A Practical Guide to the Joint Commission Standards
A Practical Guide to the Joint Commission Standards
Brenda G. Summers, MBA/MHA, MSN, RN, CNAA-BC WendySue Woods, RN, CSHA, MHSA
Competency Assessment
A Practical Guide to the Joint Commission
Standards
Third Edition
Brenda G. Summers
MBA/MHA, MSN, RN, CNAA-BC
WendySue Woods
RN, CSHA, MHSA
Competency Assessment: A Practical Guide to the Joint Commission Standards, Third Edition, is published by HCPro, Inc. Copyright ? 2008, 2004, 2001 HCPro, Inc. All rights reserved. Printed in the United States of America. 5 4 3 2 1 First edition published 2001. Second edition 2004. Third edition 2008. ISBN # 978-1-60146-251-0
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HCPro, Inc., provides information resources for the healthcare industry.
HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks.
Brenda G. Summers, MBA/MHA, MSN, RN, CNAA-BC, Author WendySue Woods, RN, CSHA, MHSA, Author Jay Kumar, Editor Brian Driscoll, Executive Editor John Novack, Group Publisher Jackie Diehl Singer, Graphic Artist
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09/2008 21498
Contents
About the authors.....................................................................................................................v Preface......................................................................................................................................vii
Chapter 1: Competency basics.................................................................................................1 Definitions and examples of low-volume/high-risk, new or changed, problem-prone, and mandated duties..........................................................................8
Chapter 2: Competency assessments and the Joint Commission standards...........................................................................................................17
Competency assessment tool.....................................................................................35
Chapter 3: Six steps to a successful competency program.................................................37 Example of portion of department-specific guidelines................................................50 Sampling of population-specific components............................................................51 Review process categories.........................................................................................57 Hospitalwide medication errors.................................................................................59 Fourth floor medication errors...................................................................................59 Fourth floor medication errors by type and shift.........................................................60 Sample questions for self-assessment of motivation....................................................63
Chapter 4: What is the competency validation cycle?..........................................................67
Chapter 5: What are validation methodologies?...................................................................81 Validation methodologies and the dimensions of competency they measure.............86
Chapter 6: Ongoing measure of core competency...............................................................97 Analyzing medication error data..............................................................................103 Aggregated medication error data............................................................................104
Competency Assessment, Third Edition
iii
C o n te n t s
Chapter 7: The competency validation process..................................................................107 Competency validation process...............................................................................110 Applicant worksheet................................................................................................111 Registered nurse job description..............................................................................114 Registered radiologic technologist job description...................................................120 Security officer job description................................................................................126 Ongoing competency assessment, Sample 1............................................................130 Ongoing competency assessment, Sample 2............................................................131 Ongoing competency assessment, Sample 3............................................................132 Annual performance evaluation: Organizational competencies...............................133
Chapter 8: Managing the competency program.................................................................139 Ongoing competency statement..............................................................................144 Competency Management Council..........................................................................146
iv
Competency Assessment, Third Edition
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