TABLE 2.

JACHO standards regarding competency assessment

Standard no.	Standard	Explanation
HR.2.10	Orientation provides initial job training and information.	As appropriate, each staff member, student, and volunteer is oriented and then assessed to the following:
The organization assesses and documents each person's ability to carry out assigned responsibilities safely, competently, and in a timely manner on completion of orientation.
		The organization documents that each person has completed orientation and has been evaluated for competency in performing required laboratory tasks as well as other parameters defined in his or her job descriptions.
		Documentation of orientation participation includes written approval by the laboratory director or appropriate supervisor noting that the individual is capable of performing laboratory duties and confirmation by the employee that he or she feels qualified after orientation to perform the tasks required.
HR.2.30	Ongoing education, including in-services, training, and other activities, maintains and improves competence.	The following occurs for staff, students, and volunteers who work in the same capacity as staff providing care, treatment, and services:
Training occurs when job responsibilities or duties change.
Participation in ongoing in-services, training, or other activities occurs to increase staff, student, or volunteer knowledge of work-related issues.
		Ongoing in-services and other education and training are appropriate to the needs of the population(s) served and comply with law and regulation.
		Ongoing in-services, training, or other activities emphasize specific job-related aspects of safety and infection prevention and control.
		Ongoing in-services, training, or other education incorporate methods of team training, when appropriate.
		Ongoing in-services, training, or other education reinforce the need and ways to report unanticipated adverse events.
		Ongoing in-services or other education is offered in response to learning needs identified through performance improvement findings and other data analysis (that is, data from staff surveys, performance evaluations, or other needs assessments).
		Ongoing education is documented.
		At a minimum, for supervisory staff, attendance at outside workshops, institutes, and local, regional, or national society meetings occurs as feasible.
Standard     HR.3.10	Competence to perform job responsibilities is assessed, demonstrated, and maintained.	Competency assessment is systematic and allows for a measurable assessment of the person's ability to perform required activities. Information used as part of competency assessment may include data from performance evaluations, performance improvement, and aggregate data on competency, as well as the assessment of learning needs. This standard encompasses the following:
		The laboratory director or appropriate laboratory supervisor regularly assesses the continued competency of staff on all laboratory work shifts through performance evaluations.
		Staff members are evaluated for competency in performing required laboratory tasks as applicable, as well as for all other parameters defined in their job descriptions.
		Supervisory staff are evaluated for performance of their job responsibilities, as defined in their job descriptions.
		A job description and a completed competency assessment, an evaluation, or an appraisal tool are on file for each contracted or employed individual.
		Each staff member's performance is evaluated and documented after orientation and annually thereafter.
		An individual qualified to provide technical judgments about performance evaluates technical staff.
		The procedures to assess and document annually the competency of technical staff include but are not limited to the following:
		Routine patient test performance, including patient preparation, if applicable, and specimen collection, handling, processing, and testing.
		The recording and reporting of test results.
		QC, proficiency testing, and preventive maintenance performance.
		Instrument function checks and calibration performance.
		Test performance assessment as defined by laboratory policy (e.g., testing previously analyzed specimens, internal blind testing samples, and external proficiency or testing samples).
		Assessment of problem-solving skills as appropriate to the job.
		If a test method or instrumentation changes or the individual's duties change, his or her performance is reevaluated to include skills in the areas of change.
		Each laboratory employee performing such tests participates in the program.
		Acceptable performance criteria are established.
		Performance levels are documented.
		When indicated, remedial action is taken and documented.
Standard     LD.2.90	The laboratory director is responsible for determining the qualifications and competence of laboratory staff.	The director determines the procedures and tests that staff members are qualified and authorized to perform and is responsible for determining the competence and qualifications of laboratory staff. The director ensures that the level of supervision provided and the level of testing complexity is commensurate with the education, training, and experience of staff. The director must also require that staff demonstrate the ability to perform all duties before actually testing patient specimens and that staff maintain competencies to perform required tasks.