Timing of Annual Competency

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Hello,

I recently had a visit from The Joint Commission for our POC inspection.  There was discussion around timing of annual competency.  We had a finding of annual competency not being available - which I can respond to - that's not the issue.  The issue is the inspector was having a discussion with the team that if annual competency is performed more than 30 days PRIOR to expiration, they can cite as it did not meet the intent of the standard. 

Since the inspector was having that discussion with the team, the team wants to respond to the timing discussion. 

As for my years in Point of Care, I have ALWAYS used the date of competency + 365 days as the "new" expiration date regardless of when it was due.   Example:  Annual competency due June 1, 2025.  Annual competency performed on April 15, 2025.  The new expiration date is April 15, 2026.  Is it right to be "dinged" on doing something proactively?

Thanks
Karen Jenkins
Point of Care 
Emory Healthcare


8 Replies

Hi Karen,
Thanks for bringing this up. We/I've agreed to testing sites 'retiming due dates' of competency assessment (as long as the annual competency due June 1, 2025 is performed earlier, eg April 15, 2025). Why? because some of our testing site leaders find it much easier to move a due competency to when they can more easily handle 'checking off'/assess, in order to do in batches and not each comp assessment as a 1:1 checkoff.
Have you sent in the question to the TJC Standards?

I don't think you can get cited for doing competencies more often than the minimum requirements.  I suspect there was confusion as to what exactly you are doing.
I know of systems that give a 3 month window to complete the annual competency...
  • Example:  The user does a competency on 1-1-24 and gets 12 months of access (to 1-1-25).  The users is then told to do the next annual competency between 9-1-24 and 12-31-24... and the user does it on 9-5-24 and gets recertified to 1-1-26... which would be ~15 months.... which is more than a year.
In your example you changed to next recertification due to be 12 months from the completed recertification.  I would review this in your challenge to the citation.

JC is pretty strict with their definitions:
Annually-One year from the date of the last event, plus or minus 30 days. Synonymous with every 12 months, once a year, or every year.
Every 6 months-Six months from the date of the last event, plus or minus 20 days.
Every 36 months-Three years from the date of the last event, plus or minus 45 days.
Quarterly-Every three months, plus or minus 10 days.

This was discussed during my last JC inspection when he was reviewing my 6 month correlations. He made a point to clarify that every 6
months meant "Six months from the date of the last event, plus or minus 20 days"

Thanks for the definitions, Glyne. 
In a recent presentation by TJC, she explained that annual competency had to be +/- 30 days. Initial training (which includes competency) needed to be within 20 days of start. 
One question I have is this-how do they define the "last event" when the competency assessments could take multiple days if there are multiple devices/tests?

I consider my "last event" as the date that I signed off/recertified on their full completed Competency Assessment. JC inspector explained that competency should be ongoing throughout the year and should not be done in one day (e.g., competency fair day). So throughout the year as I see they have performed an element of competency, I sign them off on that element as completed. I make sure that all elements are completed by the next due date and then I sign them off as completed competency assessment.  The date I sign off and recertify should be 1 year +/- 30 days of the last time I signed off on their completed competency assessment. 

Would anyone be able to share the standard that outlines these definitions, please? Thanks in advance! 

Look in the Glossary section of the JC manual.

Karen,
I agree with the sentiment above that doing the assessment more frequently isn't bad, however, your policy has to match your practice. 
I only have waived testing and PPM under TJC, so I can't speak to the wording for non-waived. 
I wonder if you can avoid using the word "annually" since TJCs definition is so strict (one year from the date of the last event +/- 30 days). I'd argue that you could make your procedure more generic and include the wording of the standard. For waived, it says, "according to hospital policy at defined intervals." If you wrote the policy to reflect that the competency may be completed 60 or 90 days before or up to 30 days after the date of the last event. I understand it can't be 60 or 90 days after and that's not what you are asking anyway.  :-)

It seems to me its the use of the word "annually" that gets us into trouble. Since TJC has a definitive definition of that word, can we get away with not using it and still be prescriptive of a defined window of time?

My opinion is that there are much worse findings that should be addressed and that this is not one of them.  Keep us posted on your outcome, if you don't mind sharing the final verdict. 
Good luck!

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Karen Jenkins
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