicians.

6.Associates are competent to perform their responsibilities. Competency assessment is performed at least once every three years and is documented. The hospital defines the competencies it requires of the associates who provide patient care, treatment, or services. Additionally:

a.An individual with educational background, experience, or knowledge related to the skills being reviewed assesses competence. An individual outside the hospital can be used for this task if a suitable individual cannot be found within the organization. Alternatively, the hospital may consult the competency guidelines from an appropriate professional organization to make its assessment.

b.Staff competence is initially assessed and documented as part of orientation.

c.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.

d.The hospital takes action when a staff members’ competence does not meet expectations.

PROCEDURE

1.Human Resource (HR) performs and documents verification of staff qualifications. Location of this documentation may be entity specific.

2.Competency-based orientation occurs at the time of initial employment, return to employment, and when changes occur in the role/responsibility of the employee:

a.Length and detail of the orientation is determined by the clinical area and is based on the complexity of the job requirements (knowledge, skills and abilities), the individual’s assessed competency, and progress towards validation of the required job skills.

b.Employees will attend organization-wide hospital orientation, clinical orientation, and participate in a unit-based orientation program.

c.If an employee leaves and returns to the organization within 12 months of the rehire date, the associate does not need to attend orientation again unless specified by the entity.

3.Unit-Based Orientation:

a.A preceptor(s) is/are assigned to each employee.

b.The job description will be reviewed with all new employees, returning employees, and annually during the performance appraisal. Documentation of this review is done in accordance with the entity procedures.

c.Continued and final completion of the competency-based orientation evaluation tool (checklist) occurs during unit based orientation. Completion of the tool should occur within 6 months of hire and will be kept in the employee’s personnel file.

4.Ongoing Competency Assessmentincludes relevant technical, cognitive and critical thinking skills related to equipment, procedure, technologies, policies on practice, age-specific care issues, cultural diversity, high risk/low frequency activities, and information obtained from quality data.

a.Each clinical area will determine ongoing competency assessment needs on an annual basis.

b.Competency performance of staff is objectively assessed, maintained, improved, and documented on an ongoing basis.

c.Competency assessments are included in the annual performance appraisal review process.

d.Methods of verifying competency may include:

i.Direct observation while the employee demonstrates the skill in the work setting.

ii.Return demonstration while the employee demonstrates the skill in a simulated setting (skills labs, mock Code Blues, etc.)

iii.Case study or exemplar.

iv.Presentations.

v.Peer review.

vi.Document review.

vii.Written tests, self-learning modules, web-based study and testing.

5.Ongoing education and training—educational programs are developed, managed, delivered, and documented both at the local entity level and at the corporate level and in collaboration with local and corporate professional development councils.

a.Educational programs are based on:

a.Needs assessments (formal and/or informal)

b.Introduction of new products and equipment

c.Regulatory agency requirements

d.Patient population served

e.Advances in health care, management, technology and current research

f.Evidence-based practice

g.Peer review activities

h.Individual staff learning needs

i.Direct and indirect observation of staff practices

j.Input from other health care team members

k.Findings from quality measurements and issues.

b.Educational offerings may include but are not limited to:

a.Formal classes

b.Inservice

c.Skills labs

d.Web-based or computer assisted instruction

e.Lecture presentations

f.Tests/quizzes

g.Videos

h.Case reviews

i.Self-learning modules

DEFINITIONS

1.Competence: Competence can be defined as the ability to perform a specific task in a manner that yields desirable outcomes.

2.Competency: Competency is an expected level of performance that results from an integration of knowledge, skills, abilities, and judgment.

3.Competence Based Orientation: A method that focuses on the end results. Orientation has criteria specific indicators to show that new staff has demonstrated the ability to perform assigned job responsibilities.

4.Competence Based Tool: A competence based orientation format which is specific for each job category and practice area. The competence based tool uses the evidence based competence pyramid to show the abilities and performance criteria. The competence based format functions as a guide to the orientation process specific to the job responsibilities of the individual and as such becomes the outline of the job-specific orientation content.

5.Competency Performance: The effective performance application of required knowledge and skill in the work setting in the evidence based practice model. The foundation to the competency model is evidence based practice. The definition of evidence based practice is a process for finding, appraising, and aggregating evidence as the basis for effective clinical practices.

6.Continuing Education: Planned, organized learning experiences designed to build upon previously acquired knowledge and skills.

7.In-service Education: Instructional or training programs designed to assist staff acquiring, maintaining, and/or increasing competency in assigned job responsibilities.

8.Orientation: A process that introduces new staff to the philosophy, goals, policies and procedures, role expectations, special services and physical facilities. Orientation is the time for introduction to the organization’s programs for safety, infection control, and quality improvement and their individual roles in those programs. Orientation occurs at the time of initial employment, sometimes return employment and when changes occur in role and/or responsibility.

9.Orientation Period: Period of time focused on supporting new staff to meet job responsibilities. The actual length of the orientation period is determined by the clinical areas, based on the complexity of the job requirements, the individual’s assessed competence and progress towards validation of the required job skills.

10.Preceptor: A person who facilitates orientation and assimilation of new staff into the work setting. A preceptor also may be assigned to assist a staff member who requires supervision with a resource person to complete a developmental or corrective action plan. The preceptor functions as a clinical role model, teacher, advocate, and consultant.

11.Validation: The verification that a skill has been performed according to standard nursing guidelines. It also includes measurement of specifically defined new skills and equipment as they are introduced into the clinical setting.

12.Validator: The designation of a person authorized to validate a skill, usually a preceptor, clinical educator, or clinical expert. (i.e. CNS).

REFERENCES AND SOURCES OF EVIDENCE

1.Abruzee, Roberts (1996) Nursing Staff Development; Strategies for Success, Mosby St. Louis.

2.American Nurses Association (2007) Scope and Standards of Practice for Nursing Professional Development. Silver Spring, MD. P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park: Addison-Wesley, pp. 13-34

4.Wright, Donna. (2007). Ultimate Guide to Competency Assessment in Health Care, 3rd edition. Creative Health Care Management, Minneapolis, MN.

5.HIPPA Compliance Federation of America Standards. Joint Commission. (2013) 2013 Comprehensive Accreditation Manual for Hospitals: The Official Handbook, Oakbrook Terrace IL.

POLICY VIOLATION

Any Centura associate who fails to abide by this policy may be subject to disciplinary action, up to and including termination.

REVIEW/APPROVAL SUMMARY

REVIEW/REVISION DATES:
(Dates in parentheses include review but no revision)
APPROVAL BODY(IES): Noreen Bernard, Sharon Pappas / APPROVAL DATE: Not Approved Yet

All official Centura Health policies are maintained electronically and are subject to change. No printed policy should be taken as the official policy except to the extent it is consistent with the current policy that is electronically maintained.

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