UNIVERSITY HOSPITAL AND CLINICAL PROGRAMS
PROFESSIONAL NURSING ORGANIZATION
POLICY STANDARDS

ADDENDUM:                N.1
EFFECTIVE:                10/92
REVISION:                  06/08
APPROVAL                  07/08

SUBJECT: ANNUAL COMPETENCY TESTING

SOURCE: Policy Standards, Section N, Patient Care Services


REFER TO: N. COMPETENCIES

Documentation of competencies is located in:

·          Personnel Files

·          Department/Unit Databases  (Department/Unit Competency Databases are accessible to all staff responsible for assignments of clinical staff.)

INPATIENT & OUTPATIENT

Annual educational activities on all units include these categories:

1.      Fire and Safety competency included in the Annual Requirements Module

2.      Confidentiality/HIPAA included in the Annual Requirements Module

3.      Child/Adult Abuse included in the Annual Requirements Module

4.      Living Will ( Inpatient Only) included in the Annual Requirements Module

5.      BCLS Certification (biannual) ( Patient Care Providers Only)

6.      /Job Specific Competency Checkoff

7.      Skin Care Competency Checkoff (Inpatient Nursing only)

8.      Restraint Competency Checkoff (Inpatient, ED/SSU, PACU)

9.      ACLS Certification (biannual) for RN's in designated areas/roles

10.  Patient Safety Competency Checkoff

11.  Annual Competency Assessment for High-risk clinical skills specific to the patient population

12. Fit testing for N95 mask (Inpatient patient care providers)

RNs, LPNs PCTSs PCA’s, PSC’s and Techs

To provide consistent application for annual high-risk, clinical skills, the following criteria apply to all Units/Clinics:

1.      Each unit/clinic will identify no more than ten (10) high-risk, clinical skills specific to the patient population.

2.      Each skill must be tested by a written test and/or performance evaluation.

3.      Eighty percent (80%) is the passing score for all written tests.

4.      Performance tests must be passed by demonstrating the procedure with one hundred percent (100%) accuracy.

5.      Two (2) retakes are permitted on either written or performance tests. Retakes must be within thirty (30) days and not on the day of the original test. Staff may continue to work until after the second failure.

6.      Testing is performed by the Clinical Services Manager or designee.

7.      Competencies may be tested at any time during the year prior to the employee's performance evaluation, as some testing must be scheduled.

8.      Failure to pass the written or performance test initiates the disciplinary process.

a.       Verbal warning is issued at the initial failure.

b.      Retakes must be within thirty (30) days and not on the day of the original test.

c.       Written warning is issued at the second failed attempt.  Retakes must be within thirty (30) days and not on the day of the second test.

d.      A third failure results in termination.

COMPUTER BASED DOCUMENTATION/CLERICAL FUNCTIONS

To provide validation of consistent application of appropriate technical and procedural principles for computerized functions that support patient care, the following criteria apply:

1.      Required functions will be identified for specific job categories and a master list maintained by Clinical Information System.

2.      Application of appropriate technical and procedural principles will be tested by performance evaluation.

3.      Performance evaluations will be conducted in the Computer Training Center or on the clinical units.

4.      One hundred percent ( 100%) accuracy is required for performance tests.

5.      Failure on performance testing of required functions initiates the disciplinary process.

a.       Verbal warning is issued at the initial failure.

b.      Retakes must be within thirty (30) days and not on the day of the original test.

c.       Written warning is issued at the second failed attempt. Retakes must be within thirty (30) days and not on the day of the second test.

d.      A third failure results in termination.

DIRECTORS/MANAGERS/STAFF EDUCATORS/INFECTION CONTROL PRACTITIONER/CASE MANAGERS

1.      Annual Competencies for the personnel listed above include:

a.       Educational requirements:

1.      Mandatory Safety Requirements as listed in K.5

http://www.uams.edu/nursingmanual/Policy-addenda/addendum-k5.htm

b.      Annual Performance Appraisal Tool

2.      Annual Competencies are embedded in the Annual Performance Appraisal Tool for the employees listed above.

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