September 5, 2004
September 4, 2015
Clinical Nutrition Services
To provide a mechanism for evaluating the competences needed by employees to
provide quality nutrition care and nutrition services. To identify areas of growth and
development to achieve continuous quality improvement and patient safety.
Competence is the possession of knowledge, skills, and behaviors to perform designated
tasks. Managers and supervisors will continually assess, maintain, demonstrate, and
improve the competence of the staff. Each employee must be assessed for competence
before hiring, during the orientation process, and annually. At the time of hire,
employees are assessed based upon education, experience, required registration,
certification, and special knowledge and skills. During the orientation process,
employees are assessed based upon job requirements and duties as well as high-risk job
functions and accountability. Competency must be established before an employee
works independently. Every year thereafter competency will be based on needs
associated with new assignments, initiatives, procedures, technologies, practices, and
policies. Ongoing assessment will involve frequently performed duties that carry a
significant amount of responsibility for correct performance (high volume high risk job
accountabilities), rarely performed duties that carry a significant risk of harm or hazard
(low volume high risk job accountabilities), and/or frequently or infrequently performed
duties that require trouble shooting skills (problem prone areas). Identified needs will
be used to plan training for new knowledge, skills, or abilities.
Competency may be general, department/area specific, job specific, and age-specific.
Age-specific competencies are required with direct patient care. Competent behavior is
multidimensional and will measure knowledge, interpersonal attributes, psychomotor
skill, and critical thinking abilities.
III. FORMS USED
Clinical Nutrition Services: Outpatient Nutrition, Inpatient Nutrition, Home Enteral
Nutrition, Nutrition Technician, and Diet Office
A. Prior to hire, the interview process is used as a means of assessing education,
experience, required registration, licensure or certification, specialty practice
certification, and special knowledge and skills.
B. During the orientation process, each specific area then trains and assesses the
employee on their job duties, accountability, and skills.
C. Each year every employee is assessed for competency during the year with
review during the performance appraisal process. Depending upon the position,
they are either given tests or case studies or are instructed to demonstrate a skill
or verbally communicate competency. Other forms of assessment may be peer
evaluation or observation.
D. Clinical Nutrition Staff with direct patient care responsibilities are assessed
through general methods such as observation, demonstration, verbal response,
and peer evaluation. Key subject areas include technical skill, communication,
customer service, quality improvement, teamwork, initiative, professional
development, and professionalism as well as age specific knowledge.
E. Technicians are evaluated on knowledge of food composition, food preparation
and serving temperatures, understanding of diet orders, menu corrections and
nutrition education, communication, teamwork, computer systems, pneumatic
tube procedures, sanitation, and other pertinent topics.
F. Students are evaluated on knowledge of food composition, food preparation and
serving temperatures, understanding of diet orders, menu correction, telephone
etiquette for room service orders, computer systems, pneumatic tube
procedures, sanitation and personal hygiene, and other pertinent topics.
Accreditation Manual for Hospitals, TJC
Conditions of Participation, CMS
UWHC Human Resources Training and Organizational Development - Role of
AND Guide - Ensuring Staff Competence (Inman-Felton and Rops)
Senior Management Sponsor: Chief Nursing Officer and Sr VP Patient Care Services
Author: Director Clinical Nutrition Services
Review/Approval Committee(s): UWHC Medical Board Nutrition Committee
Director, Culinary and Clinical Nutrition Services
Associate Chief Nursing Officer and VP Development, Nursing & Patient Care Services