Standard 04.00.09 Evaluation of Competence focuses on staff competence in knowledge, skills, and ability to perform their role responsibilities. The acute care hospital must have an objective process for assessing and evaluating the competence of all employees at defined intervals but at minimum at orientation and on an ongoing annual basis.

The hospital is not bound by strict definitions of these competencies. It has the flexibility to define them, making them job-specific and based on high-risk, low-volume procedures or related to events or trends observed across the facility or organization. Quality goals from the quality assessment/performance improvement (QAPI) plan or risk reports can be a guiding light in selecting focus areas, giving the hospital the freedom to tailor the selection to its unique needs.

Standards 04.00.11 Required Orientation Curriculum and 04.00.12 Annual Required Competencies have specific curriculum elements. All eight (8) components of these standards are required during orientation and then annually for all categories of personnel. The components include:

• Infection control, including bloodborne and airborne pathogens.
• Quality assessment and performance improvement (QAPI) program.
• Life safety.
• Equipment and device safety.
• Hazardous waste and materials safety.
• Information management, including confidentiality, computer access, and medical records confidentiality.
• Patient rights.
• Restraint use, if applicable to role responsibilities.

Standard 04.01.01 Staff Training: Identification of Patients at Risk for Harm requires hospitals to provide education and training to staff regarding:

• The identification of patients at risk of harm to self or others.
• The identification of environmental patient safety risk factors.

This training should be provided to direct employees, volunteers, contractors, per diem staff, and other individuals providing clinical care under an arrangement. Hospitals have the flexibility to tailor the training to the particular services that staff provide and the patient population. This training is required at orientation and annually thereafter.

Standard 15.02.22 Training Intervals focuses on competencies in the application of restraints, implementation of seclusion, and monitoring, assessment, and providing of care for a patient in restraint or seclusion. As mentioned previously, this competency is one of the required eight (8) competencies in standards 04.00.11 and 04.00.12 and must be completed at orientation and annually thereafter for all staff with responsibilities for caring for patients with restraints/seclusion. The required competencies include these standards:

• 15.02.24 Nonphysical Intervention.
• 15.02.25 Least Restrictive Intervention.
• 15.02.26 Safe Application.
• 15.02.27 Restraint Removal.
• 15.02.28 Patient Monitoring.
• 15.02.29 CPR Training.

Standard 16.01.06 Administration of Blood Products and IV Medications requires competencies to be based on nationally recognized standards for intravenous medication administration and blood transfusion and to address at least the following:

• Fluid and electrolyte balance.
• Venipuncture techniques, including both demonstration and supervised practice.
• Blood components.
• Blood administration procedures based on hospital policy, state law, and nationally recognized standards of practice.
• Requirements for patient monitoring, including frequency and documentation of monitoring.
• Process for verification of the right blood product for the right patient.
• Identification and treatment reactions.

These competencies should be completed during orientation and at other intervals if opportunities are identified in QAPI or risk reports.

Standard 18.00.03 Moderate Sedation Competencies should be completed for registered nurses who give moderate sedation medication or monitor patients receiving moderate sedation.

20.00.07 Emergency Services Staff Training requires, at a minimum, that staff are competent in accomplishing rapid assessment and developing intervention plans for emergencies relating to the following:

• Cardiac crises.
• Obstetrics/gynecology crises.
• Orthopedic/neurologic crises.
• Endocrine crises.
• Psychiatric crises.
• Substance abuse.
• Childhood disease and conditions.
• Trauma: highway, industrial, school, domestic.
• Epidemiologic crises.
• Pain management.

23.00.05 In-House Preparation of Radiopharmaceuticals within the nuclear medicine services requires competencies for all staff involved in the preparation and/or supervision of radiopharmaceuticals in accordance with acceptable standards of practice.

26.00.03 Staff Qualifications requires the medical staff to define in writing competencies for all therapeutic staff, consistent with state law. There should be a process for periodic review of the written qualifications and competencies to ensure compliance with changes in state law.

31.00.02 Outpatient Personnel requires hospitals to define in writing the qualifications and competencies necessary for their outpatient leader(s). These competencies should be consistent with state law and acceptable standards of practice.