Handbook of Operating Procedures > Series 400 Budget, Finance and Operations > 4.30.1 Health Science Center at UT Tyler Standardized Competency Assessment Process

4.30.1 Health Science Center at UT Tyler Standardized Competency Assessment Process

A. Purpose

To establish a competency-based assessment process, including the standardization of criteria and processes used to evaluate competencies, as well as to ensure compliance with The University of Texas System objectives, The Joint Commission standards and National Patient Safety Goals.

B. Persons Affected

All employees of the Health Science Center at the University of Texas at Tyler (UTT) who provide care, treatment and services within the organization, including those receiving pay (permanent, temporary, part-time and contract services), volunteers, and health profession students, except UTT medical staff (licensed practitioners) who are covered under the University Medical Staff section of this policy.

C. Definitions

N/A

D. Policy

Competency is defined as the demonstration of knowledge, skills, and behavior necessary to achieve consistent satisfaction of job requirements, objectives, and compliance by the UTT standards.

Competency assessment occurs on an on-going basis and is evaluated at specific milestones:

I. Employees  

Date of Hire: 

• Pre-employment screening process 
• Job Description 
• Reference Check 
• Background Check 
• Drug Screen 
• Required Immunizations 
• Manager Interview 
• Technical Testing (if applicable, i.e.: clerical, math skills, etc.) 
• Primary Source Licensure Verification 
• Verification of Required Education 

Initial Hiring Period: 

• General Departmental Orientation 
• Goals, objectives, standards, and expectations should be established within forty-five (45) days 
• Clinical competencies should be established at the 30, 60, and/or 90-day marks 
• Ongoing assessment and performance management should continue within the department 
• Feedback and goals should be provided to employees and routinely documented 

Ongoing Assessment:

 The verification of competencies is completed through a variety of activities that demonstrate the employee's ability to effectively perform and process their job responsibilities.

New Employee Orientation:

Department Specific Orientation (New nurse orientation, etc.) are communicated, managed and documented at the department level.

Annual Competencies:

Employees are to be evaluated annually during the UTT’s performance appraisal period.

Completion of the Electronic Competency Assessment

• Competencies added at intervals not outlined in this section will be completed in a time frame respective to department established protocol, not to exceed six (6) months from the assignment date without the approval of the Office of Human Resources.
• Competency assessments are expected to be performed for all employees, including internal transfers, temporary work reassignments and at other times during which an employee is required to demonstrate new knowledge or skills.
• Employees moving to a new role or new area involving a different set of competencies will not begin new duties until the new competencies are mastered and documented. The employee and supervisor should work collaboratively in assessing the employee's need for "refresher" competency assessments and new skills competency assessments.
• Competencies are assessed and verified for mastery by departmental leadership or, in certain cases, individuals deemed competent to assess and verify mastery.

Departmental leadership may identify evaluators within the department to assist in the process of evaluation. Standardized performance management templates may be used to annotate competence. The use of Mission, Vision and Values, departmental standards and expectations, core or annual competencies, and job specific criteria are just a few recommended components for employee assessment. Documentation of competencies are maintained within the employee electronic file.

The following levels and methods may be utilized for clinical personnel, either independently or in conjunction with electronic performance management templates, feedback, and goals.

Several levels of competency are available:

When selecting a competency status, the employee and evaluator may choose from three (3) levels of competency:

• "N" indicates the employee is a Novice (has not independently demonstrated skills necessary for competency)
• "E" indicates the employee is Experienced (has demonstrated necessary skills for competency but requires supervision while doing so)
• "C" indicates the employee is Competent (independently demonstrates skills necessary for competency with no need for supervision).

Several methods of evaluation are available:

• "DO" indicates the direct observation of a skill.
• "CS" indicates a case study involving a skill.
• "PE" indicates a peer evaluation involving a skill.
• "RD" indicates a return demonstration of a skill.
• "PT" indicates a post-test was used to validate a skill.
• "DG" indicates a group discussion was used to validate a skill.
• "P" indicates a presentation was used to verify a skill. 

Other Joint Commission and UTT approved methods may be used with approval from the Office of Human Resources.

Competencies are checked for performance improvement action plans and timelines, when applicable.

Competencies are designed around pre-determined knowledge, skills and abilities. 

• New policies, procedures, technologies, initiatives, mandates, laws or statutes. 
• Changes to any existing policies, procedures, technologies, initiatives, mandates, laws or statutes. 
• Identified process problems as determined by the UT System, regulatory agencies, patient safety concerns, review of data, customer satisfaction surveys and quality reports. 
• Directors/Managers must ensure that employees who do not meet competency requirements by established deadlines are given appropriate performance improvement plans, counseling and feedback, up to and including termination of employment if appropriate. 

II. AGENCY/CONTRACT STAFF

Each agency must provide: 

• Initial Hiring Competency: 
• Verification of licensure and/or certification 
• Negative drug screen 
• Verification of TB test and other appropriate screenings. 
• Two (2) or more work references 
• Competency validation of necessary skills 
• Director/Manager must ensure that departmental orientation, safety training and appropriate competencies are on file in the contract staff file. 
• Contract staff must attend any additional orientation as established by the department or UTT leadership. 
• The Director/Manager must evaluate the contract staff's performance minimally at the conclusion of the assignment period. The appraisal will be maintained in the departmental and/or nursing administrative file as necessary. 

III. VOLUNTEERS

Volunteer Assignment Process:

Initial Competencies 

• Description of service(s) the volunteer will perform 
• Application for service 
• Interview 
• Two (2) or more references 

Other criteria as established by UTT leadership 

Orientation to UTT policies and procedures

Population specific competencies

Verification of TB and other appropriate screenings.

Annual Competencies:

• New or changing policies, procedures, technologies, laws or statutes.
• High-risk functions, identified process problems as determined by the UT System, regulatory agencies, patient safety concerns, review of data, customer satisfaction surveys and quality reports. 

IV. PARTICIPANT RESPONSIBILITIES

Responsibility of the Manager/Director: 

• Distribution of the competency requirements for each job description to the employee/staff/volunteer in each role. 
• Establishment of departmental specific competencies. 
• Establishment of an environment conducive to the timely and honest completion of competencies. 
• Participation in the evaluation of competencies.
• Assisting in completion of each competency, including but not limited to, implementation of action plans to achieve mastery of skills deemed not "Competent" on the competency assessment form. 

Responsibility of the Employee/Staff/Volunteer: 

• To alert Director/Manager when he/she feels a skill has been mastered and is ready for evaluation. 
• Formal completion of all required competencies. 
• Participation as required in the overall development/implementation of competencies for the department. 

Verification of Competencies: 

• Employees/staff/volunteers will be responsible for the completion of their required competencies, and will work collaboratively with department leadership using methods of evaluation best suited for the specific competency and the employee. The assessment of "Competent" is achieved when an employee/staff/volunteer has been evaluated and found to demonstrate required  level of competency in all areas indicated. If successful evaluation is not achieved, a performance improvement action plan will be initiated, documented and filed appropriately. 
• Employees hired six (6) months or less from the date annual competencies are to be completed are not responsible for annual competency completion that year, but are subject to core competency evaluation. Annual competencies will be integrated into the next annual evaluation period. 

V. UNIVERSITY MEDICAL STAFF 

• The competency, qualifications and credentials of the University Medical Staff providing patient care, treatment or services at the University are evaluated in accordance with the University Medical Staff Bylaws, Rules and Regulations and Medical Staff policies. 

VI. VENDOR COMPETENCY 

• Vendors whose products or services require direct patient interaction must provide written documentation from their companies that they have received training and are competent to train, demonstrate, distribute and/or operate equipment related to their product or service, prior to service. 
• Vendors must maintain compliance with UTT Vendor Policy requirements. 

VII. COMPETENCY PROCESS EVALUATION 

• The Office of Human Resources and/or UTT leadership may require the reporting of competency status within a department at any time. 
  Additional departmental policies regarding competencies must be congruent with this policy and are subject to approval by the Office of Human Resources and/or executive leadership.