Testing the Team

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August/September 2003

By Julie Kiefer Eaman, MA, CCC-SLP; J Beverly Maiers, PT; Lynn Said, PT, MSA, Joseph M. Pellerito, Jr, MS, OTR; Mary Kay Currie, OT; and Susan Boeve, CTRS, ATRIC

Hiring a good staff is one thing. Making sure they stay good requires a strong clinical staff competency program.

Hiring and maintaining a competent staff is one challenge of health care management. The core of a quality rehabilitation program is a professional staff with suitable skills and experience to provide services to the general public. Definitions of clinical competency generally include the common elements of knowledge, skill, and professional judgment.¹ The integration of these three fundamentals ensures competency for the patient being served, the accrediting bodies evaluating a program, and those paying for services.

Entry-level competency is generally ensured through licensure and/or certification. Regulatory boards currently require some basic indicators of competence for entry-level practitioners, specifically graduation from an accredited program that includes a structured clinical internship and a passing score on an entry-level examination.

However, ongoing competence relates to the ability to effectively and safely practice throughout one's career.² It describes a professional's skill when confronted with changes in technology and the work environment, including the expectations of the clientele and those paying for services. Competency cannot be stagnant, but evolves. Therefore, competency measures need to evaluate a professional's ability to assimilate changes into his or her practice.³

Evaluating competency
A variety of methods have been employed to evaluate competence. Many professional governing bodies require documentation of continuing education. Although this can be an important aspect of professional development, it is not a complete measure of competency. Often a practitioner will attend a course based on interest or strength and not on need. Incorporating a self-assessment into a competency program could alleviate this concern. However, attendance at a continuing education activity does not ensure achievement of a skill or a change in practice.² Other means of evaluating competency are written tests and computer simulations. These can be objective, reliable, and valid. They can measure the professional's knowledge of a subject but do not evaluate everyday performance or the social context of practice. Chart audits can be an effective means to evaluate the multiple components of care provision and clinical performance. Again, this method may not effectively evaluate the social context or quality of care provided.⁴

Direct observation affords the opportunity to observe complex, real situations. However, it can be very difficult to observe enough behaviors to generalize the range of skills.² Subjective expert evaluation can be an effective approach to assess the art and science of clinical practice. Inter-rater reliability is not considered a strength of this method.¹

When developing the competency program at the Rehabilitation Institute of Michigan, many of these assessments were incorporated. They include a self-assessment checklist, an evaluation of basic competency, computer-based learning to assure competence in such areas as safety and environment of care, a modified chart review in conjunction with direct observation, and continuing education requirements. The program incorporates evaluation of both entry-level and ongoing competency. It is unique, as it utilizes tools with a common template to document basic competency and the results of direct observation of professionals in physical therapy, occupational therapy, speech-language pathology, and therapeutic recreation. The competence of all clinical therapy professionals is assured through a three-step program: recruitment and hiring, orientation, and ongoing performance review.

The three-step program
Recruitment and Hiring. Professional practice positions are filled by professionals with evidence of: graduation from a program accredited by that profession's governing body or a foreign physiotherapy program, and initial certification and/or license from the state and/or professional governing body. If a new graduate, he or she must register for the examination within a designated time period. Candidates are interviewed to obtain information regarding their knowledge and skills to evaluate and treat patients and their problem-solving abilities.

Orientation. New hires complete a self-assessment checklist; orientation is modified according to their needs. Orientation to policies and procedures is completed during the probationary period of employment. If a clinical practice professional rotates to a new treatment site or team, he or she participates in an orientation process at the beginning of the assignment. Emphasis is placed on procedures and skills unique to the new practice area. The original self-assessment checklist is reviewed to address areas needing consideration for the new practice setting. Basic competency is established and documented on a checklist for each employee within the first 2 months of employment.

Ongoing Performance Review. The performance of each clinical staff member is evaluated on an annual basis by his or her supervisor. Patient care skills; productivity; professional growth and development, including attendance at continuing education activities; team interactive behaviors; and customer satisfaction skills are assessed.

Mentoring and the mentoring tool are an integral part of the competency program and help evaluate patient care skills. Utilizing a scale of met, partially met, not met, and not applicable, the tool is used to document demonstration of competency in the technical, interpersonal, and critical thinking skills essential for practice. The mentoring session includes an open chart review and direct observations by a senior employee or supervisor from the same discipline. Each clinician is mentored at least once yearly.

The schedule for each clinician is based on experience level, requests for mentoring or training, and/or rotation to a new area or site. Clinicians with 0 to 3 years of experience are mentored once quarterly, those with 3 to 10 are mentored twice yearly, and those with 10 or more, once yearly. Each employee also completes mandatory computer-based learning modules to assure competence in such areas as safety and environment of care.

Evaluation success
This competency program was inaugurated by the Rehabilitation Institute of Michigan in 1998. Orientation regarding the program was provided for both managers and clinical staff members. Dedication to this new program was slow to develop. Encouragement and education were required for staff to embrace the process.

The mentoring tool was useful in evaluating sessions in acute care, inpatient rehabilitation, and outpatient rehabilitation. A quality assessment monitor was developed to collate and monitor the results from the mentoring tools. Numerical values of 2, 1, and 0 were assigned to the met/partially met/not met descriptions.

The scores from the following six items were monitored through an Access database:

Appropriate items were evaluated.
Initial goals are appropriate to patient's current diagnosis, age group, cultural background, and premorbid status.
Goals are functional.
Treatment plan is relevant to the evaluation findings, patient's rehabilitation potential, age group, cultural background, and premorbid status.
Home exercise/education and program/assignment are appropriate for the patient.
Documentation clearly details treatment and patient response. All pertinent items are included in the documentation with the appropriate use of terminology and spelling.

Over the past 4 years, results of the monitor have revealed a general consistency in competency. A criterion of 90% of the total achievable points was established and has been met for every quarter except three during the 4 years for occupational therapy and every quarter except one for physical therapy. Data for physical and occupational therapies is collated on a quarterly basis. Because of the smaller sample sizes, speech-language pathology data is reported twice yearly and therapeutic recreation information is disseminated once yearly.

The data that has been collected has been educational. It has served as a guide to plan continuing education opportunities for the staff. Trends within a particular site and across a discipline have been evaluated. The results of individual sessions have been useful when completing yearly performance evaluations. However, it can be difficult to generalize the behavior of individual clinicians, as they are observed infrequently. The validity and reliability of the data have been suspect because of the number of different observers.

Ensuring managerial compliance has been a challenge of this program. At times it has been difficult for managers and staff to schedule and complete the mentoring sessions due to staff turnover and high volumes. However, having a focused program facilitates the balance between the concerns of patient care and staff competency. The competency program was well received by the JCAHO and CARF surveyors at our last combined audit. The strength of this program is its use of adult learning concepts. Staff members report they do not view the mentoring sessions as punitive. Instead, they are given the opportunity to consult with a senior colleague who evaluates performance and also offers suggestions. In fact, the tool has been revised to expand the "mentoring" aspect of the competency sessions. More comments about the intricacies of the treatment session and techniques have been provided.

Conclusion
Creating and implementing a staff competency program can be a challenging and demanding task. However, a comprehensive program with initial and ongoing assessments of competencies can refine the skills of clinical staff members and ensure the quality of care for patients and payors.

References

Salvatori P. Clinical competence: a review of health care literature with a focus on occupational therapy. Can J Occup Ther. 1996;63:260-270.
Lane M. The case for continuing competency. PT Magazine. 1999;7(5):49-56.
Youngsrom MJ. Evolving competence in the practitioner role. Am J Occup Ther. 1998;52:716-720.
Borgeil AEM, Williams JI, Bass MJ, et al. Quality of care in family practice: does residency training make a difference? Can Med Assoc J. 1989;140:1035-1943.

Julie Kiefer Eaman, MA, CCC-SLP, is speech-language pathology practice director, Rehabilitation Institute of Michigan, Detroit; Beverly Maiers, PT, is a physical therapist for Rehab Without Walls, East Lansing, Mich; Lynn Said, PT, MSA, is physical therapy practice director, Rehabilitation Institute of Michigan; Joseph M. Pellerito, Jr, MS, OTR, is interim chairman and associate professor, Department of Occupational Therapy, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit; Mary Kay Currie, OT, is occupational therapy practice director; Rehabilitation Institute of Michigan; and Susan Boeve, CTRS, ATRIC, is senior recreational therapist for the Rehabilitation Institute of Michigan.

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