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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Policy Title: Competency Assessments
Policy Number: 9.24
Effective Date: March 1, 2017
Chapter: Human Resources
To provide guidelines for the assessment of staff competency at the time of hire, completion of
orientation, on a periodic basis (i.e., annually or as appropriate), and otherwise as needed.
II. POLICY ELEMENTS
UW Health will determine staff competency through a combination of periodic assessments. These may
include, but are not limited to, direct observation, educational activities with post-tests, peer review, self-
assessment, case studies and exemplars. This periodic assessment and evaluation of employee
performance must be documented and should be reflected in the annual performance appraisal. Managers
and employees should also refer to any applicable department policies regarding competency
III. PERSONS AFFECTED
This policy applies to all employees, including temporary, employees in training, volunteers and student
employees assigned to perform work at UW Health who provide care, treatment and services to patients.
The education and development of Graduate Medical Education trainees is coordinated through the
Graduate Medical Education office.
A. Competency Assessment At Time-of-Hire: Initial competency is established through, but not
limited to, the following:
1. A position description that is job-specific and current.
2. Comparison of education and experience on applicant's resume or job application to the
3. Comparison of applicant's special knowledge and skills to the position description.
4. Verification of licensure, registration and/or certification, as applicable.
5. Satisfactory job interview.
6. Successful completion of background and reference checks.
Please refer to Administrative Policy 9.18-Employment/Pre-Employment Reference &
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B. Competency Assessment at Completion of Orientation: End of orientation competency is
established through, but not limited to, the following:
1. Completion of UW Health New Employee Orientation (NEO). See UW Health
Administrative Policy 9.60-New Employee Orientation for more information.
2. Completion of the department, unit or clinic orientation, which includes orientation to the
area, specific job functions and tasks, equipment, skills needed as stated in the position
description, and population specific competencies, if applicable. The department shall
identify what orientation in addition to NEO must be completed before the employee
provides care or services, and that orientation must be completed and documented.
a. Validation is accomplished by return demonstration or direct observation of tasks
b. A manager, supervisor or an approved preceptor or educator may validate
c. Documentation will be recorded by a department checklist or other departmental
forms and/or by the probationary evaluation.
C. Periodic Competency Assessments
1. The department director or his/her designee(s) will review the department's competency
program at least annually and adjust the required competencies based on the following:
patient populations, including age considerations; high-volume department functions;
high-risk department functions; low-volume/high-risk department functions; or problem-
prone performance responsibilities; findings from performance improvement, risk
management, infection control and safety activities; changing technology; revision of
established policies and procedures; results of patient, physician and staff
surveys. Employees will be aware of competencies to be assessed, validation methods to
be used and person(s) who will validate competencies. Periodic competency assessments
must be documented during the annual performance appraisal.
2. Periodic competency is established through, but not limited to, the following:
a. Satisfactory completion of all annual mandatory training and in-services.
b. Demonstration of competency based on high volume, low volume/high-risk or
problem prone job responsibilities.
c. Testing of knowledge base, as applicable.
d. Assessment of specific tasks.
e. Demonstration of population specific competency, if direct patient caregiver.
D. Record Keeping
1. Departments/units/clinics will be responsible for tracking and maintaining completed
competency validations, including the time-of-hire, end of orientation and periodic
competency assessments. Electronic tracking and records are acceptable.
2. All documentation and/or electronic records must be easily accessible for audits and
This Policy creates no rights, contractual or otherwise. Statements of policy obtained herein are not made
for the purpose of inducing any person to become or remain an employee of UW Health and should not
be considered "promises" or as granting "property" rights. UW Health may add to, subtract from and/or
modify this Policy at any time. Nothing contained in this Policy impairs the right of an employee or UW
Health to terminate the employment relationship at-will.
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Administrative Policy 9.18-Employment/Pre-Employment Reference & Background Checks
UW Health Administrative Policy 9.60-New Employee Orientation
Sr. Management Sponsor: VP, Human Resources Operations
Author: HR Compliance/Corporate Counsel
Approval Committee: UW Health Administrative Policy & Procedure Committee
UW Health Chief Administrative Officer
Previous revision: 122013
Next revision: 032020