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Department of Nursing Competency Assessment Process, Adult and Pediatric (3.25)

Department of Nursing Competency Assessment Process, Adult and Pediatric (3.25) - Policies, Administrative, UWHC, Department Specific, Nursing Administrative, Education, Training and Research


Policy Title: Department of Nursing Competency Assessment Process (Adult and Pediatric)
Policy Number: 3.25
Effective Date: October 24, 2017

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 Foundation (UWMF).


A. To establish a process for evaluating Registered Nurse (RN), Nursing Assistant (NA), Medical Assistant (MA), and
Technician competencies.
B. This policy applies to UW Health employees, contracted staff, and other non-UW Health employees who provide care
for patients at any UW Health site.


A. Competence at UW Health is defined as the application of knowledge, skills, ability, and judgment expected for the
practice role according to the role and professional nursing standards at UW Health (National Council of State Boards
of Nursing, 2005). In order to be considered a competency, a document or computer based training program must be
labeled as such, include all parts as outlined in the definition and include mandatory documentation. Mandatory
education is not automatically a competency. For competency documentation to be considered completed, all
competency documents must be turned in to the appropriate education office.
i. Inpatient/Nursing and Patient Care Services – Education and Development
ii. Outpatient/Ambulatory – Clinical Staff Education
B. UW Health will determine competency through a combination of periodic assessments. These periodic assessments
and evaluations of performance must be documented and should also be reflected during the annual performance
appraisal. Competencies are determined based on patient population, procedures, high risk processes and patient
level of care. Exceptions to competency requirements may be made based on the determination by nursing
i. There are two types of competencies:
a. Organizational Competencies
b. Area/Unit Specific Competencies
ii. All current organizational and area/unit specific competencies can be obtained through the office of
Education and Development (Inpatient/Nursing and Patient Care Services) and Clinical Staff Education
C. When nursing competencies are updated, writers should collaborate with the Nursing Policy and Procedure
Committee to update relevant clinical policies as necessary.


A. For further information on competencies assessed at time of hire and new employee orientation, please refer to UW
Health Administrative Policy #9.24-Competency Assessments.
B. For all competencies, a timeframe for completion of competency paperwork will be identified prior to initiation.
Competency assessment will occur:
i. Initially upon hire
ii. Upon transfer to a new clinical area
iii. Annually
a. Through a process such as Annual review
b. With the annual Performance Evaluation process
iv. Upon reassessment as needed
v. With new practices
vi. With job performance aspects identified through quality improvement, Patient Safety Net events, patient
satisfaction surveys, review of aggregate competency data, and other sources of practice improvement
C. Validation of competence is accomplished by:
i. Return demonstration
ii. Completion of a post-test
iii. Direct observation of tasks and responsibilities
iv. Verbalized understanding of key concepts and awareness of resources
D. Validation of competency may be completed by:

Policy Title: Department of Nursing Competency Assessment Process (Adult and Pediatric)
Policy Number: 3.25
Effective Date: October 24, 2017

i. For RN staff: A manager, supervisor, Clinical Nurse Specialist (CNS), Nursing Education Specialist (NES),
Clinical Staff Educator (CSE) or Registered Nurse with knowledge and training in the practice area who is
not on probation.
ii. For non-RN staff: A clinician, designated by the manager, with knowledge and training in the practice area
who is not on probation.
E. Methods of Competency Documentation may include
i. Completion of a competency document
ii. Completion of a skills checklist
iii. Computer Based Training
F. Compliance with Competencies
i. Organizational and area/unit specific competencies must be completed by new hires or transfers by the end
of their designated orientation.
ii. Annual, periodic or new practice competencies must be completed by the identified due date.
iii. It is the employee’s responsibility, with the support of the Manager, CNS, NES and CSE, to submit
completed competency documentation.
iv. In order to ensure patient safety, 100% compliance of completion of competencies is expected.
a. For active employees, there is no grace period permitted.
b. For inactive employees returning from leave, a 45 day grace period will be permitted. Upon return
from leave, the employee is responsible for contacting their supervisor/manager for completion of
required competencies that are outstanding.
c. If competencies are not completed within the defined time frame, the staff member will be removed
from patient care responsibilities until completed. A plan will be made to address completion,
which may result in the employee needing to work on competencies when the appropriate
resource(s) are available. The continued failure to complete competencies may result in discipline,
up to and including termination.
G. Competency Development Process
i. If a need to create a new method or revise an existing method of competency and/or assessment is
identified, it is required that the individual(s) contact their unit/department CNS, NES or CSE and the
Nursing Competency Committee.
ii. Creation of new method of competency assessment or new competency
a. Review the existing method of competency assessments and check to see if there is an existing
b. If none yet exist, refer to the Nursing Competency Algorithm on U-Connect
i. To revise an existing competency or skills checklist, refer to the “Competency Revision” section of the
Nursing Competency Development Algorithm on U-Connect.
ii. Annual Review
a. Annual Review is planned, created and implemented by Education and Development
(Inpatient/Nursing and Patient Care Services) and Clinical Staff Education (Outpatient/Ambulatory),
in collaboration with Education Council, clinical staff and nursing leaders.
b. Annual Review for Surgical Services and Home Health Nursing personnel is planned, created and
implemented by educators and/or managers within these respective areas.
c. The format for annual competency verification may vary and may be a combination of on-line
content, hands-on demonstration of skills and unit/area/site specific content.
H. Evaluation of Competencies
i. Organizational competencies will be updated by the Nursing Competency Committee every three (3) years
and as needed. Any competency attached to a policy should be updated at the time the policy is updated.
ii. Unit/area/site-specific competencies will be updated by the unit/area/site manager, CNS, NES and/or CSE
every three (3) years and as needed.
a. Required competencies are based on the following but are not limited to: patient population
(including age considerations); high-volume department functions; high-risk department functions;
low-volume/high-risk department functions; performance responsibilities; findings from performance
improvement, risk management, infection control and safety activities; changing technology;
revision of established policies and procedures; or results of patient, physician and staff surveys.
iii. Factors to consider when planning Annual Competency Assessment content include:
a. Mandatory requirements from accrediting regulatory bodies (TJC, CMS, etc.)
b. Patient Safety Net event trends
c. Mandatory requirements from UW Health policies and procedures
d. Other areas for which there is identification of need

Policy Title: Department of Nursing Competency Assessment Process (Adult and Pediatric)
Policy Number: 3.25
Effective Date: October 24, 2017

I. Record Keeping
i. All competencies should be submitted to Education & Development (NED) for Nursing & Patient Care
Services for inpatient employees or to Clinical Staff Education (CSE) for outpatient/ambulatory employees
unless arrangements are made with NED/CSE for competency documentation to be housed within the
specific area/department.
ii. NED/CSE will generate reports as needed to ascertain if any staff members have not completed their
competency/skills checklist requirements. In the case employees have not completed these requirements,
appropriate action will be taken. See F. iv. c. above.


Author: Director, Nursing Education & Development
Reviewers: Manager, Clinical Staff Education
Nursing Administrative Policy & Procedure Committee Approval: September 18, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities. This
policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics and the
University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs administered by the
University of Wisconsin School of Medicine and Public Health. Each entity is responsible for enforcement of this
policy in relation to the facilities and programs that it operates.


Beth Houlahan DNP, RN, CENP
Senior Vice President, Chief Nurse Executive
A. National Council of State Boards of Nursing (2005). Meeting the ongoing challenge of continued competence.
Retrieved from: www.ncsbn.org/pdfs/Continued_Comp_Paper_TestingServices.pdf.
B. Competency Development Algorithm
C. Organizational Competency Outcome Form
D. Skills Checklist Guide


Version: Revision
Last Full Review: September 18, 2017
Next Revision Due: September 2020