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How To Develop & Implement a
Practical Staff Competency Plan
Pat Comoss RN, BS, MAACVPR
Nursing Enrichment Consultants, Inc.
Financial Disclosure
I have no financial relationships to disclose
Staff Competencies in Rehab
Upon completion of this activity, participants will be able
to:
• Discuss why an annual staff competency plan is important
for rehab personnel
• Identify criteria that are useful when choosing competency
topics
• List acceptable methods for evaluating a staff member’s
competency
• Match selected competencies to AACVPR’s published Core
Competencies for CR & PR
Staff Competencies in Rehab
Not New, Revisit
WHAT
WHY
WHEN
WHO
HOW
WHY Staff Competencies
Intrinsic Philosophy:
desire for continuous learning to be
the best rehab practitioner you can be
WHY Staff Competencies
Intrinsic Philosophy = desire for continuous learning
to be the best rehab practitioner you can be
Extrinsic Expectation:
• Hospital requirement
• Joint Commission standard
• AACVPR Program Certification criteria
WHY Staff Competencies
The Joint Commission
“Competence assessment lets the hospital know
whether its staff have the ability to use
specific skills and to employ the knowledge
necessary to perform their jobs.”
Human Resources chapter:
2015 Hospital Accreditation Standards
TJC: Standard HR 01.06.01
The hospital
• Defines the
competencies it
requires of staff who
provide patient care/
treatment/services
TJC: Standard HR 01.06.01
• Uses assessment
methods to determine
competence in the skill
being assessed
 Test taking
 Return demonstration
 Simulation/role play
 Observation of actual
patient care
TJC: Standard HR 01.06.01
An individual with the
educational background,
experience, or knowledge
related to the skills being
reviewed assesses
competence:
• Instructor
• Preceptor
• Coworker
TJC: Standard HR 01.06.01
The hospital can utilize:
• An outside individual
Such as: guest speaker,
consultant
• Competency guidelines
from an appropriate
professional organization
Such as: AACVPR Core
Competencies
TJC: Standard HR 01.06.01
Staff competence is assessed & documented
• once every 3 years
• or more often per hospital policy
WHY Staff Competencies
AACVPR Program Certification CR & PR:
Requirement #1 = Staff Competencies
• Individuals should possess a common core of
professional & clinical competencies,
regardless of academic discipline
WHY Staff Competencies
AACVPR Program Certification CR & PR:
Requirement #1 = Staff Competencies
• A program must provide evidence of annual
assessment of clinical/professional staff
competency
AACVPR Program Certification
PULMONARY REHAB Program Certification:
Four assessed competencies MUST be specific to
Clinical Competency Guidelines for
Pulmonary Rehabilitation Professionals 2014
Collins EG, Bauldoff G, Carlin B, et al.
JCRP 2014; 34: 291-302
AACVPR Program Certification
CARDIAC REHAB Program Certification:
Four assessed competencies MUST be specific to
Core Competencies for Cardiac
Rehabilitation/ Secondary Prevention
Professionals: 2010 Update
Hamm L, Sanderson B, Ades P, et al
JCRP 2011; 31: 2-10
WHAT Staff Competencies
Similar Categories for Staff Competencies CR & PR:
• Patient Assessment
• Exercise Training
• Psychosocial Management
• Tobacco Cessation
• Emergency Planning
WHAT Staff Competencies
Cardiac Rehab
• Blood pressure
management
• Lipid management
• Diabetes management
• Weight management
Pulmonary Rehab
• Dyspnea assessment &
management
• Oxygen assessment &
management
• Collaborative selfmanagement
WHAT NOT Staff Competencies
Discipline-specific
hospital/department
required competencies:
• Cardiology RNs =
conscious sedation
• Respiratory RTs =
precautions to prevent
ventilator acquired
pneumonia (VAP)
WHAT NOT Staff Competencies
Initial/Orientation checklist for
new employees
• often emphasize mechanical
functions within dept vs.
specific clinical patient care
Hospital-wide required
competencies
• e.g. HIPAA rules,
safety/security color-codes,
etc.
HOW Staff Competencies
1. Choose skills that need to be learned,
reviewed, or updated because they are:
•
•
•
•
NEW/CHANGED
HIGH RISK
LOW VOLUME
PROBLEMATIC
HOW Staff Competencies
•
•
•
•
•
•
Categories

Patient Assessment
Exercise Training
Psychosocial Management
Tobacco Cessation
Emergency Planning
Etc.

Criteria
• NEW/CHANGED
• HIGH RISK
• LOW VOLUME
• PROBLEMATIC
HOW Staff Competencies
2. Sources of choices:
INSIDE - OUT
Use Core Competency documents for staff
self-assessment =
Identify strengths & weaknesses
HOW: Inside - Out
Examples
• NEW = BODE Index calculation (PR),
MET-minutes calculation (CR)
• HIGH RISK = diabetic exercise management
(blood sugar testing, high & low cut-offs)
• LOW VOLUME = tobacco cessation
HOW Staff Competencies
Cross reference to Core = Smoking Cessation
• Core Competencies for Cardiac
Rehabilitation/Secondary Prevention
Professionals: 2010 Update – pg 7 Tobacco
cessation; Knowledge 1-7, Skills 1-3.
• Pulmonary Clinical Competency Guidelines: 2014
Update - pg. 299, Tobacco cessation; Knowledge
1-7, Skills 1-2.
HOW: Inside - Out
Challenge: find resources to teach the topic/skill
to rehab staff in rehab context
• Within facility or external expert?
• PROFESSIONAL DEVELOPMENT OPPORTUNITY
= elect a staff member to study/research the
topic & become the rehab expert
Competency: Tobacco Cessation Counseling
Name _______________________
Date ______
Dept.  Cardiac Rehab
 Pulmonary Rehab
Expectation: To provide effective counseling to help those patients who wish to quit smoking do
so during the course of rehab.
Essential Elements of Performance:
1
2
3
4
5
6
7
Proficient
Needs Review/
Improvement
Inadequate
**
Explain the impact of continued smoking on
cardiac/pulmonary disease & the benefits of
quitting now.
Recognize smoking status as a routine
outcome measure & point-out questions in
both admission & discharge interviews that
collect that information
Discuss recent alternatives to cigarette
smoking, e.g. e-cigarettes, hookah, vaping
At the beginning of rehab, assess each smoker
for readiness to change their smoking
behavior & reassess their stage every 30 days
during rehab
Use appropriate counseling strategies &
resources for each stage of readiness
List common medications used to assist
smoking cessation, including nicotine
replacement & psychotherapeutics, & provide
related information about each to patients
Identify outside resources

Hospital Tobacco Counselor

Community cessation programs

Help line by phone or internet
that can be tapped for additional help during
rehab or follow-up after rehab
Resources:
For knowledge
 AACVPR PR Guidelines (new 4th edition)
section on Smoking Cessation, pgs. 60-64
 AACVPR CR Guidelines, 5th ed., chapter 8
Modifiable Risk Factors, pgs. 90-94
 US Dept. of Health, Treating Tobacco Use
& Dependence
 Krames patient workbooks
For skills
 Workshop with hospital Tobacco
Counselor to emphasize:
a. assessing readiness to change
b. teaching prescribed medication
use
HOW Staff Competencies
2. Source of choices:
OUTSIDE - IN
Use authoritative external information for
competency ideas =
Identify need to update/upgrade program
HOW: Outside - In
Challenge: make sure chosen topic/skill is within
the scope of Core Competencies expectations
• Where does the new interest match
document?
• PROFESSIONAL DEVELOPMENT OPPORTUNITY
= elect a staff member to track connections
between chosen topics & competency bullets
Pulmonary Rehab Example
NEW/CHANGED:
Need to update PR policy
& practice to
incorporate latest
evidence-based
recommendations for
this important outcome
measure
Pulmonary Rehab Example
Changes to 6MWT Performance 2015:
• For initial assessment, do 2 walks & take best result as
baseline measure
• Use patient's own oxygen equipment & usual O2 flow =
DO NOT TITRATE O2
• Allow O2 sat to drop to low value cut-off of 80%
saturation
• For exit evaluation, look for change of at least 30
meters/100 feet to be clinically significant
Pulmonary Rehab Example
Exercise Testing p.298
Use of field testing (6MWT,
shuttle walk) as outcome
measure
• Complete 6MWT using ATS
criteria
• Appropriately monitor
responses
• Develop ExRx on basis of
results as appropriate
Competency: Six Minute Walk Test (6MWT) as a Measure of Functional Capacity in
Outpatient Pulmonary Rehab Patients
Name _____________________________ Department: __Pulmonary Rehab____
Expectation: The pulmonary rehab therapist will demonstrate correct methods of preparing,
instructing, performing, and documenting the walk test as a pulmonary rehab
clinical outcome measurement.
Critical Elements:
Proficient
1
2
3
4
5
The PR therapist will be able to:
PRE 6MWT
Recognize the 6MWT as a submaximal
exercise testing procedure
Identify appropriate patients to
participate, following policy for
indications & contraindications
Communicate advance instructions to
patient by phone or mail:

Wear walking shoes

Bring usual walking aids

Bring own oxygen equipment

Take usual meds at usual times
Prepare for possible emergencies during
the test:

Location of crash/cart/defibrillator

Availability of supervising
physician

Access to emergency medications =
albuterol, nitrogylycerin, oxygen

Means of calling for help
Set-up space & equipment in advance:

Flat unimpeded walking path,
ideally 100 linear feet

Cones to mark ends of walking path

Chairs for patient to stop if needed

Stop-watch or other timer

Borg 0-10 scale for rating both
RPD & fatigue

Clipboard with script of patient
instructions & report form to record
laps & responses

B/P cuff & stethoscope

Wearable oximeter

Telemetry monitoring = optional
Needs Review/
Improvement
Inadequate
**
6
7
8
9
10
11
12
13
14
15
Plan for patient to use own devices
during test performance = walking aids,
oxygen equipment

If using oxygen, maintain usual
flow rate & keep constant during
test = DO NOT TITRATE
Identify one exception for applying
oxygen during test if not used routinely
= if patient desaturates to 85% or less
on room air after 10 min rest
Position patient in a chair near start of
walking path to:

Relax & breathe quietly 5-10
minutes

Confirm that usual meds were taken
& that oxygen is set at usual levels

Attach oximeter to provide
continuous O2 sat data during walk
No warm-up is needed
DURING 6MWT
Discuss the importance of following a
standardized procedure for test
performance for test to help assure
reproducibility
Perform pre-test measurements:

Heart rate, BP, & O2 saturation

Dyspnea level & fatigue level
(Borg 0-10)
Explain that this is a self-paced walking
test for the purpose of seeing HOW
FAR a person can walk in 6 minutes
time
Read ATS scripted instructions to each
patient for each test
Demonstrate correct walking technique
such as:

Where to walk out & back

How to go around cones without
slowing down

And so on
Select a mid-point along the path to
stand for best observation & coaching,
including visualization of oximeter data
as patient passes by
Give rationale for NOT walking with
patient, unless there is a safety issue or
fall risk = if needed, walk behind
patient to not influence their pace
16.
17
18
19
20
21
22
23
24
25
26
Provide scripted instructions every 1
minute during test = DO NOT use other
words of encouragement
Allow patient to stop & rest if needed =
lean against wall or sit down, but clock
keeps ticking
When stops occur, use scripted
instruction every 30 seconds to “please
resume walking whenever you feel
able”
 Note time stopped & when restarted
Monitor O2 sat & HR each time patient
passes therapist’s position
 Without interrupting walking pace,
have patient hold up hand to see
oximeter data when passing by
React immediately to stop test if/when
O2 sat drops to 80% or less = new cutoff value
As 6 minute endpoint approaches, warn
patient that “time is almost up, when I
say STOP, please stop where you are &
I will come to you”.
At 6 minutes, go to patient’s side to:
 Obtain HR & O2 sat data
 Take blood pressure
 Ask RPD & fatigue ratings
 Ask why they could not walk any
farther
POST 6MWT
Have patient sit in chair & relax for 510 minutes
Complete test documentation including
 Total distance walked
 Number & length of stops
 Lowest O2 sat & highest RPD
observed during test
 Signs/symptoms reported
 Reason could not go farther
Translate total distance walked into
mph & METs to help with starting
exercise training on the treadmill
At entry walk, continue with other
admission assessments & repeat walk at
end of visit (at least 30 minutes later)
27
Explain that rationale for 2nd walk test
ton same day is to allow for patient’s
learning curve & provide opportunity
for improvement in performance
Use best result (longest distance) of 2
initial tests as outcome data
28
Describe 2 types of exceptions to
repeating the walk test a second
time:
 Patient who does quite well the
first time = unlikely to do better
 Patient who is quite sick &
struggles to complete first walk
= unable to walk again
29
At exit walk, compare results to entry
walk data & explain extent of change to
patient
Explain that rationale for only 1 walk at
exit is because patent is now familiar
with the 6MWT procedure
State that a clinically significant change
from entry to exit test is 30 meters/100
feet = the minimal important difference
(MID) to indicate functional
improvement as a result of rehab
30
31
Resources:
For knowledge
 ATS/ERS Technical Standard: Field
walking tests in chronic respiratory
disease; European Respiratory
Journal, 44:6; December 2014; 14281446.
For skills
 Instruction/demonstration session by an
RT experienced in 6’ walk studies
 Practice & return demonstration to each
other
 Observation of an actual test on a PR
patient
Cross-reference to:
AACVPR Clinical Competency Guidelines for Pulmonary Rehabilitation Professionals.
JCRP 2014; pg 298, Exercise Testing: Knowledge bullets 1-5 & Skills bullets1 & 4.
Evaluation: Signature _______________________________
Date ________________
** any/all ratings of Inadequate require a corrective action plan tailored to the staff member involved
Cardiac Rehab Example
NEW/CHANGED:
Need to update CR policy
& practice to
incorporate latest
evidence-based
recommendations for
this important outcome
measure
Cardiac Rehab Example
Changes to BP Management 2015:
• New target value for secondary prevention of cardiac
events = 140/90mmHg
• Much lower is not necessarily better & may contribute
to side effects or complications
• Decreased coronary or cerebral perfusion
• Orthostatic problems
• DBP less than 65mmHg should be avoided in older
patients
Cardiac Rehab Example
BP Management p.6
Normal range of BP at rest
& with exercise;
Current BP targets for
secondary prevention
•
•
•
Accurate determinations
Recognition of deviations
from range
Measurement of
outcomes
Competency: The Role of Cardiac Rehab in Managing Hypertension
Name _______________________
Date ______
Dept. Cardiac Rehab
Expectation: The cardiac rehab staff will monitor patients’ blood pressure at rest & during
exercise and compare findings to current treatment recommendations & evidencebased goals for managing hypertension
Essential Elements of Performance
The cardiac rehab staff will be able to:
1
2
3
4
5
6
7
8
9
Define current blood pressure(B/P) values for:

Normal B/P < 120/80 mmHg

Pre-hypertension = 120-139/80/89 mmHg

Hypertension > 140/90 mmHg
Describe the underlying pathophysiology of
hypertension as endothelial dysfunction
inhibiting arterial ability to dilate & constrict
Identify the new “reasonable” BP goal for
secondary prevention of cardiovascular
events as less than 140/90 mmHg for most
patients
Emphasize that the new goal also applies to
cardiac patients with heart failure, kidney
failure, & diabetes.
Explain the rationale for the new goal number
as based on evidence that less than 130/80
does not change morbidity or mortality
outcomes in CAD patients
Discuss the concerns that lower BP goals may
have contributed to:

Decreased coronary & cerebral perfusion

Increased orthostatic side effects
Recognize that some patients may benefit
from a goal of 130/80 or less, such as those
with:

Stroke/TIA

Abdominal aneurysm

Selected MI patients
Monitor patients for low DBP since less than
65 mmHg has been linked to an increase in
orthostatic-related complications in older
patients
List treatment priorities recommended in the
2015 evidence-based document on
hypertension management as:

Lifestyle management
Proficient
Needs Review/
Improvement
Inadequate
**
10
11
12
13
14
15
16
17
18
Outline the role of cardiac rehab in
hypertension treatment as providing lifestyle
management education & counseling for
hypertensive cardiac patients, including:

Diet management

Sodium reduction

Physical activity advice
Recommend the DASH diet as the eating
pattern of choice to help control hypertension
& list its major components as:

Non-fat dairy products

Poultry, fish, legumes

Monounsaturated oils & spreads

Nuts (walnuts, almonds, hazelnuts)
State the recommended sodium intake for
patients with hypertension as 1500-2400 mg
per day
Identify the physical activity goal for all
cardiovascular patients including those with
hypertension as:

Minimal = 150 minutes per week of
moderate activity/exercise

Optimal = 500-1000 MET-minutes per
week
Explain that the combination of healthy eating
& regular exercise that has been shown to
have the biggest impact on B/P lowering
includes:

Dash diet

Low sodium

Weight loss
List the top 3 classes of drugs recommended
for pharmacologic management of
hypertension as:

Diuretics

Beta-blockers

ACE inhibitors/ARB
Reinforce the importance of medication
compliance & provide patients with ideas &
techniques, e.g. pill boxes, to help improve
compliance
Change the target goal number for B/P in your
program’s outcome data documents to the
new recommendation of less than 140/90
mmHg
Monitor your outcome data to determine how
many patients achieve the new goal in 2015
Resources:
For Recommendations
AHA/ACC/ASH Scientific Statement:
Treatment of Hypertension in Patients with
Coronary Artery Disease. Circulation, May
12, 2015.
For Reinforcement
Staff meeting with Medical Director to
discuss the new guidelines & their
application in the cardiac rehab setting
Cross-reference to Cardiac Rehab Core Competencies:
AACVPR Core Competencies for Cardiac Rehab, 2010: page 6 Blood Pressure Management;
Knowledge bullets 3-4, 10-11; Skill bullets 3-4.
Evaluation: Signature _______________________________ Date ________________
** any/all ratings of Inadequate require a corrective action plan tailored to the staff member involved
HOW Staff Competencies
WHAT
WHY
WHEN
HOW
WHO
WHEN Staff Competencies
Schedule an in-service
presentation and/or
practice session
• Annually
• Quarterly
GOOD PEOPLE HOSPITAL
2015 Staff Competency Plan
Outpatient Cardiac Rehab Program
Topic1
Rationale2
1st q
Exercising
LVAD
Patients
LOW VOLUME:
 A growing number of heart failure patients are being
treated with Left ventricular Assist Devices (LVAD)
 Rehab staff need to understand the purpose & potential
of LVAD devices
 Familiarity with device safety features, alarms, batteries,
etc. & how to respond to each is essential to patient care
in rehab

Strength
Training
Calculating
total exercise
volume
Assessing
readiness to
change risk
factors
Notes:
Schedule3
2nd q 3rd q
4th q
X
Adjustment of assessment & exercise guidelines, e.g. no BP or
pulse checks, is required for this special population
HIGH RISK:
 Strength/resistance training is an increasingly common
element of a rehab exercise program
 Proper patient selection maximizes patient safety
 Proper performance minimizes side effects/injuries
 Program policies need to reflect national guidelines and be
consistently followed to avoid patient complications
NEW:
 Evidence-based recommendations show that optimal exercise
benefits accrue to patients who perform a total volume of
500-1000 MET-minutes of exercise per week
 That volume is comprised of both in rehab & outside exercise
 MET tables enable combining those exercises
 All staff should know how to compute that exercise volume
data
PROBLEMATIC:
 All patients are not ready to change all risk factors just
because they are now in rehab
 Staff needs to know how to determine if, when, & what a
patient is ready to change
 The trans-theoretical model (TTM) of readiness to change
provides a practical means of determining readiness that can
be integrated into initial & ongoing patient assessments
 Staff responsible for patient assessment need to implement
the stages of change questions
X
1. Each topic requires a cognitive component (new knowledge) and a performance (new skill)
component. Learning packets that include an article, sample policy, etc. and a skills checklist
are developed for each topic and completed by each staff member.
2. Topics selected by the staff are important aspects of care that are high risk, low frequency,
problem-prone, or new.
3. Completion of each competency includes review/revision (or original development) of the
corresponding program policy, treatment protocol, or chart form.
X
X
Staff Competencies: SUMMARY
• WHAT = documentation of staff knowledge, skill,
& ability
• WHY = improve quality of program; requirement
for TJC & AACVPR
• WHEN = 4 each year for cert/recert
• HOW = learn, practice, demonstrate, document
• WHO = staff member, outside expert
Cardiac Rehab - SPECIAL NOTE
Core Competency document
is basis for new CCRP certification!
Professional certification exam to be given at
this AACVPR National Meeting:
September 7, 2016
New Orleans, LA
Pulmonary Rehab – PREVIEW
PR Core Competency document
will be basis for new CPRP certification!
Now in development!!
References
Hamm LF et al. Core Competencies for Cardiac
Rehabilitation Professionals: 2010 Update.
JCRP 2011;31: 2-10.
Collins EG et al. Clinical Competency Guidelines
for Pulmonary Rehabilitation Professionals.
JCRP 2014; 34: 291-302.
References
Holland AE et al. An official European Respiratory
Society/ American Thoracic Society technical
standard: field walking tests in chronic respiratory
disease. Eur Respir J 2014; 44: 1428-1446.
Rosendorff C et al. Treatment of Hypertension in
Patients with Coronary Artery Disease. Circulation
2015; 131: e1 – e36.
Staff Competencies in Rehab
Thank You!
Good luck with planning & documenting your
program’s staff competencies!!
[email protected]
Staff Competencies in Rehab
Q&A
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