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FastFacts
Feature Presentation
November 11, 2013
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Today’s Topic
We’ll be taking a look at…
Performance Management Policy
Revisions: Competency
Assessments
Slide 3
Today’s Presenter
Sharon Kemp
Sr. Director of JHHS Compensation
Dana Moore
Director of Regulatory Affairs
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Session Segments
Presentation
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&A
After the presentation, we’ll hold a Q&A session.
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questions.
Sharon and Dana will answer as many of your questions as time
allows.
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Slide 6
Survey
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Slide 7
How To View Full Screen
Performance Management Policy
Revisions
Competency Assessments
Presented by: Sharon Kemp and Dana Moore
November 11, 2013
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Competency Assessment
Requirement
The 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.
3/16/2016
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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/64/220
6/policy_2206.pdf?_=0.281708408807
3/16/2016
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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.
3/16/2016
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Initial Assessment
• 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/requi
red_education/index.html
3/16/2016
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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
3/16/2016
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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.
3/16/2016
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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 (*).
3/16/2016
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Annual Assessment Methods
• Annual competencies will be documented on the official Competency
Assessment Tool template or an equivalent form of documentation.
• To meet TJC standards, the equivalent form must contain the skills that
are required for competency, the method of verification (e.g.,
observation, simulation, review of work product), an explicit rating
(meets vs. does not meet) and include the signature of the assessor
and the date assessed.
3/16/2016
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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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•
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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.
3/16/2016
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Slide 22
Q&A
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Slide 23
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Slide 24
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