COMPETENCY OF ASSOCIATES POLICY

Effective Date: October 20, 2017

Revision Date: January 1, 2022
Approval: Kimberly King Webb – SVP, Chief Human Resources Officer
Policy Initiated by: Human Resources
Application: Enterprise

PURPOSE
To provide a mechanism for directing and evaluating the competencies required of our Associates to
provide quality healthcare services to our customers. Competencies identify areas of growth and
development, and provide opportunities for ongoing learning to achieve continuous quality
improvement.

POLICY
Associates, contract/agency personnel and volunteers must be competent and qualified to meet performance
expectations and/or to provide quality patient care to the specific age patients they serve. As such, they will
be assessed initially and as appropriate to ensure continuing competency.

1. Defined Competencies:
a. Competency is defined as the minimum basic job knowledge, including skills, ability, and/or
behaviors required to safely fulfill the responsibility of a job or assignment.
b. Competencies will be identified and defined by individual position or department.
c. Competencies that require special attention are those that are considered high risk, low
frequency, or are identified as problem prone by the department or service line leadership.

2. Assessment Methods: Techniques used to evaluate competencies may include a variety of assessment
methods. Methods used may include, but are not limited to:
a. skill performance activities
b. self-learning packets / activities
c. computer based education – tests
d. videos
e. group exercises
f. proficiency exams
g. return demonstrations

3. Competency must be assessed by a qualified individual. Qualified individuals have equivalent or higher
level of skill or competency.

Page 1 of 2
 4. Frequency of Competency Assessment:
a. Competency is assessed initially upon hire or prior to completion of the Introductory Period and
whenever management deems it appropriate
b. The components of initial competency assessment may include:
i. Interview and screening process as defined in the New Hire Process
ii. Completion of General Orientation
iii. Completion of Clinical Orientation, if applicable
iv. Completion of self-assessment, skills checklist and validation by a qualified individual
based on objective criteria
v. Department specific orientation
vi. On the job training with a preceptor or coach
c. Requirements for competency assessments and documentation include, but are not limited to:
i. Maintenance of current licensure, certification, or registration as required in the
Associate’s job description
ii. Annual (HLC) education modules
iii. Ongoing performance assessments and related actions
iv. Ongoing competency assessment (age specific, department specific checklist, position
change, new equipment, etc.)
v. Summary of CE, CEU and training participation, if applicable

5. Documentation of all competency assessments is maintained in the Associate’s paper or electronic

personnel file maintained by Human Resources or in the Departmental Education File.

6. Failure to Maintain Competency:

a. In the event that an Associate or Volunteer does not meet the required competencies, a plan
for correction is implemented, and performance is re-evaluated within a specified timeframe.
Failure to comply with corrective action may lead to disciplinary action, up to and including
separation of employment.
b. Agency/Contract staff who do not meet the required competencies will be not be retained.
c. Associates must complete all required competencies by the respective due dates. If the
competencies are not completed by the respective due dates, the Associate must complete
them within fourteen (14) days or the Associate is suspended without pay. Termination will
result if the competencies are not completed and verified by the end of the second week of
suspension.

7. The Department leadership (Director/Manager/Supervisor) is responsible for monitoring, assessing and

addressing performance to ensure Associates meet established competency requirements.

8. Associates are responsible for completing and maintaining their own competencies. The
manager's role is to validate the Associate has successfully completed all required
competencies. The Associate is deemed "competent" with the completion of 100% of the
indicated competencies for that job class.

Page 2 of 2