Twenty-two percent of behavioral health organizations surveyed in 2016 received a survey finding related to competence assessment. Frequently, the finding relates to a staff person or contractor not having their clinical competence assessed by an individual qualified to do so. The relevant standard is HRM.01.06.01 EP 2 in the BH Manual and HR.01.06.01 EP 3 in the Hospital manual: “Staff with the educational background, experience, or knowledge related to the skills being reviewed assess competence.”

Here’s how this standard is typically reviewed by surveyors: During the Human Resources interview, they ask for the file of a specialty or “one of a kind” practitioner such as an occupational therapist, a dietician, or a rehab therapist. Then, the surveyor reviews the HR file to see if that practitioner has had input to their clinical competence assessment from someone in the same discipline. The requirement is that the individual conducting the competency assessment must have the appropriate background/ training to assess the clinical competence of the practitioner being evaluated.

So, where do problems arise? The following are examples from actual surveys:

  • The organization had only one dietician and her performance evaluation had been conducted by an administrator with no input from another dietician.
  • The nurses who worked in a community based program had been evaluated by the program director who was not a nurse.
  • The contract OT had never had any type of competence assessment.
  • The activity therapists were being reviewed by the Director of Nursing.

So, it’s important to ensure these types of practitioners get input from a peer in the same discipline. What are your options? First, identify if there is a clinical peer within your own organization. This can either be someone in a supervisory position or a colleague working in the same position. If there is no clinical peer within your organization, is there a “sister facility” with the same type of practitioner who can provide a peer review? If neither of these is an option, TJC allows for obtaining a peer recommendation from an individual outside of the organization; e.g. from a peer at another agency where the practitioner works.

What about the scenario in which there is no peer within the organization and the practitioner does not work at another agency where they can get a peer recommendation?  In this case, the best approach is to retain (i.e. pay for) a peer from outside the organization to conduct the clinical review on your practitioner.

A few points of clarification on this topic:

  • The individual who is the administrative supervisor for the practitioner can complete the non-clinically related portions of the performance evaluation. Input from a clinical peer is only required for the clinical responsibilities.
  • The peer input should include some type of firsthand review of the practitioner’s work: e.g. evaluation of clinical documentation; observation of work; case presentations, etc.
  • The working definition of a peer that we have seen accepted by TJC is the following:
    • The peer is a practitioner in the same discipline; e.g. nurse to nurse.OR
    • The two practitioners are peers because they both work under the same job description. For example, the Outpatient Therapist job description allows for the position to be filled by a social worker, a licensed mental health counselor, or a marriage and family therapist. In this case, these individuals are considered peers.

So, be sure to identify any staff or contractors who are “one of a kind” practitoners. Make sure you have a process in place for evaluating their clinical competence and avoid this common deficiency on your next survey!


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