Mandatory Training & Competency

Mandatory Training is the education that occurs, throughout the tenure of employment, to ensure that needed skills are effectively introduced and periodically reinforced. Learning & Organizational Development oversees organization-wide mandatory training through assignment of CBL's on topics identified by regulatory agencies.

Competency Assessment is the process used  to document the on-going ability of the employee to perform the skills necessary to do the job.

These two areas of workplace development, Mandatory Training and Competency, are designed to work as a cohesive system, used to train, validate and document compliance with the requirements of official regulatory agencies (JCAHO, CMS, and OSHA) and internal hospital departments such as Quality, Risk Management and Accreditation.

Using a virtual continuum, the following shows the sequencing of each of the components of the Mandatory Training and Competency process.

Each component of the ongoing process is explained below.

INITIAL COMPETENCY ASSESSMENT: The new employee's first, or Initial Assessment, begins during the orientation process and includes a self-assessment which helps the manager plan and facilitate an effective orientation process to address the employee's level of expertise. The process of self-assessment and training culminates in validation of competency through direct observation or outcomes review.  Initial competency assessment is documented on the Orientation Competency Assessment and Evaluation (OCAE) form.  The process begins at the onset of employment and is normally completed over the next six months, which is considered the orientation/probation period.

At the end of six months, the completed OCAE form is maintained in the employee's work-based competency file.

For staff performing Point of Care Tests (POCT), in addition to the OCAE form, a separate POCT Initial Competency Assessment form must be completed.  The POCT Initial Competency Assessment form is maintained in the employee's file and is used throughout the duration of employment as skills are re-evaluated and new skills are added.

ONGOING COMPETENCY ASSESSMENT: Because professional growth and learning continues throughout an employee's career, Ongoing Assessment of the employee's competency should also occur whenever the employee is required to master new skills. Direct observation, or outcomes assessment, is used to verify the employee's competence to independently perform job responsibilities.  Competence in skills acquired each year is documented on the Annual Competency Record form, which remains in the employee's work area employment file.

ANNUAL COMPETENCY ASSESSMENT: Yearly skills assessment is required in the form of an Annual Assessment, used to re-validate identified job skills which are selected as low frequency, high risk, or problem-prone skills. Documentation of this annual assessment is made on the Annual Competency Record form. This annual assessment process is performed separate from, and in addition to, the Annual Performance Appraisal process.


MANDATORY TRAINING FOR NEW HIRES: The Mandatory Training for New Hires involves completion of Computer-Based Learning modules (CBL's).  These modules provide informational training to address regulatory requirements.  This training must be completed within the first two weeks of hire, with the exception of the Blood-borne Pathogens module, which must be completed prior to patient or patient sample contact. In addition to the CBL's required for all new employees, job specific CBL's may also be required and assigned by individual departments, as determined by local managers and administrators.

Documentation of mandatory training is housed in NetLearning, the web based education tracking system.  Employees are alerted by email when a training module has not been completed by a specific due date.  Subsequently, the manager is notified if compliance remains unfulfilled. View a list of current new hire mandatory training CBL's.

MANDATORY ANNUAL RETRAINING: The process of Mandatory Annual Retraining is used to review all information that is necessary for staff to know to remain safe and perform their job.  Documentation of annual mandatory training is housed in NetLearning.  Annual retraining CBL's are assigned to all staff and must be completed by July 31st of each year.  The manager and administrator are notified if compliance is not fulfilled.  View a list of current annual mandatory retraining CBL's.