Developing Staff Competencies in Behavioral Health

By: Shannon Roberts, RN, Senior Clinical Compliance Educator

Shannon Roberts is a registered nurse with over two decades of experience in a variety of outpatient settings, including end-stage renal disease, assisted living, and behavioral health. In her current role at ACHC, she provides comprehensive clinical, accreditation, and industry education to customers and stakeholders.

Posted: April 6, 2026

Competencies are measurable patterns of knowledge, skills, abilities, and behaviors needed to perform work roles successfully. While competency evaluations are common in health care, many behavioral health organizations have not developed a formal competency program and do not conduct annual personnel competency assessments.

As a result, personnel may lack standardized validation of essential skills, which contributes to inconsistent practices, variable quality of care, and increased organizational risk. Without a structured competency program, it becomes difficult to ensure that personnel meet regulatory requirements, maintain clinical proficiency, and adopt current best practices.

Lack of competency programs

Behavioral health has historically placed more emphasis on therapeutic rapport than on standardized assessments. As a result, competencies that are deeply ingrained with clinical culture in other healthcare settings are often lacking in behavioral health organizations.

Several factors contribute to this gap:

  • Behavioral health settings often operate under significant resource constraints. Limited budgets, staffing shortages, and high caseloads may push competency development down the priority list.
  • Leadership may underestimate the value of competencies and competency assessments, deeming them unnecessary based on the assumption that licensure or prior training sufficiently guarantees proficiency.
  • Organizations may lack expertise in designing competency frameworks tailored to behavioral health roles, making the task feel overwhelming or unachievable.

Supporting success

ACHC believes that building a strong competency assessment program strengthens an organization. To meet ACHC Behavioral Health Accreditation Standards, behavioral health organizations must define and assess personnel competencies.

The following ACHC Standard relates to competency assessments:

BH4-6A: Written policies and procedures are established and implemented requiring the organization to design a competency assessment program on the care/service provided for all direct care personnel.

By setting clear expectations, prioritizing high-impact competencies, and fostering a culture where transparency and continuous learning are encouraged, leadership sets the tone for safe, reliable, and consistent care.

When competency management is embedded in daily operations, rather than treated as a periodic task, it reduces organizational risk, improves service outcomes, and enhances overall credibility and accountability.

Tips for compliance

  • Keep policies clear and easy to access. Use plain language and store policies in an easy to find location (e.g., intranet, shared drive, or learning management system).
  • Focus on the most important competencies. Start with 3–5 high-risk competencies. Validate skills like deescalation, documentation accuracy, suicide risk assessment, and medication safety. Then expand from there.
  • Incorporate competencies into existing training. Include post-training tests to check for understanding and skills improvement.
  • Encourage a “no fear, just ask” culture. Leaders can model transparency by saying, “If you’re unsure, ask. We’d rather clarify than correct.”
  • Build assessment into daily routines. Add quick reminders to daily huddles or shift notes (e.g., “Check suicide risk tool is completed.”).

Strategic tool

The most effective and sustainable change for your organization begins at the leadership level, with a clear commitment to practical, measurable, and ongoing competency assessment.

Reframing competencies from a regulatory checkbox to a strategic tool can drive development of a rightsized competency program that aligns with behavioral health workflows, improves staff confidence, reduces variability, and enhances service recipient safety.

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Read more articles about Behavioral Health Accreditation here.