Competencies: See One, Do One, Teach One. Is This Best Practice?

Cynthia Grush, BSN, RN, can be contacted at cgrush@vccolorado.com.  Adele Serio, MSN, RN, RCIS, can be contacted at aserio@vccolorado.com. 

Competencies in the cath lab are not only necessary for staff proficiency and safety of the patient, but also for the protection of the institution. In reality, no one exactly practices the old adage “see one, do one, teach one”, but maintaining competencies while adjusting to an ever-changing schedule in a busy lab is a constantly looming challenge, prompting many managers to wish they could apply this old saying! At our center, The Vascular Center of Colorado, Colorado Springs, Colorado, it prompted a discussion on how to improve competency programs. As a result, we developed a program that ensures staff education and skills are supported while patient care is delivered safely, thereby placing the institution, staff, and patients at less risk.

The Vascular Center of Colorado (VCC) is a joint venture between physicians and Penrose-St. Francis Health Services in Colorado Springs. Established in 2005, the VCC provides invasive lab supplies, implantable devices, and staffing for two local hospitals: Penrose Hospital and St. Francis Medical Center. By means of six labs at Penrose and one lab at St. Francis, a broad scope of coronary, electrophysiology, interventional radiology, endovascular, and neuro-interventional radiology services are supported. It is through years of frustration and inability to maintain optimal employee skills in all service lines that a successful competency program was developed. 

Competency: a definition

A competency model is a framework for organizing and measuring a collection of observable skills, behaviors, and attitudes that impact the quality of work leading to high performance and success.^1,2 Certainly, competency assessment varies among specialties and fields. For example, a company manufacturing baby bottles will evaluate employee competency differently than a facility with employees working in a cath lab. A competency model defines a minimum of what staff must know in order to responsibly execute their jobs. Competency assessment actually extends beyond the evaluation of only clinical skills (Table 1).³  In fact, personnel decisions can result from such assessments (e.g., hiring, promotion, demotion, performance evaluation, retention).⁴

Beyond your team: system impact

As the war for talent rages, many companies have placed competencies at the foundation of their strategic planning initiatives.¹ The fact is, companies are using competencies not only to appraise performance, but also to:

• Recruit prime employees to ensure they fit the organizational model;
• Set and measure performance evaluations more objectively;
• Direct employees how to best contribute to the company;
• Improve employee satisfaction while assuring talent management;
• Provide a distinct roadmap for employees’ professional development with career planning.¹

At this point, you’re probably thinking this article has the potential to be a bunch of bureaucratic mumbo-jumbo. However, research has proven that strategic and well-planned talent management is directly associated with increased employee satisfaction.² Aligning competencies with the organization’s mission and values establishes a direct link between the company’s goals and what it takes to get there. The most effective approach will create and employ competency models that improve personal performance while increasing expertise throughout the organization.¹ To accomplish this level of expertise, competencies must be measureable while integrating pre-determined characteristics such as values, motivation, initiative, and self-control, in order to differentiate high performers from average or low performers.⁴ It is also important to be cognizant of the fact that the assessment must be legally defensible should it become the basis for resulting demotion, dismissal, or the like.⁴ 

Purpose & aim of competencies

In today’s world, competency is no longer just attending an in-service. Competency assessment must become a fluid, ongoing process.³ As an organization evolves over time, there should be ongoing assessments to verify that the appropriate staff are skilled to meet the changing demands of their roles. In addition to the obvious goal of validating personnel skills to ensure high quality care, maintaining up-to-date competencies confirms the facility is in a constant state of regulatory readiness. 

The days of having a static skills checklist are long gone. A dynamic list of assessments primarily focuses on:

• New hires: Licensure, certifications, prior experience, and skills assessment while interviewing and during preceptorship;
• Initial competencies: Central orientation and ongoing preceptorship, focused on knowledge, skill, and ability required for the first six months to a year;
• Ongoing competencies: Build upon initial competencies as well as reflect upon new, variable, high-risk/low-volume, and problematic aspects of the job.⁴ 

The American Nurses Association has stated that competence is not the sole obligation of the facility, educator, or the individual staff member. Rather, it is a shared responsibility of the profession, individual nurses, professional organizations, credentialing and certification entities, regulatory agencies, employers, and other key stakeholders to ensure staff have well-defined, evidence-based, measureable goals.⁵  

Challenges

Having worked in many cath labs, our experience has been that none have yet devised a challenge-free competency program. However, there are several barriers that can be circumvented when leaders proactively address some of the known obstacles, which include:

Lack of time

Unpredictability is the only constant in a cath lab. Change is inevitable. A schedule is merely an outline usually to be quickly disrupted. “There is not enough free time to do competency training.” This defense arises often when attempting to accomplish in-services, attend presentations, or host hands-on demonstrations. It’s frequently hit-or-miss as to who can attend.

Staff schedules

Creative scheduling is necessary to support the variety of work in a cath lab. When competencies are required, staffing is a huge challenge. Sometimes, managers will up-staff to ensure the workflow is uninterrupted. However, up-staffing is not a guaranteed solution. Staffing the 21st century department requires one to be aware of multi-generational needs and pursuits. Some staff work 10- or 12-hour shifts; some are assigned per diem or late starts. Whatever the matrix, all staff are never easily available to attend all events.

Measurement

Competencies should evaluate the level of understanding related to a specific task or action, particularly in regards to how the knowledge is applied. The result requires measurement in real-world situations.³ When an assessment is well organized, there is an expected end result that can be measured. Finding a measurement tool for all competencies can be challenging. However, measurement is an element that absolutely cannot be disregarded.

Composition of a competency program

So, what should (and should not) be included in a competency program? As indicated earlier, employment status assists in guiding the topics to be assessed for each individual employee. New hires are not expected to be as skilled as tenured employees, but each must be assessed and prove their respective level of understanding as appropriate for their position and assignments. Normally, high-risk and low-volume equipment and procedures should be presented to staff more than once a year. Additionally, demanding and problematic equipment or procedures requires more frequent hands-on practice. Cath labs are not required to check off every skill needed to carry out the job. Instead, they should focus on the activities that most affect the work.³ Ongoing competency assessment is NOT an annual re-assessment of the initial competencies for the job.³ As items and topics requiring evaluation change over time, so should the competency program. For instance, the femoral approach was the primary arterial access method for caths in years past. Today, over half of the caths performed at the VCC use the radial approach. Staff was previously deemed proficient in the use of femoral closure devices due merely to their volume, which eliminated the need for annual training. With the decrease in femoral-directed cases, the necessity for an annual evaluation of femoral closure device insertion has arisen.

Validation options

There are a multitude of verification methods to document an established standard is met. There is not one method that effectively assesses all domains at once. Each method captures a separate aspect of the job: technical, critical thinking, and interpersonal. To make the most of the program, use as many verification options as possible to create interest and curiosity. Donna Wright has been a leader in innovative competency training for years. Her website shares innovative tools one may use instead of re-creating the wheel. The site gives detail for the following list of verification methods (https://www.chcm.com/solutions/competency-assessment/). 

Suggested methods of competency validation:

• Post tests
• Return demonstrations
• Case studies
• Observation of daily work
• Exemplars
• Peer reviews
• Self-assessment
• Mock surveys
• Performance improvement monitors
• Presentations

One very effective technique initiated to verify competence at the VCC is the development of super users. This concept is also known as “train the trainer”. Having numerous employees in a department who understand the intricate details regarding the use of challenging equipment is not only a benefit in troubleshooting cases, but also provides immediate access to an on-site expert. At the VCC, every six months a list is posted asking two staff to volunteer to be super users for infrequently used/complex equipment, or procedures, i.e., laser atherectomy. Concentrated training is given in a manner to produce a strong foundation of understanding. This employee(s) becomes an asset to impart the same level of expertise to others, offering a further opportunity to verify competence. Confidence and skill is fabricated within the organizational structure as a safety net is woven by layers of fully-equipped personnel.

The VCC Experience

The VCC was not immune to the challenges noted above. It was thought that blocking the schedule would ensure everyone could attend competency training. Inevitably, several would be on vacation, sick, or working in an emergency. In an effort to reach as many staff as possible, the cath lab was closed for several hours on multiple days for all to attend training stations. This process proved erratic and unreliable, while accomplishing meager long-term results. Staff stated that this process held little value as tasks were addressed hastily primarily to legitimize that competencies had been completed, rather than encouraging substantive education. In response to staff’s honest concerns, process re-designing began.

In December of 2014, the model was transformed. Rather than struggling to reach everyone by lumping all the competencies into limited sessions, the overall program was segregated into 12-month installments. Instead of packing all the required and suggested education into a short period, using the entire calendar year expanded the opportunity for participation. Figure 1 (the VCC Training Calendar) illustrates how the department was sub-divided into specialty groups to properly assign clearly defined material to be completed every month for each service line.  Addressing topics using a variety of validation methods added interest while generating goal-specific measurement tools. Ninety percent of on-time completions was determined as a realistic goal. Possibly having a few not meet the goal was a much better outcome than what we had been experiencing.  

Each month, a copy of the competency assignment was distributed to each employee. As the January 2015 calendar illustrates in Figure 2, each competency had a variety of choices presented as to how respective tasks could be completed. Offering options allowed staff to successfully complete the assigned work via the method through which they learn best. Additionally, it assisted staff individually to coordinate the offerings around their personal schedules. The deadline was for employees to voluntarily complete their assignments by the last work day of the month. 

By the end of December 2014, voluntary staff participation in the competency program was not meeting the compliance objective of 90% of staff to complete their assignments by the last workday of the month. The management team sensed the voluntary element did not demonstrate the importance of timely completion, so accountability for delinquent completion was introduced. One hundred percent of staff completed the assigned work on time in February and March. April had a lapse to 91%, but compliance returned to 100% in May, as illustrated in the Figure 3 compliance graph. Annual employee evaluations now include the percent of on-time competencies as an extra incentive for employees to stay current.

The VCC Competency Program is clearly successful in several measureable ways. First, all staff are participating at the level they are required without impacting workflow. Second, staff are in a state of regulatory readiness, since mandatory modules are up-to-date. Third, staff have the option to complete their assignments over the course of a month, so the staffing matrix and lack of time have less negative impact. In fact, people have a smaller amount of time invested in training and validation, as education is focused only on individual staff’s specific needs. Fourth, compliance is easily measured. 

Countless changes have occurred in health care, so modifying any workflow takes time. In this case, the VCC Competency Program has proven to actively engage staff in having more control and oversight over their own education. A recent employee survey revealed the impact of staff buy-in by improving the results regarding education from 82% satisfaction in 2014 to 90% in 2015. Clearly, everyone is more prepared to perform their duties with confidence and skill. As the sage educator Benjamin Franklin posits, “Tell me and I forget. Teach me and I remember. Involve me and I learn.”n

References

1. Noonan M. Competency models- What are they anyhow and what’s the big deal? St. John Consulting Group. June 2012.  Available online at https://www.stccg.com/competency-models-what-are-they/. Accessed August 19, 2015.
2. Orr JE, Sneltjes C, Guangrong D. Best practices in developing and implementing competency models. Korn/Ferry Institute. July 2010. Available online at https://test.kornferry.einstern.athttps://s3.amazonaws.com/HMP/hmp_ln/imported/documents/briefings-magazine-download/Competency_Modeling1.pdf. Accessed August 20, 2015.
3. Wright D. The ultimate guide to competency assessment in healthcare. 2nd ed. 1998. Eau Claire, WI: PESI Healthcare, LLC.
4. Guide for writing functional competencies. University of Baltimore. October 2005. Available online at: https://home.ubalt.edu/tmitch/651/PDF%20articles/Guide%20for%20Writing%20Functional%20Competencies%20(Annotated).pdf. Accessed August 19, 2015.
5. American Nurses Association. Competency model. 2013. Page 4. Available online at https://www.ana-leadershipinstitute.org/Doc-Vault/About-Us/ANA-Leadership-Institute-Competency-Model-pdf.pdf. Accessed August 19, 2015.
6. Society of Invasive Cardiovascular Professionals. Revised position statement — staffing in the cardiac catheterization and EP lab. Available online at https://www.sicp.com/content/       revised-position-statement-%E2%80%93-staffing-cardiac-catheterization-and-ep-lab. Accessed August 19, 2015.