St. Marys Medical Center Competency Assessment Employee Name_______________________________________________________ Job Title: Dept.

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Time Frame: July 1, 2012___________ through: ___April 15, 2013____________ This form is to be completed by the employee. For each of the competency statement listed below, the employee may select which method of verification he or she would like to use for validation of his or her skill in that area. See separate forms on the intranet for details on each specific method of verification requirements. The form indicated for a selected method of verification must be used. In addition, some competencies must be completed by a certain deadline in order to use. When all competencies are completed, make a copy of this form and all supporting forms for your records and submit the original to your unit Director. You do not have to wait until April 15th to submit documentation, but all must be done. Refer to your Staff Development Specialist and/or Director for questions.

You only need to select one verification method for each competency
Competency Leadership Skills: Accountability/ Professionalism Method of Verification Exemplar Active participant on a project through a unit or hospitalwide council, committee, or Professional Organization. Exemplar Write an exemplar of how you handled or defused a situation or an issue, giving feedback or holding someone accountable to a practice standard. Presentation (must be completed by January 15, 2013) Do a presentation or video addressing a topic related to accountability or professionalism. Group Discussion Actively participates in a planned discussion group regarding accountability and/or professionalism. Evidence of Daily Work Primary Preceptor for RN, NR, PCT, or UA Evidence of Daily Work Submit evidence supporting incorporation of RBC and CARING Behaviors into daily work Discussion Group/Reflection Discuss use of RBC and CARING Behaviors with a difficult patient and/or family member. Exemplar Write an exemplar on Building Bridges with another department. Instructions/ Validation Form AP1

Form AP2

Form AP3 ______________

Signature of SDS

Form AP4

Human Caring & Relationship Skills: Relationship Based Care/ CARING Behaviors

Form AP5 ______________

Signature of SDS

Form RBC1

Form RBC2

Form RBC3