Category: Professional Posters
Purpose: Many organizations struggle with creating and sustaining an organized staff competency plan that meets (or exceeds) federal, state, regulatory and accreditation requirements. At Palomar Health, the competency maintenance plan was convoluted and complex which led to non-compliance with CMS requirements. The goal of the project team was to develop a robust, relevant, automated, low-maintenance system to track competencies in order to assure staff is appropriately prepared for duties assigned as well as meeting/exceeding federal, state, regulatory and accreditation requirements.
Methods: This study was completed at Palomar Health, a three-hospital system with a 288-bed hospital (retail pharmacy on site), a 107-bed hospital and a 50-bed hospital with an infusion center. The culture and lack of leadership led to a disjointed competency system that delivered education via multiple methods and was ineffective at accurately or consistently tracking completed assignments. A gap analysis was performed on the exisiting competency system to identify variations from accredititation standards. Evaluation included a review of the online competency and training documentation system (iXpand), stand alone competencies (e.g., Pyxis, Medkeeper, sterile prepartaion), the process for competency assignment and tracking, leadership support and pharmacy culture. Gaps identified were used to create an action plan (30-day completion plan as promised to the California Department of Public Health) that helped to evolve and simplify the existing process, including combining and streamlining education delivery methods and documentation into a centralized, automated, electronic, organization-wide process. Duplicate competencies were eliminated and remaining competencies were updated as needed. Healthstream learning management system access was added to provide better accessibility and tracking. A new competency plan was created for the pharmacy that will be reviewed annually. Any new assignments will require System Director approval and be tracked for completion .
Results: Over 9000 electronic and paper competency records for 119 employees were reviewed as part of the gap analysis. Prior to project implementation, technicians and pharmacists were assigned 177 and 373 competencies, respectively. At the completion of the project, competency assignments for new hire technicians and pharmacists were reduced to only 31 and 46, respectively. All competencies are now initiated and tracked via iXpand and Healthstream. The compliance rate with assigned competencies increased from 43% prior to implementation up to 98.7% after completion. iXpand now automatically assigns competencies based on job code/title and accrediation/regulatory requirements (e.g., new hire, annual).
Conclusion: The use of a multi-step assessment tool and action plan led to streamlined competency requirements for pharmacy staff which resulted in a substantial increase in competency completion and documentation compliance per accreditation and regulatory requirements.