Evidence-Based Best Practice for Nursing Skills Competency Assessment: A Policy Development Project for Standard Work Utilizing the Donna Wright Competency Model

Practice Problem: Traditional nursing competency assessments use a process-focused approach determined by leaders. A checklist methodology for conducting nursing competencies does not empower nurses to create their own learning experiences. PICOT: The PICOT question that guided this project was: In an acute care setting (P), how does the development of an evidence-informed policy for competency assessment utilizing the Donna Wright Competency model (I) compared to current competency assessment practices (C), improve the guidance for nurse educators in the development of standard work and communications regarding competency assessment (O)? Evidence: Studies using the DW Competency Assessment Model have shown that this model provides structure and consistency through the collaboration of nursing staff members, nursing leaders, and other key stakeholders. Intervention: The development of an evidence-informed policy for competency assessment using the Donna Wright Competency model was the selected intervention completed over six weeks. Outcome: The development of the policy for competency assessment guided the nurse educators and other key stakeholders with the standard work and communication of competency

Global, national, regional, and local healthcare systems are vested in establishing standardized nursing competencies processes to prevent serious public health problems. For example, medical errors lead to serious patient safety issues (Rodziewicz et al., 2021). Therefore, if nurses show poor nursing competence, the risk of medical errors increases, leading to negative patient outcomes. According to Rodziewicz et al. (2021), approximately 400,000 hospitalized patients experience a degree of medical harm yearly. Rodziewicz et al. (2021) state medical errors account cost approximately $20 billion a year and result in approximately 100,000 deaths. Patient safety is a major concern in healthcare. Patient safety is defined as "preventable harm to a patient during the process of healthcare or as the prevention of errors and adverse events caused by the provision of healthcare rather than the patient's underlying disease process" (Kangasniemi et al., 2013, p. 904). From an ethical perspective, patient safety protects and promotes human dignity (Kangasniemi et al., 2013).
The issue of continued nursing competence goes beyond the initial licensure process (Whittaker et al., 2000). The regulatory approach for continuing competence is not the sole responsibility of a given state's nursing board. The responsibility of nursing competence expands to nursing organizations, the private sector, and state and federal government agencies (Whittaker et al., 2000).
Since the organization will be implementing a new nursing competency standard of practice, a policy for the standard work using the Donna Wright Competency Model is essential.
A local competency policy guides the organization's competency assessment process. According to Annesley (2019), policies frame the individual's professional practice, roles, knowledge, and responsibilities.

PICO Question
The PICO question that guided this question was: In an acute care setting (P), how does the development of an evidence-informed policy for competency assessment utilizing the Donna Wright Competency model (I) compared to current competency assessment practices (C), improve the guidance for nurse educators in the development of standard work and communications regarding competency assessment (O)?

Population
The term "acute care" describes a level of healthcare where an individual requires brief and immediate treatment (Acute Care Hospitals & Their Role in Healthcare, 2019). The care provided in an acute care setting is typically a hospital setting where clinicians such as a nurse, medical doctors, and other healthcare professionals can diagnose, treat, and care for a variety of medical conditions (Acute Care Hospitals & Their Role in Healthcare, 2019).

Intervention
The intervention objective was to develop an evidence-informed policy for competency assessment using the Donna Wright Competency assessment model. According to Wright (2005), competencies are best determined by the nurses doing the work, and not by leadership. Thus, Wright (2005) suggests the specific departments or units determine the competencies needed for the given unit or department. Wright's competency assessment model consists of the following three elements: ownership, empowerment, and accountability (Wright, 2005). At the ownership level, nurses take ownership of their outcomes, practice, and competencies. Thus, the empowerment phase allows nurses to take control of their practice by placing them at the center of the verification or validation process (Wright, 2005). Finally, embracing an accountability-EVIDENCE-BASED BEST PRACTICE FOR NURSING SKILLS 8 based culture allows the nurses to be personally committed to achieving the utmost best practices within the organization (Wright, 2005).
A main component of the Donna Wright Competency assessment model is the competency verification methods used to measure the knowledge for a specific competency (Wright, 2005). Therefore, the evidence-informed policy includes the validation tools to measure a given competency. The eleven verification methods are tests, return demonstrations, evidence of daily work, case studies, exemplars, peer review, self-assessment, discussion groups, presentations, mock events or surveys, and quality monitors (Wright, 2005). According to Wright (2005), providing several verification methods creates a culture of empowerment.

Comparison
The federal hospital is not currently using a standardized competency model. The current competency assessment practices at the facility vary from unit to unit. The purpose of developing a policy was to describe the system for supporting and verifying clinical competencies of nursing staff utilizing a dynamic approach to gain and demonstrate competence to expert skills by following the Donna Wright Competency model.

Outcome
The overarching outcome of this project was to improve the guidance for nurse educators in the development of standard work and communication as it relates to the competency assessment of clinical staff.

Evidence-Based Practice and Policy Framework
The CDC (Centers for Disease Control and Prevention) POLARIS policy process framework guided the policy development. The CDC POLARIS framework is an analytical model recommended for healthcare policies and may be adapted for policy development. The five domains of this policy process include (1) problem identification, (2) policy analysis, (3) strategy and policy development, (4) policy enactment, and (5)

Evidence Search Results
The preferred articles included experimental studies, nonexperimental studies, quasiexperimental studies, quality improvement projects, and a Delphi study. The generated PICO question guided the search.

Search strategy
The project manager searched CINAHL Complete, OVID Emcare, PubMed, and JBI EBP databases. The subject headings included nursing, EBP competence, policy development, and model. The titles and the abstracts were reviewed. The search was limited to published peer reviews from 2014 to current. Twenty-seven articles were generated in the CINAHL database using the search headings. Next, the OVID database generated 3707 articles, PubMed generated 481 articles and the JBI EBP database resulted in 1343 articles.

Study selection
The literature selection was restricted to experimental studies, nonexperimental studies, quasi-experimental studies, quality improvement studies, and a Delphi study. The literature selections were limited to studies that include nurses, EBP competence, policy development, and the EBP model. The reduction of articles was due to the exclusion of articles concerning nursing students and competencies relating to nursing students. The inclusion of articles focused on practicing nurses primarily in the acute care setting and policy development. The details of the articles chosen are identified in a table format located in Appendix A. The project manager was aware that further articles were needed to develop a policy on the standard work using the Donna Wright Competency Assessment Model. Figure 1 provides a PRISMA flow chart diagram of the studies included in the synthesis.

Synthesis of the Literature with Themes
The literature review conducted assisted in answering the generated PICO question. The literature selections revealed similarities in themes relating to the importance of evidence-based practice (EBP) skills and knowledge in the clinical setting.

Donna Wright Competency Assessment Model
The importance of competency validation methods has been explored in the literature.
Wright's competency model is known for empowering nurses to create their own learning experiences through various types of competency validation methods versus checklists (Salmela & LaValley, 2021). Authors have agreed that the checklist methodology for conducting nursing competencies is not a valid method for measuring competency (Durkin, 2019;Salmela & Fencl, 2021;Wright, 2005).
Wright's competency model is being used across various healthcare organizations. Moreover, the commonality within the literature review suggests the importance of professional competence in nursing practice (Durkin, 2019;O'Neal & Fencl, 2021;Salmela & LaValley, 2021;Schanne et al. 2016). A competency assessment model provides structure and consistency through the partnership of staff members and key stakeholders (O'Neal & Fencl, 2021).

Competency Framework
Additionally, Sastre-Fullana et al. (2014) and Ahmadi et al. (2017) suggest that a competency framework in nursing assists managers and educators take the initiative to guide professional competence by choosing the appropriate strategies or validation methods. Sastre-Fullana et al. (2014) concluded competency frameworks can be used in the development of policies to better comprehend the standards of practice as it relates to nursing competence. Ahmadi et al. (2017) concluded that an appropriate competency framework ensures safe nursing practices, prevents adverse effects, and improves performance at all levels of nursing.
One of the themes of this concept analysis is how leadership leads the path to the development of policies, which impact health services, health care, and public policy (Ahmadi et al., 2017).

Policy Development
In healthcare, processes change and evolve frequently to keep up with the latest and best

Importance of evidence-based practice
All the selected articles agree that integrating an evidence-based practice improves quality and health outcomes (Gallagher Ford et al., 2020;Gorush et al., 2020;Halm, 2018;Liu et al., 2021). Thus, EBP decreases costs and empowers clinicians to deliver safe care (Gallagher Ford et al., 2020;Halm, 2018). Therefore, implementing and sustaining EBP competence will transform an organization's culture over time (Gallagher Ford et al., 2020).

The Institute of Medicine (IOM)
The Institute of Medicine is a nonprofit organization focusing on biomedical science, medicine, and health (NCHPAD, 2021). Three articles indicated how the IOM's goal was to have greater than 90% of the clinical decisions be evidence-based by 2020 (Gallagher Ford et al., 2020;Halm, 2018;Liu et al., 2021). Yet only 25% of clinical decisions currently are evidencebased (Gallagher Ford et al., 2020;Halm, 2018;Liu et al., 2021). Moreover, evidence shows that nurses in hospitals and healthcare systems in the United States may not be competent in any EBP competencies for practicing nurses (Gallagher Ford et al., 2020).

Evidence-based continuing education
There is a need globally to improve outcomes and quality of care by using evidencebased practice (EBP) (Liu et al., 2021). The gap in EBP knowledge and skills needs to be addressed to ensure best practices and outcomes (Gallagher Ford et al., 2020;Liu et al., 2021).
An EBP continuing education skill-building program has been proposed to improve EBP beliefs, implementation, competence, and knowledge (Gallagher Ford et al., 2020;Gorush et al., 2020;Liu et al., 2021).
The EBP continuing education program consists of a 5-day EBP immersion involving a seven-step EBP process and effective strategies for integrating and sustaining an EBP program within healthcare organizations (Gallagher Ford et al., 2020;Gorush et al., 2020). The goal of the 5-day EBP immersion is to gain and sustain EBP competence over time (Gallagher Ford et al., 2020). Halm (2018) proposed using a valid and reliable tool to evaluate the effectiveness of educational programs in improving EBP knowledge, skills, and competencies. Halm (2018) suggested using the Modified Fresno-Acute Care nursing test to assess the EBP knowledge and skills of acute care nurses.

Utility of the Policy Review
The Donna Wright (DW) Competency Assessment Model stresses that competency skills are necessary to provide optimal patient care (Tharpe- Barrie et al., 2020). This model empowers nurses to construct their own learning experiences for continued professional growth (Salmela & LaValley, 2021). Furthermore, the model focuses on technical, interpersonal, and critical thinking skills by giving 11 different validation methods (Salmela & LaValley, 2021).
Additionally, the DW model nursing competencies are measured to ensure that the best care is delivered to patients (Wright, 2005). The model also looks at the process of measuring competencies thoughtfully and critically (Wright, 2005). Finally, the DW model focuses on elements relating to competency assessment success (Wright, 2005).
In addition, the DW model uses an outcome-focused and accountability-based assessment approach by identifying nursing competencies through a collaborative effort between the nurse manager or nurse educator and staff based on a prioritized need (Wright, 2005). Also, competency verification is accomplished through different methods such as guided reflective practice, outcome measurements of daily work, and verification that develops critical thinking (Wright, 2005).
In comparison, traditional competency assessments use a process-focused approach and are determined by leaders such as nurse managers and educators (Wright, 2005). Thus, there is no collaborative effort between the nursing leaders and nursing staff. Moreover, competency verification is done only by a few methods such as tests and checklists.
According to Wright (2005), it is important to review competency assessment strategies to promote individual accountability. The DW model holds the nursing staff accountable for their competency assessment (Wright, 2005). Thus, the nurse manager or educator's role is to create an environment that encourages and supports their achievements versus conducting a "check off" of skill sets (Wright, 2005). Therefore, the establishment of a local competency policy incorporating the DW model will guide the organization's assessment process by defining what constitutes competency in the facility, a detailed description of the DW competency process, and a description of the staff responsibilities (e.g., leaders, educators, managers, and staff) and detailed procedures concerning initial and ongoing competency process (Wright, 2005). According to O'Neal and Fencl (2021), competencies are the key to becoming a competent professional nurse. O'Neal and Fencl (2021) state that the use of evidence-based practices in patient care facilitates nurses' professional competence which leads to the optimal and safe care of patients. The incorporation of a local policy for the use of the DW model sets mandatory competency standard practices for the organization.

Setting, Stakeholders, and System Change
The project manager conducted a DNP scholarly project at a local large federal hospital in California. The hospital system provides health care services to more than 50,000 veterans in Moreover, the organization's main goal is to obtain Magnet status and become a high-reliability organization.
Furthermore, the organization's mission is to fulfill President Lincoln's promise, "To care for him who shall have borne the battle, and for his widow, and his orphan" by caring for America's veterans (U.S. Department of Veterans Affairs, 2021b). The core values inherent to the VA's mission include integrity, commitment, advocacy, respect, and excellence (U.S.

Stakeholders
The project manager identified the following stakeholders: the project manager's preceptor, the organization's patients, the quality service value staff, the risk management department, nurse managers, staff nurses, nurse educators, the nurse practice committee, the office of nursing services, patient safety staff, and the chief executive officer. The objective of the policy is to improve the guidance for nurse educators in the development of standard work by utilizing a policy involving the Donna Wright Competency model. Thus, an interprofessional collaboration of all the stakeholders was required to implement a standardized policy using the Donna Wright Model for competency assessment successfully.

System Change
A SWOT (strength, weakness, opportunities, and threats) analysis is a tool in decisionmaking used to evaluate a strategy or for directing teams during a project (Jenčo & Lysá, 2018).
Furthermore, a SWOT analysis (Appendix B) provides insight into the current and future state of the organization's system needs (Elasser et al., 2018). The strengths identified include using the LEAN process, remote access to care, government support, and integrated technology. The weakness includes the organization's size contributing to slow progress, funding, suboptimal staff engagement, and strained timelines (Elasser et al., 2018). Some of the opportunities noted include focusing on strategic versus tactical planning, access to government funding, and expanding services through technology (Elasser et al., 2018). Lastly, threats identified are government budget cuts, staffing shortages, and unknown political forces (Elasser et al., 2018).
A macrosystem plays an important role during change. First, the mission, vision, and organizational goals are identified (Kosnik & Espinosa, 2003). Macrosystems facilitate system transformation at all system levels (Kosnik & Espinosa, 2003). Performance is measured against the organization's plan and goals (Kosnik & Espinosa, 2003). Then, the planned goals are communicated to the stakeholders, and education is provided concerning the proposed change project (Kosnik & Espinosa, 2003). The deployment of strategic actions is translated into specific and measurable goals (Kosnik & Espinosa, 2003).

Policy Development Plan with Timeline
The guiding objective for the policy development project was the application of the CDC POLARIS framework in the appraisal and development of a policy statement for the implementation of the Donna Wright (DW) Competency model as the framework for competency assessment. Additionally, the policy will serve as a communication plan for implementing the DW model. The SMART (specific, measurable, achievable, relevant, and timebound) goals assisted with the application of the CDC POLARIS framework to develop the policy.

Specific
To achieve the policy development goal, the participation of key stakeholders was integral to the development of the policy.

Problem Identification
The first step in policy development was developing a problem statement. The stakeholders assisted with framing the problem. The key stakeholders included the director of nurse professional development, the chief of quality service value, nurse educators, and nursing staff. The federal hospital will be implementing the DW model within the upcoming months.
Unfortunately, the organization did not have a clinical competency policy relating to the DW model. The timeframe objective was to have a policy developed by November 2022 as this is the proposed date the organization will be implementing the DW competency model. The project manager had not previously developed a policy. This obstacle was overcome by using the CDC POLARIS framework to develop the policy. The policy guides nurses in effectively utilizing the DW model for nursing competencies. Furthermore, the nurse educators and nursing staff will have a better understanding of the knowledge, skills, and behaviors that are required through the competency assessment.

Policy Analysis
During the policy analysis step, the project manager analyzed the current competency assessment policy for the organization. Before the development of a local policy, the organization did not have a local policy addressing the Donna Wright Competency model. The main individual involved in the policy development was director of clinical staff development within the nursing staff education department. This stakeholder is a subject matter expert in the Donna Wright Competency Assessment Model. She assisted in providing and interpreting the information required for the policy analysis. The population affected by the policy is the nursing personnel. There were no budget constraints during the development of the policy. A barrier identified that could prevent the policy from being developed, enacted, or implemented is staff changes within the organization.

Strategy and Policy Development
The director of nurse professional development assisted with drafting the policy. The project manager was required to use the organization's policy template (Appendix C). The language for the policy included concepts from the Donna Wright Competency Model. The policy provides definitions for competence, competency, hire competency, initial competency, competency verification methods, ongoing competencies, annual competencies, clinical champions, and qualified validator. Additionally, the responsibilities of the nurse manager, nurse educator, nursing staff, and chief nurse executive are outlined. The procedure sections include a description of initial competency, ongoing competency, and evaluation tools. Lastly, the policy includes the references used in the development of the policy.

Policy Enactment
Policy enactment involves obtaining permission to implement the policy (The CDC Policy Process: POLARIS Policy Analysis, 2021). The project manager obtained permission from the director of nurse professional development and the chief of quality service value of the local hospital organization.

Policy Implementation
The director of nurse professional development will be conducting ongoing education for the nurse educators and nurse managers. The nurse managers for each unit and nurse educators will be educating the nursing staff regarding the new clinical competency policy embracing the DW model. The current policy for clinical competencies will be replaced by the new policy. The director of nurse professional development will ensure that any previous clinical competency policy is replaced with the new one under the organization's policy directive.

Measurable
The objective was to develop the policy for nursing competency using the DW Competency model and have it completed by November 2022.

Achievable
The facility provided a written letter of permission to develop a standard operating procedure (SOP) addressing the use of the Donna Wright Competency model as the framework for competency assessment. Additionally, the project manager received an alternative project approval letter from the school of nursing to complete the policy review.

Relevant
The development of a standard operating procedure policy will guide the organization's competency assessment process by defining what constitutes a competency within each unit or department, providing a detailed description of the DW competency assessment model, and giving a description of the staff responsibilities (e.g., leaders, nurse educators, nurse managers, and nursing staff).

Time-bound
The project manager completed the development of the standard operating procedure (SOP) policy within a 6-week timeframe. During week 3, the project manager completed a draft of the SOP. In week 6, the project manager disseminated the developed policy to the organization during the monthly quality service value monthly meeting. Figure 2 provides a project timeline for the completion of the policy development.

Impact
This project aimed to develop a standard operating procedure policy for nursing competency assessment by addressing the Donna Wright Competency Assessment Model as the standardized framework for the policy. The organization is on a journey of becoming a highreliability organization (HRO). One of the main pillars of an HRO is the presence of continuous process improvement to ensure the best quality of care is provided to patients. Thus, enacting a policy for nursing competencies has several benefits. Additionally, the project manuscript will be archived in the Scholarship and Open Access Repository (SOAR) at the University of St. Augustine for Health Sciences. The submission of the project manuscript to this repository will allow for access to scholarly projects throughout the academic and professional nursing communities.
Furthermore, an oral presentation of the DNP scholarly project will be available through GoReact. GoReact is a private portal where the project manager, the project manager's peers, and instructors can see the presentation. The peers and instructors will have the opportunity to provide feedback through the video tags.

Conclusion
The development of a policy project was conducted at a large federal hospital in Southern International Nursing Review, 67, 11-18. Wright, D. (2015). Competency assessment field guide: A real world guide for implementation and application. Creative Health Care Management. Wright, D. (2005). The ultimate guide to competency assessment in health care (3rd ed.).
Creative Health Care Management. Project Timeline

PURPOSE AND AUTHORITY
a. The purpose of this standard operating procedure (SOP) is to establish procedures on orientation and competency assessment utilizing the Donna Wright outcome-focused/accountability-based assessment model for nursing staff. This model along with a peer review process serves to assess and assure nursing competency. This SOP must be followed by nursing staff who provide care to the veteran population served.
b. There is no governing document.

a. Initial competency
(1) After completing nursing orientation as verified by completion of the nursing orientation checklist, the nursing staff will be provided with unit-level orientation and inservice programs to verify clinical competencies specific to their current assignment.
(2) Verification of competency will be documented on the Initial Unit Orientation & Competency Checklist within 30 days of hire or start date.

b. Ongoing Competency
(1) Annually the nurse manager and/or nurse educator initiates competency identification by staff requests and needs, issues identified through process improvement activities, and incident reports. The focus of competencies will also include high-risk activities, problem-prone activities, and new or changed procedures and equipment.
(a) Worksheet for Identifying Ongoing Competencies (Appendix A) (2) Nurse Manager may request input from the nurse educator to help prioritize the topics listed.
(a) A maximum of ten (10) items can be selected as high priority.
(3) Nursing education will transcribe the high-priority topics to the Competency Assessment Form (Appendix B) placing the items under one of three domains: technical, critical thinking, or interpersonal.
(a) The Competency Assessment Form is prepared for use by Nursing Education to include methods of verifying clinical competence. Methods can include but may not be limited to: • Tests (5) Nursing staff will identify the preferred method of competency verification and complete the required sections of the Competency Assessment Forms before the due date. Resources for completion may include but are not limited to: • Nurse Educator led programs • Online resources • Unit resources • Simulation training programs (6) Quarterly or more frequently, the nurse manager will follow up with individual staff members in their unit regarding the completion of the various competencies. By mid-year, competencies should be at least 50% complete.
(a) The periodic review of competency completion will provide an opportunity for the Nurse Manager to encourage completion by stressing the importance of the competencies and identifying obstacles to completion.
(b) Periodic review will be documented by the Nurse Manager on the Competency Completion Summary (Appendix C) form.
(7) After the competency assessment period, all forms will be completed and submitted to the Nurse Manager. By September 15 th , the Nurse Manager submits a report to the Associate Director of Patient Care Services/Nurse Executive regarding competencies evaluated for the year and the number of staff with verified competencies.
(a) The Associate Director of Patient Care Services/Nurse Executive will certify 100% review and validation of nursing competencies through the Director and VISN Leadership to the Office of Nursing Services. This annual certification (in a simple memo format) needs only state all nursing competencies are completed for the past fiscal year.
(b) Additional Information Related to Nursing Competencies 1) When nursing staff is expected to provide care on another unit, cross-training is provided before that person administers unsupervised care, unless already deemed competent in the area.
2) As appropriate, nurses functioning in expanded roles (e.g., clinical specialists, infection control nurses, nurse managers), will provide the scope of nursing care as outlined in their functional statements. The yearly performance proficiency and competency assessment/verification process will constitute approving their specialized functions.
3) During the competency assessment period, if new or changing procedures, equipment, or policies are identified, alternate methods of training will be utilized to assure staff knowledge.

4) Competency Assessment Audit Tools for use by VALB or an Office of Nursing
Services are available on the XYZ Nursing Competency SharePoint.

ASSIGNMENT OF RESPONSIBILITIES
a. Nurse Manager: The nurse manager will initiate/evaluate the needs of the unit with input from the nursing staff. The nurse manager assures all nursing staff meets the identified role/unit competencies. Each nurse manager is responsible to: 1) Set target dates for completion of competency evaluations for each nursing staff member assigned to the unit.
2) Assign responsibility for reviewing and verifying specific competencies of nursing staff to a trained competency verifier 3) Ensure all staff remains current in their competencies. If a staff member cannot independently perform or verbalize a skill, an education action plan is outlined and implemented, including a timeline and re-evaluation date.
4) Keeping a current copy of each permanent employee's competency verification on the unit.

5) Nurse
Managers are responsible for informing the Nursing Education of any identified learning needs unmet at the unit level related to the competency program.
6) When the nursing staff member is transferred to another unit, the new nurse manager will assess the needs of that employee and initiate the unit orientation and initial competency verification process.
b. Nurse Educators: The Nurse Educator is assigned the responsibility to provide: 1) Expertise to support the council, managers, and employees in their areas of responsibility in the competency assessment process 2) Expertise in matching the appropriate verification methods to the competencies identified by the nursing staff.
3) Support or help facilitate the manager and staff in the identification of the competencies, and can help oversee and support the competency verification.
c. Nursing staff: The nursing staff is assigned the responsibility to: 1) Complete competencies as indicated using the verification methods from the approved list for each competency.
2) Participate in competency development.
3) Participate in the evaluation of the competency process. 4) Complete the assigned competencies on time.
5) Collect evidence demonstrating his or her competency to ensure competencies are completed and verified.
d. Chief Nurse Executive: The Chief Nurse Executive is assigned the responsibility to: 1) Support the annual establishment of unit ongoing competencies and verification of these competencies.
2) Provide annual certification of nurse competency to the Leadership Board.
3) Ensure appropriate action is taken if a nurse is deemed to be not competent to perform functions of their position.

DEFINITIONS
a. Competency is the nursing staff's demonstrated ability to demonstrate the knowledge, attitudes, skills, and behaviors essential to the delivery of quality nursing care.
b. Competence is the potential ability to integrate the knowledge, skills, and behaviors required for performance in a designated role.
c. Initial Competencies. Individuals are hired with basic competencies learned during formal training. By virtue of an RN's and LPN's licensure and graduation from a school of nursing, the assumption is made that the RN and LPN are competent to deliver basic nursing care at the appropriate level. By virtue of a nursing assistant, having six months of experience and/or being certified, the assumption is made that the individual is competent to deliver basic nursing care at the appropriate level. Competency in the XYZ Hospital processes and programs is gained during the orientation period generally lasting 21-35 days. Competency validation is recorded on the Initial Nursing Orientation sheet. d. Ongoing Competencies. A dynamic program based on the needs of the nursing staff, new, or changing processes, high-risk, and problematic job duties. This type of program places accountability on the staff and is supported by Nurse Managers. e. Annual Competencies. Core competencies for the medical center to include annual mandatory reviews. The core competencies are assigned based on the requirements from directives, accrediting agencies, and safety programs.
f. Hire Competencies. Ensuring that the employee meets the minimum requirements of his/her job description. Will include validation of the following: • Licensures or certifications

REVIEW
This SOP must be reviewed, at a minimum, at recertification, when there are changes to the governing document and any regulatory requirement for more frequent review.

RECERTIFICATION
This SOP is scheduled for recertification on or before the last working day of September 15, 2027. In the event of contradiction with national policy, the national policy supersedes, and controls. High Med Low What are the high-risk procedures/processes? Procedures or processes required by standards, regulations, or policy?

SIGNATORY AUTHORITY
Are the high-risk procedures/processes time-sensitive?
What are PROBLEMATIC aspects of this job? (Identified through quality management data, incident reports, patient or staff surveys, and other forms of evaluation)

Directions for completion:
To successfully identify true ongoing competency needs, an ongoing competency assessment must be completed for each position. As many staff as possible should participate in the assessment, including the nurse manager, clinical coordinators, nurse specialists, nurse educators, and staff in the position being assessed. Ongoing competency needs are based on the following questions: • Are there any new procedures, policies, equipment, or initiatives?
• Are there any changes in procedures, policies, equipment, or initiatives?
• What are the high-risk procedures/processes? Procedures or processes required by standards, regulations, or policy? Are the high-risk procedures/processes time-sensitive?
• Are there any problematic procedures? (Quality data & incidence review; i.e. # of CAUTI in a specific area) Complete the brainstorming of competency needs before prioritizing. The competency needs are prioritized as high, medium, and low using the following considerations: • Does the competency appear in more than one box?
• What are the outcomes for the patient and the employee?
• Is it high-risk and time-sensitive?
• Are there regulations, standards, or policies that mandate competency verification?
Make notes for why or why not this competency was chosen; this provides documentation. The completed assessment will be submitted to the Unit Manager and Nursing Education Department (Clinical Staff Development).
Also, note areas needing education rather than competency verification since there is a difference.
Competency assessments are based on knowledge, performance behaviors, or psychomotor skills. Cross out those areas listed below not applying to your area.

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