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Why conduct a Competency Assessment at your facility?

Quality of care requires ongoing competency evaluations

As clinical processes continue to grow in complexity, it is increasingly vital to patient safety that health care organizations ensure the competence of their care providers.

Through practical experience or bad experience, as clinicians we are aware of the need and benefit of structured orientation and competency assessment.  Regulatory agencies such as The Joint Commission (TJC) and the Undersea and Hyperbaric Medical Society (UHMS) have provided us with the guidelines to implement process to ensure that clinicians and providers are competent when performing patient care.  To ensure compliance with TJC, Det Norske Veritas (DNV) or the UHMS accreditation team recommend that each facility evaluate the institutional policy and process for new employee “unit” orientation and ongoing competency evaluation.

What is Competency Assessment?

By definition, Competency is the application of knowledge and skill in performance.

  • Competency is best assessed via return demonstration and observation.  Additional methods include, but are not limited to, simulation, mock reviews and case studies.
  • Competency is NOT assessed via an education module with a post-test.  An education module with a post-test measures knowledge, not competence (or proficiency). 

One may be very knowledgeable about a skill, but incompetent to actually safely perform that skill.

What is the difference between Education, Training and Competency Assessment?

The requirements found in the Human Resources (HR or HRM) chapter of the accreditation manual (HR.01.05.03 or HRM.01.05.01, BHC) speak to both ‘education’ and ‘training’ that provide the foundation for competency. [1]

  • Education is the process of receiving systematic instruction resulting in the acquisition of theoretical knowledge. 
  • Training differs from education in that ‘training’ focuses on gaining specific - often manually performed - technical skills.
  • Competency requires a third attribute - ability. Ability is simply described as being able to ‘do something’. The ability to do something 'competently' is based on an individual’s capability to synthesize and correctly apply the knowledge and technical skills to a task.

Competency (see HR.01.06.01) differs from education and training in that competency incorporates all three attributes:

knowledge, technical skills, and ability - all are required to deliver safe care, correctly perform technical tasks.

Assessing competency, then, is the process by which the organization validates, via a defined process, that an individual has the ability to perform a task, consistent with the education and training provided. 

What is the difference between Orientation and Competency Assessment?

  • Orientation is defined by TJC as "A process used to provide initial training and information while assessing the competence of clinical staff relative to job responsibilities and the organization’s mission and goals."[2] Examples include [2]
    • Key Safety Content: 
      • Fire Safety and response
      • Infection prevention and control
      • Emergency response (code blue, rapid response, etc.)
      • Active shooter
      • Bomb threats
      • Personal safety
      • Emergency Management (internal/external disaster plans)
      • Medical equipment failure and reporting process
      • Utility system disruptions and reporting process
    • Work schedule
    • Pain management, etc
  • Competency may be described as a combination of observable and measurable knowledge, skills, abilities and personal attributes that constitute an employee’s performance.  The ultimate goal is that the employee can demonstrate the required attributes to deliver safe, quality care.[2] While The Joint Commission does not define required competencies that must be completed, when determining competency requirements, consideration should be given to needs of its patient population, the types of procedures conducted, conditions or diseases treated, and the kinds of equipment it uses. Competency assessment then focuses on specific knowledge, technical skills, and abilities required to deliver safe, quality care.[2]

Are there any guidelines for Competency Assessments? 

The following are the guidelines by TJC and the UHMS for assessment of competency:

The Joint Commission Elements of Performance for HR.01.06.01

  • The organization defines for each of its programs/services the competencies it requires of staff who provide care, treatment, or services.  Note: Competencies may be based on the programs/services provided and the population(s) served.
  • Staff with the educational background, experience, or knowledge related to the skills being reviewed will assess competence.
  • As part of orientation, the organization conducts an initial assessment of staff competence before they assume their responsibilities. This assessment is documented.
  • The organization assesses staff competence whenever job duties and responsibilities change.
  • Staff competence is assessed and documented once every three years, or more frequently as required by organization policy or in accordance with law and regulation.
  • The organization takes action when a staff member’s competence does not meet expectations.  Note: Actions may include, but are not limited to, providing additional training or supervision, or modifying job duties and responsibilities.

Undersea and Hyperbaric Medical Society Accreditation guidelines for competency assessment

  • It is recommended that training of hyperbaric chamber personnel be closely monitored, following the guidelines and publications of the UHMS, the Baromedical Nurses Association, and the National Board of Diving and Hyperbaric Medical Technology (NFPA 99 2021 A. [3]
  • At minimum, the governing body policies related to granting clinical privileges for the hyperbaric practitioner include the following elements: education and training, peer evaluation, current state license, DEA certification, a list of privileges requested, and other criteria directly related to the quality of care.
  • Performance appraisals, with feedback to each employee of the hyperbaric facility, are conducted at least annually.

What can programs do to ensure competent performance?

Joint Commission Human Resources (HR) Standard HR.01.06.01 requires accredited organizations to ensure that their staff are competent to perform their responsibilities. Although TJC and the UHMS Accreditation standard(s) provide guidelines, some organizations struggle with meeting them. 

Below is a list of practices adopted by some of the accredited institutions: 

  • Initial assessment period:
    • The initial assessment period should include a review of the job performance (using the applicable job description) at 90 days. Some nursing orientation periods are > 90 days; if this is the case the review of the job performance is done at the end of orientation.  
    • Competency assessment is part of the initial assessment but may be completed prior to the review of the job performance (e.g., for orientations less than 90 days).
    • Competency assessment must be completed prior to employee practicing independently (TJC Standard: HR.01.04.01 - Orientation - Key orientation elements are assessed prior to providing care) 
    • The initial assessment of competency may be documented on a Competency Assessment Tool template or an equivalent form of documentation.
    • During the initial assessment, the preferred and most effective way to determine competency is through direct observation of the skill being performed. When an opportunity to observe the skill is not available, mock scenario, or return demonstration may be used.  In some situations, a review of clinical documentation in the medical record related to the behavior or skill, if appropriate.
  • Annual competencies:
    • Annual competencies may be documented on a Competency Assessment Tool template or an equivalent form of documentation.
    • To meet TJC standards, the equivalent form must contain the skills that are required for competency, the method of verification (e.g., observation, simulation, review of work product), an explicit rating (meets vs. does not meet) and include the signature of the assessor and the date assessed.

How can programs easily set up and manage wound care and hyperbaric medicine-specific competencies? 

The WoundReference Competency Tool empowers programs to meet TJC and UHMS recommendations by offering: 

  • Pre-built, customizable competency templates and training modules for clinicians and staff
  • Documentation, management and tracking features that allow managers to see outstanding competencies and where employees might need education and training
  • Continuing education credits to the wound and hyperbaric clinic team


The WoundReference Competency Tool allows programs to quickly set up and optimize Competencies. The WoundReference Hyberbaric Oxygen Therapy Knowledge Base features guidelines to promote high standards of patient care and operational safety within the hyperbaric program and other important tools. The WoundReference Curbside Consult gives you actionable, specific answers from our expert panel in a timely manner. 

For customized safety programs and other wound care and hyperbaric medicine consultation services, visit MidWest Hyperbaric


We thank Julie Rhee ScM, for style editing

About the Authors

With over four decades of healthcare experience, Jeff currently holds the position of Principal Partner at Midwest Hyperbaric LLC and the Co-founder and Chief Clinical Officer of Wound Reference. Jeff has excelled in critical care throughout his career, devoting almost a decade as a Flight Respiratory Therapist/Paramedic for the Spirit of Kansas City Life Flight. In 1993, Jeff transitioned into the field of Hyperbaric Medicine and Wound Care, where he committed 21 years of his career to serving as the Program Director for a 24/7 Level 1 UHMS Accredited facility with Distinction. In this role, he continued to provide patient care while overseeing all administrative, clinical, and daily operations within the Wound Care and Hyperbaric Facility. Jeff is a Registered Respiratory Therapist and a Certified Hyperbaric Technologist (CHT). He has also undergone training as a UHMS Safety Director and a UHMS Facility Accreditation Surveyor. Jeff currently serves as a member of the UHMS Accreditation Council, the UHMS Accreditation Forum Expert Panel, and the UHMS Safety Committee. Additionally, he is an esteemed member of the NFPA 99 Hyperbaric and Hypobaric Facilities Technical Standards Committee. Jeff's dedication to the field has earned him numerous prestigious awards. In 2010, he received the Gurnee Award, which honored his outstanding contributions to undersea and hyperbaric medicine. Three years later, in 2013, he was awarded the Paul C. Baker Award for his commitment to Hyperbaric Oxygen Safety Excellence. Most recently, in 2020, Jeff was honored with "The Associates Distinguished Service Award (UHMSADS)," a recognition reserved for exceptional Associate members of the Society who have demonstrated exceptional professionalism and contributions deserving of the highest accolades.
An Advanced Certified Hyperbaric Registered Nurse and Certified Wound Specialist with expertise in billing, coding and reimbursement specific to hyperbaric medicine and wound care services. UHMS Accreditation Surveyor and Safety Director. Principal partner of Midwest Hyperbaric LLC, a hyperbaric and wound consultative service. Tiffany received her primary and advanced hyperbaric training through National Baromedical Services in Columbia South Carolina. In 2021, Tiffany received the UHMS Associate Distinguished Service Award. "This award is presented to individual Associate member of the Society whose professional activities and standing are deemed to be exceptional and deserving of the highest recognition we can bestow upon them . . . who have demonstrated devotion and significant time and effort to the administrative, clinical, mechanical, physiological, safety, technical practice, and/or advancement of the hyperbaric community while achieving the highest level of expertise in their respective field. . . demonstrating the professionalism and ethical standards embodied in this recognition and in the UHMS mission.”
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