Stafford Hospital Endoscopy – Initial and Ongoing Competency Validation
Angel Patterson BSN RN - SH Endoscopy
As the Stafford Hospital (SH) Lead Endoscopy RN, my manager approached
me to look over the SH Endoscopy Competency Based Orientation Tools (CBOTs)
in preparation for Joint Commission. I recognized the need for the implementation
of a uniform SH Endoscopy CBOT and Annual Competency compliance by Joint
Commission standards. My ACE project focused on preparing SH Endoscopy
CBOTs for Joint Commission and initiating Annual Competencies. I am also
the designated SH Endoscopy Policy Reviewer by management since 2013.
As a result of the project study, 3 Endoscopy RNs and 6 Techs were identified
with incomplete/inconsistent CBOTs. No Annual Competencies had been completed
for 3+ years. I have taken ownership of the SH Endoscopy CBOTs. It is
a priority to have 100% compliance.
I sent out emails to each RN and Tech to meet with me to complete their
CBOTs. We are required to be 100% compliant when Joint Commission visits
SH. I created an Endoscopy Annual Competency check off sheet. I emailed
Endoscopy Reps for training and In-Services.
A literature search was performed using CINAHL and consistent data found
initial competency should be attained and annual competence should be
I plan to continue to review SH Endoscopy CBOTs annually. I will ensure
that RNs and Techs complete Endoscopy Annual Competencies. I will foster
a good working relationship with the Perioperative Nurse Educator to continue
Joint Commission compliance.
- SH Endoscopy CBOTs were completed October 31, 2015.
- Endoscopy Annual Competency Form is used in real time, checking off skills
as it is performed during a procedure.