Enterprise Risk Management (ERM) Legal & Regulatory Patient Safety/Clinical Care

Competency Validation as a Tool for Risk Mitigation

Establishing a competency validation program is an effective risk mitigation strategy. Knowledge surrounding a concept or skill is only a portion of what competence means. The Merriam-Webster Dictionary adds that competence is having the ability to apply the knowledge, perform the skill effectively and efficiently, and possess prudent judgment related to that concept or skill. Martinek Bahon explains that competence in health care includes the goal to provide safe patient care using demonstrated abilities in technical, critical thinking and decision making. All of these combined develop the standard of practice to which other professionals’ practices are compared. In health care, it is not enough to be fluent in didactic skills. Due to the vulnerability of patients and the significance of each health care worker’s role in providing safe patient care, validation of skill competencies for all front-line employees in a health care organization is a recommended practice that should include mandated periodic testing.             

Required Competencies Examples

Nurses are taught fundamentals in nursing school. However, there are many skills they have not been taught but will nevertheless be required to perform. For example, if a newly graduated nurse is assigned a patient who has a wound vac on which the nurse has never trained, he/she will not have the knowledge to operate the machine, manage alarms safely, troubleshoot issues or know if there is special care required using it on the patient’s wound.

Another example is a seasoned nurse caring for a post-surgical patient who begins to decline quickly. If the nurse is not knowledgeable about the post-operative complication of Local Anesthetic Systemic Toxicity, he/she may not recognize signs and symptoms to report to the physician or know to implement the appropriate treatment for this complication (based on provider orders). A newly hired environmental services colleague may not have worked in a health care setting and is unaware of infection prevention practices such as in the prescriptive cleaning techniques in surgical services settings. According to Wood and Connor (2018), best practice for environmental cleaning begins in the least soiled area of the operating room and progresses to the most soiled area of the operating room and from top to bottom.

A seasoned medical assistant in a physician practice may have to learn new skills to meet changing best practices. For example, a medical assistant who transfers to an orthopedic practice may need to have competency skills validation on the removal of sutures because he/she has not performed that skill in recent practice. All of these scenarios play out daily in our health care organizations. All revolve around the goal of patient safety.

Patient safety is the foundation upon which health care organizations are built. The Centers for Medicare and Medicaid Services (CMS), The Joint Commission, Healthcare Facilities Accreditation Program, Accreditation Association for Ambulatory Health Care and local and state health departments are a few of the oversight institutions that guide health care organizations to deliver safe, quality patient care. These organizations develop and maintain standards on which some decide hospital reimbursement based on compliance with their standards.

Every patient care environment has standards of practice or protocols. Having standardized protocols is safer because it reduces variability, however, some practices may differ from department to department. It is imperative that each area regularly reviews its practices and protocols to ensure compliance with regulations, conform to evidence-based practices and accurately reflect the protocols.

Assessing Competency

Competency validation should be based on these standards of care and protocols. Not only are the frequently performed skills and cognitive competencies validated during orientation and annual skills training, but also the low volume-high risk skills such as emergency scenarios and equipment need attention. Competency validations could be reviewed during root cause analyses or recommended after to ensure training is provided. Adding the education and competency for all colleagues, not just those lacking, would be prudent in ensuring safe patient care.   

Simply having a colleague sign an attendance roster to prove validation of skills is not a best practice. In skills-based validation, a better option, a colleague performs the skills in accordance with the established protocol to ensure all steps are performed correctly. This is beneficial for task-based skills but may not be the best option for critical thinking assessment. For knowledge-based competencies, learning paired with a question-based exam is effective. This option could also can be used for judgment and critical thinking-based skills.

Not all competency assessments are created equal. There are a multitude of options available for validating skills, although some may provide a higher level of confidence for competency verification than others. According to Monaghan (2019), providing education with demonstration without a form of hands-on validation is not an effective method since adult learners typically only retain about 30% of education provided in this format.

Two options that could be used for competency validation of skills and critical thinking are simulations and written exemplars. In a simulation, the colleague is presented a scenario that not only requires the successful performance of certain tasks, but also discussion and performance of skills related to critical thinking and judgment such as in an emergency situation. Simulations not only provide hands-on practice, but a safe learning environment to process complex scenarios and display physical skills to the validator (Sami, et al. 2019). The simulation can be based on the standardized, controlled technique of objective structured clinical examination (OSCE) (Sears, et al., 2014). This technique uses a predetermined scenario that is relevant to the learners’ area of practice and allows for real-time observation of the clinician’s ability to assess the situation, develop a plan, discuss critical thinking elements and display behaviors in a safe, learning-focused environment.

In an exemplar, colleagues are presented a scenario and compose a written response based on actions they would take. The response is reviewed by an educator or leader in that area and judged based on established recommendations in literature and policy. The educator or leader then coaches the team based on the responses (Morrell and Campbell, 2016). Although this is not the most effective way to validate manual skills, this could be beneficial in reviewing critical thinking and judgment skills. When responding to a risk event, it is reasonable to assess for skill competency of the involved staff. This not only assists in identifying potential education gaps during a specific risk event, but also could identify more widespread education gaps in other areas of the organization. By identifying and addressing competence needs, additional training and education can assist in ensuring safe patient care.

It should be noted that colleagues in many organizations have received very little education related to risk identification and event reporting, risk mitigation, patient safety and Just Culture. Orientation periods are often short in duration and typically require the focus to be on education, validation of skills and compliance with policies and procedures. Castello, et al. (2019) advocated the use of the Health Professional Education in Patient Safety Survey to assist is assessing colleagues’ confidence levels in different aspects of risk management and patient safety. Based on the results of the survey, education can be tailored to the needs of each group surveyed.

Each patient encounter, procedure and job function provides ample opportunity for early identification of patient safety concerns and management of risk events. If an organization’s goal is to prevent patient harm and establish an overarching culture of safety, it stands to reason that education related to patient safety and risk mitigation should be a priority during the orientation period and going forward.  Establishing a competency validation program can enhance patient safety as part of an effective risk mitigation strategy, which provides early indicators when education or additional training is needed. This prevents patient harm events and reduces liability cases. Complete and accurate documentation of staff skill competency records are essential for the defense of liability cases. Continued advocacy for early and ongoing risk management education and competency programs assist organizations in taking a proactive stance toward risk mitigation.


The Joint Commission. Provision of Care, Treatment and Services. Retrieved at https://e-dition.jcrinc.com

Bahon, Martinek. (2017), Canadian Journal Respiratory Therapy.

Castello, M. Ferrara, P., Destrebecq, A. & Terzoni, S. (2019). The perception of clinical risk

among students of different health professions: A multicenter study. British Journal of Nursing, 28(3). 193-197.

Merriam-Webster electronic dictionary. https://www.merriam-webster.com/dictionary/competence.

Monaghan, M. (2019). Making safe patient handling and mobility training effective. Part 1. What to watch, where and when to teach it and how to teach it. International Journal of Safe Patient Handling and Mobility, 9(4), 143-148.

Morrell, B. & Campbell, N. (2019). Two paths to competency validation. Journal for Nurses

in Professional Development, 32 (6), 331-334.

Sami, A., Nabeel, A., Amatullah, A. (2019). Simulation-based training to improve obstetric/perinatal nurse’s competency in managing obstetric emergencies in Saudi Arabia. International Journal of Caring Sciences, 12(3), 1788-1795.

Sears, K., Godfrey, C., Luctkar Flude, L., Ginsburg, L., Tregunno, D. & Ross-White, A. (2014).

Measuring competence in healthcare learners and healthcare professionals by comparing self-assessment with objective structured clinical examinations (OSCEs): A systematic review. JBI Database of Systemic Reviews and Implementation Reports, 12(3), 24-38.

Wood, A. & Connor, R.  (2018). Environmental Cleaning. Association of Perioperative Registered Nurses 2018 Edition (2018 ed., pp. 7-28). AORN, Denver CO

Author: Angela Lucas, MSN, BSN, RN, CCRN-K, has more than a decade of experience in ICU, leadership, OR and risk management in Northern Indiana.

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