UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE
TITLE: COMPETENCY BASED PRACTICE: Annual Testing
Effective Date: April, 2005 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Education
Reviewed April, 2010 May 2014
PURPOSE: The University of Wisconsin Medical Foundation (UWMF) and the
Department of Family Medicine (DFM) is committed to the clinical staff remaining
competent in their prospective positions. As part of this commitment UWMF believes
that its clinical staff will be given opportunities to maintain competent practice. An
opportunity to assess clinical competency will be through Annual Competency Test.
DEFINITIONS: Competency is defined as having a sufficient skill, knowledge base,
unique quality or experience in order to successfully master or accomplish a task or series
POLICY: Each clinical staff member will participate in the annual skill testing program.
COMPETENCY SET-UP PROCEDURE:
1. Each year the Clinical Staff Education Department will select 1-2 skills or areas
to be used for competency testing. Determination will be by means of, but not
High risk/low volume procedures or skills - (ie: emergency protocols)
Top problem areas from Incident Reports - (ie: medication errors, injuries)
Specialty procedures, skills or equipment set up
New clinical policies and procedures
Needs assessment from lead physician, clinic manager or administration
Needs assessment from clinic staff
2. Instructors for the annual skills testing will include members from the Clinical
Staff Education Department and clinic staff who have undergone training in order
to ‘test out’ other staff. A staff person cannot ‘test out’ another staff person with
higher educational training unless that staff person is in the team leader position.
3. Tracking compliance for the Annual Skills testing will be completed by the clinic
manager and reviewed yearly with each employee at the time of their evaluation.
4. The Evaluation Process for the Annual Skills Testing Program will be completed
by the Clinical Staff Education Department, to include but not limited to:
Staff and Provider satisfaction post testing
Decrease in incident reports
1. Employees undergoing annual skills testing will be asked to complete review
materials and pre-test prior to the demonstration of skills testing. This written
portion will be provided by the Clinical Staff Education Department or in
collaboration with the department.
2. All staff will complete the Annual Skills testing when the testing is scheduled for
their clinic. Should staff not be able to complete this testing on time, they will
need to complete testing with their appointed clinic staff person or make up at
another clinic site if they are doing the same skill.
3. Any employee who does not pass the written or demonstration portion of the
competency testing program will have a follow-up remediation session.
Remediation will be determined on a case by case basis.
4. At the end of the Annual Skills Testing session, the manager will receive a
summary on how their staff did and any remediation recommendations.
CLINIC MANAGER RESPONSIBILITIES:
1. Ensure that all clinical staff (RN, LPN, CMA, RMA and MA) completes the
review materials and pre test prior to attending annual skills testing.
2. Ensure that all clinical staff attends the annual testing.
3. Provide a privacy room or area for the annual testing.
4. Ensure that employees not in attendance of annual skill testing fulfill the
5. Conduct disciplinary action (per Human Resources Policy) with noncompliant
WRITTEN BY: Ronnie Peterson, R.N., M.S., Manager of Clinical Support
REVISED BY: LaVay Morrison, RN, BSN, Clinical Staff Educator
American Academy of Ambulatory Care Nursing, A Guide to Ambulatory Care Nursing and
Competency Assessment, 2005.
Richard Welnick, MD, Medical Director, Ambulatory Clinic Operations, UWMF
Sandra A. Kamnetz M.D., Vice Chair, Department of Family Medicine
Medical Director Date
Vice Chair, Department of Family Medicine Date