St.

Marys Medical Center Nursing Clinical Operations Competency Assessment Assessment and Intervention Skills Safety Practices Presentation Name/ID#_____________________________________________ Date________________

Form SAFE 4

Unit/Dept_______________________________________________ Job title______________ If you select this method of verification, the topic, objectives and timeframes must be pre-approved by the Staff Development Specialist and Unit/Dept Director so multiple people will not be presenting the same topic at the same time. If you do not meet your timeframe for staff education, you will need to check with the Staff Development Specialist to see if you can still proceed. Do a presentation, whether it be an in-service, a video, or poster/story board on a topic related to safety such as needle sticks, falls/patient mobility, associate injuries, hand hygiene, use of Personal Protective Equipment, disruptive behavior, using the proper lifting equipment, Healing without Harm/ error prevention techniques, and much moreuse your imagination. If you choose to do an in-service, you must have at least 10 staff members attend discuss number of participants with Staff Development Specialist if department small. Consider doing a fun type video such as the Rounding Queen shown during the HCAHPS education. Several people may work on a video together. In order to use a video as your verification method, you must participate with development of the objectives and content of the video (not just be in the video). You will still need to show to at least 10 staff. Topic: Objectives:

Timeframe for staff education to be completed: ____________________

Staff Education must be completed prior to February 28, 2014

SDS pre-approval signature/date_______________________________ Development Team: (responsible for planning objectives and content) if make a video: Once education is completed submit the Staff Development Attendance Record, summary of evaluations and copy of the video (if applicable) to your Staff Development Specialist. The Staff Development Specialist will review and then sign your competency form. This page will not be submitted to your Unit/Dept. Director, only the Staff Development Specialist signature. It is your responsibility to obtain this signature.