Why focus on competencies?

In healthcare there are hundreds of competing priorities

All areas of healthcare are under pressure at the moment, and difficult choices constantly need to be made on where to focus scarce time and resources. So it’s important to ask the question: with all that needs to be done, why competencies? Of course you can argue in absolute terms that improving the management of competencies is a useful thing to be doing, but what about relatively? Why competencies instead of all the other important areas that also need attention?

Our view is that effective competencies is one of the most important areas for focus in any healthcare provider. It comes down to four powerful reasons:

Four core reasons for prioritising competencies

1. Patient safety Having assurance in the effective clinical skills and knowledge of healthcare professionals is absolutely vital for the safe care of patients
2. Staff Supporting staff in their professional development underpins retaining motivated and effective clinical teams across the organisation
3. Managing scarce resources Trying to look after competencies on pen and paper wastes a lot of valuable clinical time – and if you don’t have an accurate view of skill mix, you can’t properly manage staff
4. Providing assurance Many different stakeholders (including patients, regulators and commissioners) demand assurance and evidence for the safe and effective running of healthcare providers

1. Patient safety

It all starts with the patients

It’s important that in all our discussions about competencies and the wider skills of healthcare professionals, we don’t lose focus of why it is so important – for looking after patients safely.

While there are lots of factors that go into providing safe care for patients, I would argue that there are few more important than the skills of the people looking after them. If you imagine you or your loved ones as a patient in need of care, one of your top concerns will rightly be that the people looking after you have all the skills they need to provide the best possible care.

And even when you consider many of the other important factors in providing safe care, you find the skills of professionals underpin those too:

• Equipment needs to be safe and ready to use You need the people who are using and looking after it to be suitably trained
• Drugs and medical devices need to be administered safely You need the staff administering them to have the right knowledge and skills
• Clinical teams need to be effective and work well together You need managers and leaders with the appropriate skills

While I’m not saying all of this can be solved by skills and training alone (culture is hugely important and much more elusive), it’s clear that clinical skills are absolutely vital to providing safe, effective and compassionate care to patients.

But why are “rigorous” competencies so important to patient safety?

It’s important to say right from the start – of course we aren’t saying that healthcare professionals don’t have any of these skills. In the vast majority of cases staff will be well trained and motivated to work to the very highest standards. But the importance of these competencies means they need to be managed to the very highest levels.

“Vast majority” isn’t good enough for healthcare

Even if 99% of staff had the right skills, kept fully up-to-date, that wouldn’t be acceptable even for the 1% of patients cared for by those who don’t – and this is not the ambition for any healthcare provider. And, in a theme we will repeatedly return to, without a rigorous competency system you can have no idea what that proportion of staff without the right competencies is; it could 1%, it could be 0.1%, but equally it could be 10% or even more.

Varying standards

Without a rigorous competency system, you could find that healthcare professionals are being assessed in competencies, but not properly. This could be through any combination of:

• Outdated or expired standards
• Not the full set of or appropriate standards for that particular clinical setting
• Not fully tested, in all applicable circumstances
• Assessed by someone who themselves isn’t fully competent

What this also risks introducing is unwarranted variance: in the absence of a robust process to ensure consistency across the organisation, it’s left up to local initiative (generally ward sisters or matrons) to do their best. And “doing their best” will apply across all aspects of competencies: choosing appropriate standards, setting performance criteria, overseeing the process, monitoring and reporting and filling in any gaps or ambiguities in central guidance. This results in a wide mix of quality across the organisation. You will have a few places where amazing, innovative and rigorous work is being done. You will have the majority where it is being handled ok, on a good day. And then you will have the most dangerous, the areas where it is being done badly or not at all. And to return to that theme… you can have no real idea (beyond instinct) which is which.

Again, it’s important to state that this is not casting judgement on the individual professionals. In all the cases above the people involved would most likely believe they are fully competent, and be heartbroken to find out they were not.

Fraud

Thankfully, cases of fraudulently claiming clinical skills are extremely rare in the UK – but it isn’t impossible. And whilst nobody can really know how many people “exaggerate” their qualifications more generally, it’s clear that it does happen all across society. Vigilance is always required; this extreme story from Kenya on the BBC shows some of the perils of fraud when rigorous standards are not clearly upheld:

“There are people who do assignments in nursing. I wouldn’t really want to go to hospital to be treated by someone who paid someone else to take the exams. You know it’s really dangerous. It actually gives you goose bumps,” he says. “It should be abolished.”

Most paper records are signed off with just very simple ticks or initials and kept largely unsecured, making them extremely susceptible to fraud. And even if cases are extremely rare, the consequences can be incredibly serious.

Human error

Far more prevalent than malicious fraud is simple human error – honest mistakes. Unfortunately, paper records and loose competency processes are widely susceptible to mistakes. Amongst the thousands of paper records being signed-off, there will inevitably be instances of:

• Signing off the wrong person
• Not ensuring that all required steps are completed
• Using outdated standards, by using old printed materials
• Completely missing competencies or stages
• Allowing standards to lapse or not progress

Not all these mistakes will have equally serious consequences, but all represent potential risk to patient safety.

Common language

Establishing a common language helps with patient safety too. Clear and well-defined competencies setup a shared way of working amongst staff, and implementing this consistently across the hospital means far clearer and easier working across teams and departments. When this is missing, mistakes become far more likely – one person’s interpretation of how to safely work can be quite different to another’s. Patients can fall through the gaps of confusion around responsibilities, tasks and safe care.

2. Staff

If the primary motivation is caring for patients, the second comes in close behind: caring for staff.

Professional pride

Nobody goes into a career in care without a deep desire to help other people. And everyone will want to provide the best possible level of care they can. So it is not surprising that healthcare professionals can feel deeply unhappy if they believe they (and their teams) do not have the right skills, knowledge and support to deliver the best possible care to patients.

This can also lead to people feeling personally exposed – if they are being asked to carry out tasks or undertake responsibilities but know that they are not adequately equipped with the suitable clinical skills, this can lead to high level of anxiety and stress in already stretched members of staff.

Professional development and staff morale

As part of a satisfying career, most people want to have the opportunity for personal development; to learn new skills and be able to take on new responsibilities. But with no clear system to do so, it is very easy for staff professional development to drift or even stall entirely. As with patient safety, variation in professional development will creep in – some areas will be excellent, but others may be terrible.

Poor staff morale leads to a wide range of other issues for the organisation – foremost is retention and recruitment, but also productivity, sickness levels and resilience.

This impacts healthcare managers and leaders too. One of the most satisfying parts of managing a team is helping individuals to develop and progress, and not being able to do that consistently and effectively can undermine managers as well as the teams they manage.

Not having existing skills recognised

Even before you get to progressing and developing new skills, staff joining the organisation may be instantly demotivated by not having their existing skills recognised. Without the ability to securely transfer records between organisations, incoming healthcare professionals can effectively be assumed to be incompetent again until they can prove otherwise. Not the warmest welcome to a new organisation.

Up-skilling staff

By empowering and up-skilling staff, you can help them do more and achieve more for patients and the hospital. Failing to support staff in developing the right skills stops them delivering the best they can, and offers a poor foundation for other quality improvement initiatives.

But this is also about building a strong foundation for future clinical professional development. The people being trained in clinical skills today will be the people teaching them tomorrow and, more widely, these will be the leaders of tomorrow; embedding the importance of learning the skills properly and safely will passed on to future generations of healthcare professionals.

Fair performance management

Objective assessments of performance form the bedrock of fair and effective performance management – if you don’t have an objective standard for competence, then how to you fairly hold people to account for achieving it or not? And fair here is important – if people do not clearly understand what is expected of them, how can they be expected to achieve it? And if you don’t have objective standards then how do you prevent subjective, unconscious bias creeping into performance management?

Equally, what evidence are you submitting of non- or poor-performances? How do you ensure that performance management issues and their resolution is supported by clear, standardised approaches? Or do people end up feeling victimised, that the culture is against them, because you haven’t been able to clearly articulate their areas of poor-performance?

Effective performance management is the right thing to do for your teams, but it is good for the organisation too – it helps the best rise to the top, effectively supports those who are struggling, and ensures that non-performance is resolved to keep patients safe.

3. Scare resources

We have up to this point discussed competencies as a worthy area of focus for scarce resources. But failing to have a rigorous competency system in place may end up significantly costing the organisation in wasted resources.

Unable to plan

Effective use of the staff you have

Without a clear, live and detailed picture of the skills across the hospital, leaders stand very little chance of being able to make the most effective use of the staff they have. With healthcare under enormous pressure, failing to make effective use of the scarce resources that are actually available is a hugely unnecessary burden on the organisation.

This impact at both the highest levels (establishment planning for the whole organisation, recruitment plans etc.) all the way down to the most detailed (rostering and training in each clinical area) – short term and in the longer term too.

Planning for the future

If you don’t understand the skills you currently have in the workforce, you can’t effectively plan for the future. With a clear picture on staff competencies you could identify current and likely future gaps and come up with training plans that help your workforce meet the care needs of patients, by training the right number of people in the appropriate skills. Without this you risk both over- and under-developing staff in different areas, or at best trying to train people as a knee-jerk reaction to urgent pressures.

Wasting staff time

Time and effort are wasted throughout

A vast amount of vital clinical time that is being wasted just through the process of managing competencies. This comes from a variety of sources: time writing competency documentation, assessments and feedback, reports and plans – all from handwritten notes or clunky Word documents and Excel spreadsheets.

Finally, with poorly managed processes it is easy to add on unnecessary supernumerary time, for drawn-out and unmanaged induction of new staff that ends up taking weeks longer than it should.

Competencies are not portable

Paper records also mean that competencies are not portable – they are physically anchored into those folders. So when staff move, their records struggle to move with them. This is a challenge within a hospital (cross-covering shifts), and an impossibility across different hospitals.

Hospitals are faced with an unenviable choice:

• Take every person’s word for it on their existing competencies
• Re-assess existing competencies for incoming staff

Most will lean on the side of safety, and re-assess incoming staff on the skills they already have. This may be an accelerated assessment (for example requiring fewer supervised assessments), but can still involve days or even weeks of repeated time.

And a lot of this time is doubly wasted – as it involves both the person assessing and the person being assessed.

Each hospital reinvents the wheel

Simultaneously across the country hundreds of different people are independently writing competency assessments for fundamentally the same skills. Even where competency standards have been published by external bodies, most are not in a form that can be directly used by healthcare providers, so assessment standards will need to be re-written.

And this reinvention doesn’t just come with the cost of wasted time, it comes with risk. No organisation will get this consistently right across all competencies, across the whole workforce.

Poor use of the modern workforce

It’s a reality of the modern healthcare workforce, that fewer and fewer staff are working full-time, regular patterns. This can be for reasons that people welcome (more flexible hours, career breaks and parental leave) and those that they may not (reliance on agency workers, higher attrition rates of staff). But either way, all organisations need to adapt and work effectively with more flexible working arrangements. And whatever the circumstances, no manager wants to undermine or fail to support the team working for them.

But in the absence of a robust system, doing justice to these team members is very difficult – there just isn’t the time or opportunity to work through complicated competency setups. Time is wasted on repeated onboarding checks of temporary staff, but in the absence of full records this is a necessary evil for compliance and safety. Alternatively, temporary staff are unable to work at their actual level of skill because they lack documented evidence of the relevant competencies.

And for staff returning from absence (e.g. after paternity leave), there may not be any clear way of assessing and re-validating skills that may have lapsed over that time.

4. Assurance

Healthcare is an important (and emotive) topic for most people. We care deeply that our loved ones will be looked after safely and kindly, and we want to be re-assured that this will always happen. So as a society we have put in place a wide range of checks and balances in place to seek this assurance – regulators like the CQC, commissioners (such as CCGs), internal NHS Trust Boards and Governors, and more informal bodies like patient interest groups. The competencies of the clinical workforce are a key part of the assurance that all these assurance groups seek.

But without a rigorous system, hospital leaders are left with no information or insight and no assurance to provide patients, commissions or regulators. This is vital information, and there are critical questions that are going unanswered

• Do the staff on each ward have the appropriate skills for the patient they care for?
• Where are staff learning and developing, and where are they being neglected?
• Which competencies have expired or need updating, and which staff need re-assessing?
• Which parts of the clinical skills are a teams strong at, and which do they struggle with?
• How are staff progressing through induction and becoming part of the numbers, and where are they being delayed as supernumerary?

How can you know?

Lord Kelvin is often quoted as saying “If you can’t measure it, you can’t improve it” (even if he didn’t say it quite that neatly), and there’s a similar quote from Peter Drucker: “If you can’t measure it, you can’t manage it”.

The relevant point here is – if you don’t have the data and analysis to prove that your staff have the relevant skills… how can truly know whether they do or not? And whether they are improving or not? Before you can provide assurance to any external stakeholders… are you even able to sit round the table with your own teams and say with confidence that you understand the situation yourselves?

Can you trust your policies?

Competencies are also a key part of where policy meets the real world – policies show intent, but competencies show action. And if you don’t know if your clinical teams have the clinical skills stated in the policy, how can you say have any confidence that policy is working?

This falls under a wider point about policies:

There is little point writing detailed policies and clinical standards if you don’t have a mechanism for ensuring they are understood and implemented effectively by frontline staff, and a way of knowing whether they are (1) being followed and (2) having the desired impact

You risk wasting a lot of time and effort (plus demotivating staff) by writing detailed policies that have no chance of being implemented because local teams do not have the detailed frameworks to be able to make them a reality on the ground.

In fact it might be worse, because you’re giving yourself false assurance that you have this covered, when in reality you absolutely do not.

False assurance

Imagine you put a new process, potentially in response to a serious incident or as part of a quality improvement initiative. You’ve written the policy documents and everyone is saying they are happy with it. You may even have a report and all indicators are showing as green. Leadership at all levels feel satisfied that the job is being done properly and patients are safe.

But then an incident happens, and everyone wonders how that could possibly happen, when all indicators were telling you that all was fine.

Here the issue is false assurance. Having the policy written and published gave everyone the confidence that the matter was settled, and because of that they paid less attention than they would have done without this work. But without mechanisms like competency management in place, the reality is that there is no more assurance than without the policy, there is just far less focus than there was before the policy was implemented.

And if that feels like it would be a major issue, just imagine all the other policies that are are also offering false assurance, but you haven’t yet had the incident to make you realise that the assurance is false.

How can you implement change?

And to expand upon the point above – a lack of a rigorous competency process makes implementing any clinical change or quality improvement process far harder. There will not be many QI initiatives that don’t fundamentally require staff to learn new skills, or at the very least need some assurance that all the relevant staff have the skills needed. But having to manually collect and manage this process specifically for a single QI initiative, potentially across thousands of members of staff, is enough of a barrier to stop that initiative being successful – or indeed may put off implementing it at all.

The solution

Well, of course we’re going to say Compassly. But we believe just awareness of the scale of the problem is important – so please feel free to share this thinking to help with the wider understanding of the problem.

And we have a wider mission to help all healthcare professionals with their professional development, so over time we will be publishing resources and guidance here to help. Please check back regularly as we publish more material to the Resources section of our website, or follow us on Twitter to keep up to date.

Disagree? Think we’ve missed something?

Please get in touch – we’d love to include your views to give a fuller picture, and we’ll continue to update this article as we hear of other perspectives or areas that we have missed.

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