Category: HR-PERF
POLICY & PROCEDURE
Subject:
Competency Assessment of Associates
Classification:
Management Approved
Policy Owner:
Senior Vice President, Human Resources
Approved by:
WFH President and CEO
POLICY:
It is the policy of Wheaton Franciscan Healthcare to assure that the competency of
all associates is assessed, maintained, demonstrated and continually improved.
Effective: July 1, 2010
An annual performance review process is used to evaluate associates in respective
positions. The competency assessment process is integrated into these programs
as part of the evaluation process.
Competency of associates must be validated during orientation and on an ongoing
basis by Human Resources (HR) personnel, educators, validators, directors,
managers and/or designees.
Leadership staff and HR must develop strategies to support individual performance
improvement.
RATIONALE:
This policy is designed to support our Mission, Vision, and Values through our
Standards of Behavior. The WFH values of respect, integrity, development,
excellence, and stewardship serve as the guide to provide both compassionate and
superior service to the communities we serve. Through the competency assessment
of our associates we can achieve our Vision to be recognized in each community we
serve for superior and compassionate patient service, clinical excellence, as the
health care employer of choice, and preferred partner of physicians by ensuring a
safe, healthy and efficient work environment. This is accomplished by setting clear
expectations of behavior, competence, and performance and holding associates
accountable to job competence.
SCOPE:
This policy applies to all associates working in entities owned and/or managed by
Wheaton Franciscan Healthcare with the exception of employed physicians.
PROCEDURE:
A. Initial Competency Assessment
1. Human Resources completes the pre-employment phase based on the
job description for the position and including but not limited to:
a. Validation of required education, license(s), certification(s) and
other credentials
b. Verification of previous work experience
c. Personal and professional references
d. Statements and behaviors of the applicant during the interview
process
2. Orientation
a. Orientation includes general, entity, departmental, and unitHR-PERF
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specific competency related activities.
b. During the first 30 days of employment, all associates must
complete the system-wide orientation program.
c. All associates must complete the Department Orientation
Checklist within the first 30 days of hire.
d. All initial job competencies must be validated prior to working
independently.
e. Additional competencies determined by a manager or designee
must be validated prior to performing that aspect of the job
independently.
3. Transfers
a. The associate file, including all competencies, any documented
assessments and summary records of competency should be
sent by the current manager to the manager of the new
department prior to the transferred associate’s first assignments
in the new department.
b. Department-specific items on the Department Orientation
Checklist must be reassessed in the new work setting and any
competencies required by the new department that have not
been previously demonstrated by the associate will be
assessed/validated before the transferred associate performs
the new activities independently.
4. Change of Job Responsibilities/Cross-training
a. When associates are being taught new roles or are temporarily
assigned (floated) to an unfamiliar work area, they may only
assume responsibilities commensurate with their level of
knowledge, skill, and orientation to the new area.
b. Cross-training is complete when role and/or setting specific
competencies have been demonstrated by the cross-training
individual, evaluated, and documented by the manager or the
manager’s designee.
5. Leave of Absence:
a. Associates returning from approved leaves of absence, paid
time off, and seasonal associates are required to complete a
plan of action when their approved time away from work has
resulted in the associate not completing their competency
requirements. The department leader (or designee) will
determine
which
competencies
will
need
to
be
revalidated/completed and determine time frames for
completion.
B. Ongoing Competency Assessment
1. Competence assessments will be performed for each associate annually
during the performance evaluation.
A review of the associate’s
competence of essential job duties will be noted on the performance
evaluation form.
2. Competencies that need to be assessed and reassessed on an ongoing
basis will be based on techniques, procedures, technology, equipment,
or skills needed to provide care, treatment, and services. Competencies
which are validated for the performance review year are documented on
the associate’s on-line transcript or other applicable document.
3. The department leader or designee will determine the ongoing
competencies appropriate for their staff annually. The following factors
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can be considered:
 Job description
 High risk, low volume, and/or problem prone activities in their
specific work environment
 Medical device safety inspection
 Population-specific and developmental needs of patient
populations (where appropriate)
 Performance evaluation tools
 Policies, procedures and protocols
 Internal and external standards (including regulatory)
 Process improvement data
 Risk and Quality management findings
 Outcome data analysis
 Suggestions from staff
4. Documentation of validated competencies will be kept in the associate’s
file or on-line transcript and this information will be shared with those
responsible for job assignments, as necessary.
5. The department leader or validator must ensure that required
competencies are validated before an associate independently performs
related work activities.
C. Performance Improvement
1. When an objective evaluation of an associate’s competencies reveals
that improvement is needed, the manager will discuss with the associate
and document strategies for improvement with a timeframe for
completion on the Action Plan for Unmet Mandatory Education and
Competency form or applicable document. This can include counseling,
self-directed learning, inservice, skills training, competency validation,
modification of the associate’s work assignment, continuing education
and/or a development plan that will help the associate meet
expectations.
2. In the event that the improvement strategies for achieving the required
competencies fail after the stated time period, refer to the disciplinary
and corrective action policy. The department leader (or designee) may
temporarily modify the associate’s job assignment and or take corrective
action in conjunction with Human Resources support and counsel.
DEFINITIONS:
Competency Program – Includes job descriptions with initial job competencies,
verification of license, registration and/or certification, a system-wide orientation,
department specific orientation, an initial assessment of competencies, annual
performance feedback, on-going competency validation of incumbents, population
appropriate competencies and continuing education.
Competency – A person’s actual performance in a particular situation. It describes
how well a person demonstrates his or her knowledge, attitudes, skills and behaviors
according to expectations for specific situations.
Competency Statement – A broadly written statement that defines aspects of
performance associated with success in the role.
Competency Assessment – The process of identifying an associate’s ability to
perform as expected.
Initial Job Competency – Validation of actual performance of job duties
documented by the end of the department/unit orientation and prior to working
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independently.
Additional Competencies – Specific competencies determined by manager or
designee that are related to the role/job performed by associates based upon the
department scope of service.
Ongoing Competencies – Periodic assessment of selected competencies
developed from quality data, new/changed policies and procedures or technologies,
and/or high risk/high volume job functions.
Annual Competencies – Competencies required annually are those determined by
standards of care and/or regulatory agencies.
Orientation – The process of introducing new staff to the organizational culture.
This includes mission, goals, policies and procedures, role expectation, physical
facilities, and other factors needed to function in a specific role and/or work setting.
Associate – Any individual directly employed by Wheaton Franciscan Healthcare.
Validator – Anyone who is knowledgeable in competency assessment (knows
purpose, follows assessment procedures and documents properly) and has
demonstrated competency in the skill/area being validated.
Replaces:
Competency of Associates (All Saints 2008)
Competency Assessment of Associates (Milwaukee 2008)
Competency of Associates (Franklin 2008)
Competency and Performance Feedback (Iowa 1986)
Competency of Associates (Marianjoy 2006)
Cross reference:
Associate Selection and Placement Policy (except FMI and OLA)
Associate Selection and Placement Policy (FMI)
Associate Selection and Placement Policy (OLA)
Disciplinary and Corrective Action Policy (except FMI and OLA)
Disciplinary and Corrective Action Policy (FMI)
Disciplinary and Corrective Action Policy (OLA)
Leadership Excellence, Accountability and Development Program (LEAD) Leadership Performance Management (except FMI)
LEAD (FMI)
New Associate Orientation Program (except FMI)
New Associate Orientation Program (FMI)
New Associate General/Department Orientation Checklist
New Leader Orientation Checklist (Iowa)
New Leader Orientation Checklist (Marianjoy)
New Leader Orientation Checklist (Southeast Wisconsin)
Performance Excellence Program (except FMI)
PEP (FMI)
Temporary Personnel Policy (except FMI)
Temporary Personnel Policy (FMI)
Competency Forms are located at:
http://www.wheatonhr.org/Forms/EducationDevelopment.aspx
Review Period:
Two (2) years
Original Policy Date:
July 1, 2010
Dates Updated:
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