Competency Control

Accredited providers, and those now becoming accredited, know that there are many requirements that must be met either to pass an initial survey or to maintain accreditation each year. While all of the DMEPOS accreditors have their own individual processes, each requires that you comply with CMS’ Final Quality Standards.

In those 19 pages, there is one very short paragraph addressing “Human Resource” issues. One of the items listed as a requirement in that paragraph is “competency.” This one little word can be very confusing.

Often, providers confuse competency either with educational requirements or annual staff evaluations, but these are three different and distinct items.

An educational requirement is the requirement that an organization provide education to its staff members. Such topics usually provided during the course of a year include instruction on HIPAA, OSHA, infection control or blood-borne pathogens. Sometimes such education is provided in the form of a video or a personal presentation. Some providers subscribe to online educational programs that meet this requirement and allow for staff to go online after hours rather than tie up time in the workday.

An annual evaluation is the review performed each year that assesses whether an employee is performing the duties of his or her job appropriately. Generally, annual evaluations are aligned with the duties found in an employee’s job description. An annual evaluation is performed to evaluate how the employee performs in his/her role, such as how well he/she accepts responsibility, that he/she is reliable, prompt, reports for work as required and performs required tasks appropriately, etc.

For accreditation, a competency assessment refers to a test completed by an individual to ensure that he/she is capable of performing a task correctly without supervision. An example would be completion of a competency test for a glucometer or a concentrator, thus ensuring that the staff member is competent to set up the device, instruct a customer on proper use of the item and provide any troubleshooting guidance needed.

For Medicare, documentation of a staff member’s competency is a requirement for all technical staff, meaning those staff members who teach or instruct a customer. For example, an HME provider’s technical staff members include drivers who deliver and set up equipment in the home. A pharmacy staff member working in a retail setting who instructs customers falls into this category, but a pharmacy cashier who directs a customer to the trained staff member who performs the instruction does not.

It can be easy to forget everyone who qualifies as technical staff for this requirement. A provider’s technical staff also includes any customer service personnel who troubleshoot equipment over the phone or provide after hours on-call instruction, or a supervisor who may substitute for a driver.

Accreditation standards require that providers ensure that anyone who instructs a customer independently (without supervision) is competent to do so. Most accreditors require competency assessments for all newly hired staff and then an assessment of staff members’ competency annually to ensure they are still instructing correctly and have not fallen into any bad habits.

There are many ways to assess competency without re-inventing the wheel. Annual competency evaluations can be handled with a “lab workshop,” where everyone is brought together to demonstrate the use and troubleshooting of various items and a checklist is completed.

For non-clinical tasks such as suctioning or trach changes, etc., you might subscribe to an online program where employees can review a video or go through a course and then take a test that requires a passing score to complete successfully. Sometimes these online competencies offer an opportunity for Continuing Education Units (CEUs); that is a nice option but not a requirement.

A policy and procedure manual purchased should contain all of the required competency forms needed to meet this requirement.

When assessing competency in person, and for all clinical competencies, accreditation standards require that the competency be assessed by someone capable of assessing the staff member’s proficiency. In general, an owner or supervisor is considered competent to evaluate non-licensed staff as long as that person can justify his or her ability to supervise or train others.

When manufacturers come into your business to demonstrate a new piece of equipment, ask them to bring a competency form that they can sign off on for each staff member once they have observed a successful return demonstration of the item.

For licensed staff, such as respiratory therapists performing clinical services, competency can only be assessed by another respiratory therapist who observes clinical tasks being performed. An owner or supervisor who is not similarly licensed cannot adequately assess the clinical competency of a licensed professional.

This can present a problem for a small provider, for example, who may have only one RT on staff.

In this case, the provider can contract with another RT, possibly from a local hospital or nursing facility, to perform this evaluation. If you do contract with an outside professional to perform the evaluation, the best way to meet the requirement is to use a written checklist. Make certain all of the required tasks are listed and evaluated and, upon successful completion, keep a copy the evaluator’s current license.

As you create or update your company’s internal competency program, review your individual accreditor’s competency standards to ensure that you are meeting them. While competency assessments should not pose an undue burden, they should always be part of the orientation process when new staff members are hired and a component of annual reviews.

Accreditation ensures that providers have competent staff instructing customers and the documentation to prove that competency.

Mary Ellen Conway, RN, BSN, is president of Capital Healthcare Group, LLC, Bethesda, Md., which provides health care management expertise in accreditation preparation and survey follow-up, operations assistance, design of quality improvement programs and outcome measures. You can reach her at 301/896-0193 or through www.capitalhealthcaregroup.com.