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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 we 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.

Are there 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 HRM.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 2012 A.
  • 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 are the recommendations 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. 

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.

Recommended elements that should considered in the development, implementation or evaluation of the competency assessment:

  • 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 method for documenting the initial assessment of competency is as follows:
    • Skills Competency Checklist
    • Competency Assessment Tool Template – to be used for initial competency assessment only if no Orientation Skills Competency Checklist is used or if there are additional competencies that require validation.
  • Annual competencies will be documented on the official 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.


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


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