Creating competency standards that work
Creating competency standards that work
A real-world approach to measure staff competency
It’s easy to create competency standards to satisfy some accrediting body’s requirements, but establishing a competency program that creates knowledgeable and qualified staff, improves outcomes and increases patient satisfaction is another beast altogether. While they may seem like lofty goals, they’re readily achievable if you know how to go about it.
The first step in any competency program is actually a two-step process, according to Lynn Hadaway, MEd, RNC, CRNI, of Hadaway & Associations, an infusion therapy consulting firm in Milner, GA.
"First, you need to write your competency statement and then choose the performance criteria that you are going to include underneath that competency statement that measures whether the nurse met the competency," she says.
When producing a competency assessment program, consider all the resources available to you. Hadaway says this should include Centers for Disease Control and Prevention guidelines, Intravenous Nurses Society standards of practice, League of Intravenous Therapy Educators guidelines, recently published studies and manufacturers’ guidelines.
"Then the individual provider looks at their particular patient populations and their particular needs, and writes their own internal standards based on that assessment and research," says Hadaway.
Initial competency
There are two parts of any competency program: initial competency evaluation and ongoing. The key to the initial competency is evaluating where your staff or new hire is, and giving that individual whatever training is necessary to cover all the necessary information.
"You expect nurses to come in with basic knowledge of the nursing practice, and you would have to orient them to the way things are done in that facility or by that provider," says Hadaway. "You’re not going to be able to cover everything and educate them from the ground up, but you have to provide all the resources for them and do so in an organized manner.
"In an ideal world, it will be specific to each person’s needs," says Hadaway of the initial competency evaluation and training. "If you have someone who has been doing home infusion for 10 years and is simply coming to another provider, they could go through orientation very quickly vs. someone who is new to home infusion."
It is for that very reason that Ritzman Infusion, an Akron, OH-based alternate site infusion pharmacy that provides consulting services to infusion providers, uses an up-front assessment of nurses when consulting with home infusion providers regarding competency.
"Ideally, we like to start by establishing where they are with their knowledge level," says Brenda Lance, RN, MSN, the nurse coordinator for Ritzman Infusion. "There is a written test, but we also talk with nurses and ask infusion-related questions."
Deb Riley, RN, CRNI, and an infusion liaison nurse for Ritzman, says the provider she is working with is a prime example of the need to customize a competency program.
"We have tried two different avenues with the agency I am working with now," she explains. "We started off trying to get all of the nurses competent and that proved to be an impossibility."
The number of referrals for home infusions coming in to the home care provider were sporadic at best. As a result, it was impossible to keep all the nurses’ skills at an optimum level.
"It’s one thing to say, We do infusion therapy because we have nurses that have done an IV at one time or another,’ as opposed to saying, We do infusion therapy well and we have a trained staff always available,’" says Riley.
It is that line of reasoning that led Riley to institute an infusion team for her current client.
"Now all the nurses come through a basic-level infusion class so they can have an intelligent conversation with someone, assess what the needs are and triage that call," says Riley.
The basic-level class is a 4.5-hour class that addresses the different types of lines, terminology, drug interactions, telephone triage, and legal aspects of providing infusion therapy.
"We train all nurses to use our telephone triage sheet we use that can calm the patient down. The nurse gets the patient’s name and address, finds out what medications they are on, and determines if we need to send them straight to the hospital without wasting any time on the phone or triage a little more and send out an on-call nurse," says Riley.
She adds that legal liability is an area often overlooked.
"As a profession, nurses have been notoriously neglectful in identifying our legal roles," she says. "A lot of providers don’t realize what they don’t know. In a nutshell, we look at what standards of practice they are held accountable to, such as the INS and the state and agency standards, in a court of law."
Once all nurses go through the basic-level class, members of the infusion team then go on to an eight-hour second-level class, which is more in-depth and complex than the basic-level class.
"This class deals with pain management, actual management of the lines, dressing changes and working with the different types of pumps," says Riley.
The class is broken into two sessions, and followed by a written test the nurse must score 80 or above, as well as a skills competency class in which they insert a peripheral IV, access a port, do change dressing, flush a Hickman catheter and change a subcutaneous site on an anatomical body.
Hadaway points out clinical competencies should be a part of orientation.
"Orientation is getting somebody comfortable with the structure and the function of the organization," she says. "Orientation will include things such as personnel policies, where and how things are stored, and how you function within the organization, so orientation is much broader than the clinical competency."
Ongoing competency
Once staff and new hires are deemed competent according to the initial competency training and evaluation, there is the ongoing competency training to consider.
"The Joint Commission [on Accreditation of Healthcare Organizations] doesn’t tell you that you have to do procedure X with Y frequency," says Hadaway.
"Every company has its own policy as to how often it will assess competency," says Lance, "but we feel comfortable doing that assessment annually."
While most providers assess competency on an annual basis, the competency assessment and training should vary according to its subject matter.
"This should change based on quality improvement, performance improvement data, where your problems are and what your patients’ outcomes are," says Hadaway. "If you notice that you have a problem with phlebitis after you are putting in PICCs or midlines, you would look at competency as far as catheter advancement techniques, but if you have a problem with catheter-related infections you may look at something totally different."
This is an area Hadaway says many providers overlook.
"Some providers set up a program and say, We’re going to do X, Y, and Z procedure initially and then again every year,’" she says. "But nurses who perform PICC or midline procedures on a regular basis and have good outcomes really have no need to go through that evaluation again. You need to address competencies where you’ve got problems."
That’s exactly how Ritzman Infusion works with its clients.
"Each year we change the hands-on competency by tracking our infections and reports and looking at what volume we are doing," says Riley.
Ken Speidel, PharmD, and the director of pharmacy for Ritzman, says the ongoing competency should change regularly based on the latest provider data.
"The point needs to be made that home infusion is so dynamic in terms of specific demographics of the patients that you must look at what the volume of need is," says Speidel. "We look at statistics on a monthly basis and it can be surprising how your volume can change from X% of your patients on TPN [total parenteral nutrition] and shift to Y% the next month."
Speidel adds that another potential scenario could result in a dramatic change in your service offering.
"For example, your inotropic volume may increase dramatically because a new physician has come into the area with a more aggressive treatment approach towards heart failure. Home infusion can be a very fluid type of business in that you have to assess your therapy volume on a regular basis."
When considering areas to address in your ongoing competency standard, Hadaway suggest looking at three areas:
1. Problem areas in common procedures.
2. High-risk procedures.
3. Low-frequency procedures.
"If you have a high-risk procedure that is done infrequently, that may be something you want to target," she says.
Real-world evaluation
Speidel and Hadaway both agree clinical knowledge and classroom observation should not be the only assessment of nurses.
"When you assess competency with a written test or lab situations, you’re not really assessing competency," says Hadaway. "You’re saying that person has the capacity to act professionally, but you really don’t know if in the real world of work they can pull it all together. If you are doing a peripheral venipuncture on an anatomical model or even on a real person in a classroom, it is a simulated situation.
"You can see that the individual holds the catheter correctly, makes the venipuncture, advances it correctly and tapes it down," Hadaway continues, "but will that person be able to look at all the patient criteria, make the right choice about the catheter gauge and site, use appropriate infection control methods, properly insert the catheter, secure it, answer the patient’s questions, and do all this while their pager is going off, and they are 10 minutes late for a meeting back at the office?"
Speidel agrees any competency program should in some way include the measurement of an associate’s interpersonal abilities, whether it be by observation in the field or some other method.
"The traditional home care company may only consider whether the nurse can access a port, but overlook whether the nurse has the interpersonal skills to deal with a chronically ill patient," he says.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.