Fourth in our series on TJC Survey Management Strategies

It’s Day 3 of your TJC survey. Time for the TJC Competence Assessment Session. Surveyors have given you a list of staff names. Now they’ll review your Human Resource and Staff Training files for those individuals.

We’ve seen this session go smoothly. And we’ve seen it descend into chaos. The result can be several findings on your survey report in the Human Resources chapter.

So, what are the current high focus areas? And the common compliance challenges? Let’s review those and help you get prepared for this session.

TJC Competence Assessment Session: Surveyor Focus

The goal of this one hour session is to evaluate how you assess the competence of your staff. And how you orient and educate your employees. For additional insights on the topic of competence assessment, see our previous post Competence Assessment in Behavioral Health.

Who should Attend?

Your HR Director and Staff Training Director are the key players for this session. For hospitals, you may want to have your Director of Nursing attend if several files selected are nursing files. That way, the DON can explain in detail the orientation and competence assessment process for nursing staff.

Which Files Get Selected?

Surveyors typically ask for files of staff they’ve encountered during tracers. So, keep track of that as tracers occur. In addition, the following “high profile” files are often selected:

• Contractors
• Dietician
• Food Service Director
• Infection Control Coordinator
• Pharmacist
• X-ray technicians
• “One of a kind” therapists: music, art, activities

Keep in mind surveyors will review for documentation of all the requirements in the Human Resources chapter of the Hospital or Behavioral Health manuals. That includes credentials, orientation, competence assessment, and performance evaluations.

You may keep this information in a few different files. Such as separate HR and staff training files. Be sure to bring both of those files to this session.

TJC Competence Assessment Session:  Compliance Challenges

There are clear trends in survey findings related to competency assessment. So, let’s take a look at those.

Contractors: Orientation and Competence Assessment

Don’t forget that contractors need some type of orientation to your organization. That doesn’t need to be as extensive as your staff orientation. But it does need to include an orientation to their role, to safety, and to any other job related requirements.

Similarly, contractors need to have some assessment of their competence. That can either be done by the contracted agency or by you.

For more details, see the following TJC FAQs: Competency Assessment vs. Orientation and Contract Staff – Applicability of Human Resource Standards.

Competence Assessment by a Peer

You may have some “one of a kind” practitioners in your organization. For example, one dietician or one music therapist. Their competence assessment needs to include input from a clinical peer.

An administrative supervisor can do the non-clinical portion. But input on their clinical performance needs to be done by a clinical peer.

That goes for contractors too. See more on this topic in our post TJC HR Requirement: Competence Assessment by a Qualified Individual.

Credentials Verification

It’s surprising how many organizations still get cited for late or missing verification of credentials. For example, licenses or queries to the National Practitioner Data Bank.

So, be sure you have a process in place to verify credentials at time of hire and again at time of expiration. Even if you have the current license in the file, surveyors will check to see if you verified it prior to the expiration date of the previous license.

Performance Evaluations

This is “low hanging fruit.” But many organizations still get cited for overdue or missing performance evaluations. You can fix this before your survey so don’t get caught on this one. Hold managers accountable for getting these done on time.

Organization Specific Requirements

Always remember: TJC surveys you not only for compliance with their standards but also with your own policies.

For example, if you require all staff to have certain health screenings, they will hold you to that. Even though it’s not a TJC requirement.

So, be sure to thoroughly vet your training requirements in terms of what’s required by law or regulation. And what you may (or may not) want to additionally require as organizational policy.

Survey Management Take-Aways

The following tips may sound basic. But we guarantee they’ll help you have a smooth and successful TJC Competence Assessment Session:

• Make sure your HR and Staff Training files are well organized and easy to review. Disorganized files are frustrating for surveyors.
• Be aware of the “high profile” files typically selected by surveyors. Get those in shape now.
• Audit your files on an ongoing basis for compliance with TJC HR requirements.
• During survey, review beforehand all the files you’ll provide to surveyors. You may be able to correct some missing documentation and avoid a citation.

Barrins & Associates Mock Survey

Our Mock Surveys include a robust Competence Assessment Session. We have an audit tool we share with clients. Many report they use the tool on an ongoing basis to stay prepared for surveys. They also report fewer findings on their actual TJC surveys. Always a welcome outcome!