to main content Competency Assessment vs Orientation | Ambulatory | Human Resources HR | The Joint Commission
Coronavirus Resources
  • Careers
  • E-Alerts
  • Contact Us
Main Menu
The Joint Commission
Visit Joint Commission ResourcesVisit Joint Commission InternationalQuality Check
Login
  • Who We Are
    Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm.
    • Who We Work With
      • Our Partnerships
      • Payor Relations
      • State Recognition
    • Why Work With Us
    • Facts About The Joint Commission
      • History of The Joint Commission
      • Joint Commission FAQs
      • Board of Commissioners
      • Joint Commission Advisory Groups
      • Quality Check and Quality Reports
    • Policies and Financials
      • Code of Conduct
      • Conflict of Interest Policy
      • Designated Copyright Agent Policy
      • Financial Statements
      • Firewall Policy Summary
      • Linking to The Joint Commission Website
      • Public Information Policy
      • Reprint Permission Policy
    • Federal Relations and Public Policy
    • Joint Commission Officers
      • Jonathan B. Perlin
      • David Baker
      • Brian Enochs
      • Michael Kaba
      • Kin Lee
      • Ana Pujols McKee
      • Paige Rodgers
      • Deborah A. Ryan
      • Margaret VanAmringe
      • Lisa Vandecaveye
    • Joint Commission Resources
    • Joint Commission International
    A doctor reviews information on a tablet with a nurse

    Who We Work With

    Learn more about the communities and organizations we serve.

    A group of business professionals collaborate on a project in a conference room

    Why Work With Us

    See how our expertise and rigorous standards can help organizations like yours.

  • What We Offer
    In addition to accreditation, certification, and verification, we provide tools and resources for health care professionals that can help make a difference in the delivery of care.
    • How We Can Help
    • Accreditation
      • Health Care Settings
      • Become Accredited
      • Accreditation Guide
      • Accredited
    • Certification
      • What is Certification
      • Certifications by Setting
      • Explore Eligibility
      • Learn the Process
      • After your Review
      • Certifications without Accreditation
    • Verification
      • Improve Maternal Outcomes at Your Health Care Facility
      • Maternal Levels of Care Verification
      • Publicity Kit
    • Complimentary Resources
      • Webinars
      • Newsletters
      • R3 Reports
      • Sentinel Event Alerts
      • Patient Safety Topics
      • DASH
    Female nurse holding senior woman's hand.

    How We Can Help

    Learn how working with the Joint Commission benefits your organization and community.

    Shot of a group of medical practitioners having a discussion in a hospital.

    Accreditation Guide

    Find the exact resources you need to succeed in your accreditation journey.

  • Our Priorities
    Learn about the priorities that drive us and how we are helping propel health care forward.
    • Health Care Equity
      • Accreditation Standards & Resource Center
    • Emergency Management
    • Infection Prevention and Control
    • Suicide Prevention
    • Workplace Violence Prevention
    An elderly woman in a wheelchair is helped by a friendly nurse

    Health Care Equity

    Drive performance improvement using our new business intelligence tools.

    Veterinarian washing hands with soap at sink

    Infection Prevention & Control

    Find evidence-based sources on preventing infections in clinical settings.

  • Standards
    Set expectations for your organization's performance that are reasonable, achievable and survey-able.
    • About Our Standards
    • Standards Field Reviews
      • Proposed Requirements Related to Environmental Sustainability Field Review
    • National Patient Safety Goals
      • Ambulatory Health Care: 2023 National Patient Safety Goals
      • Assisted Living Community: 2023 National Patient Safety Goals
      • Behavioral Health Care and Human Services: 2023 National Patient Safety Goals
      • Critical Access Hospital: 2023 National Patient Safety Goals
      • Home Care: 2023 National Patient Safety Goals
      • Hospital: 2023 National Patient Safety Goals
      • Laboratory Services: 2023 National Patient Safety Goals
      • Nursing Care Center: 2023 National Patient Safety Goals
      • Office-Based Surgery: 2023 National Patient Safety Goals
    • Prepublication Standards
      • New Requirements for Certified Community Behavioral Health Clinics
      • Revision to MS.06.01.05, EP 7
      • The Term Licensed Independent Practitioner Eliminated
      • Updates to the Patient Blood Management Certification Program Requirements
      • New Assisted Living Community Accreditation Memory Care Certification Option
      • Revisions to PI.01.01.01, EP 4
      • Health Care Equity Standard Elevated to National Patient Safety Goal
      • New and Revised Emergency Management Standards
      • New Health Care Equity Certification Program
      • Updates to the Advanced Disease-Specific Care Certification for Inpatient Diabetes Care
      • Updates to the Assisted Living Community Accreditation Requirements
      • Updates to the Comprehensive Cardiac Center Certification Program
    • R3 Report
    • Standards FAQs
    • Universal Protocol
    • Patient Safety Systems PS Chapter
    Nurse and doctor talking to happy hospital patient after surgery

    National Patient Safety Goals

    Find out about the current National Patient Safety Goals (NPSGs) for specific programs.

    doctor chatting to sales rep in hospital corridor

    FAQs about the Standards

    We help you measure, assess and improve your performance.

  • Measurement
    Learn about the "gold standard" in quality. We develop and implement measures for accountability and quality improvement.
    • Measures
      • Assisted Living Community Measures
      • Cardiac Care
      • Emergency Department
      • Health Care Staffing Services
      • Hospital Outpatient Department
      • Hospital-Based Inpatient Psychiatric
      • Immunization
      • Palliative Care
      • Perinatal Care
      • Spine Surgery
      • Stroke
      • Substance Use
      • Tobacco Treatment
      • Total Hip and Knee Replacement
      • Venous Thromboembolism
    • Specifications Manuals
      • Electronic Clinical Quality Measures
      • Chart Abstracted Measures
    • Reporting
      • Accreditation - Hospital
      • Certification
    • Pioneers in Quality
      • Facts
      • Proven Practices
      • Expert to Expert Series
      • Recognition
    • Resources
    • ORYX FAQs
    • Quality Measurement Webinars & Videos
      • Video Shorts
    • Assisted Living Community (ALC)
    Business information and info-graphics concept.

    Measures

    Learn about the development and implementation of standardized performance measures. View them by specific areas by clicking here.

    Happy Medical Team Looking at Laptop in Doctor's Office.

    Pioneers in Quality

    Gain an understanding of the development of electronic clinical quality measures to improve quality of care.

  • Resources
    Obtain useful information in regards to patient safety, suicide prevention, infection control and many more.
    • Health Care Equity
    • Publicity Kits
    • Patient Safety Topics
      • Zero Harm
      • Emergency Management
      • Health Care Workforce Safety and Well-Being
      • Infection Prevention and Control
      • Report a Patient Safety Concern or Complaint
      • Suicide Prevention
      • Workplace Violence Prevention
    • News & Multimedia
      • The Joint Commission Stands for Racial Justice and Equity
      • Blogs
      • Joint Commission Saves Lives
      • Events
      • Fact Sheets
      • Newsletters
      • News Releases
      • Podcasts
      • Speakers Bureau
      • Video Resources
      • Webinars
      • The Joint Commission and Social Media
    • Patient Safety
      • 2022 Patient Safety Awareness Week
    • Sentinel Event
    • The Physical Environment
      • Utility Systems - EC.02.05.01
      • Means of Egress - LS.02.01.20
      • Built Environment - EC.02.06.01
      • Fire Protection - EC.02.03.05
      • General Requirements - LS.02.01.10
      • Protection - LS.02.01.30
      • Automated Suppression - LS.02.01.35
      • Life Safety Code
    • For Nurses
    • For Physicians
      • Physician Leader Monthly March 2023
      • Physician Leader Monthly February 2023
      • Physician Leader Monthly January 2023
      • Physician Leader Monthly December 2022
      • Physician Leader Monthly November 2022
      • Physician Leader Monthly October 2022
      • Physician Leader Monthly September 2022
      • Physician Leader Monthly August 2022
      • Physician Leader Monthly July 2022
      • Physician Leader Monthly June 2022
      • Physician Leader Monthly May 2022
      • Physician Leader Monthly April 2022
    • For Consumers
      • Speak Up Campaigns
      • COVID-19 Vaccines
      • TakeCHARGE
      • The Joint Commission Journal on Quality and Patient Safety
      • The Smart Parents Guide
      • You The Smart Patient
    • Research
      • Operations Support Research
      • Evaluation Research
      • Health Services Research
      • DataMart
    • Awards
      • Ernest Amory Codman Award
      • John M. Eisenberg Patient Safety and Quality Award
      • Bernard J. Tyson National Award for Excellence in Pursuit of Healthcare Equity
    • Continuing Education Credit Information
      • Continuing Education Credit Information FAQs
    Talking to audience.  One member of the board speaking in microphone among other participants of meeting.

    News & Multimedia

    Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications.

    Group of young creative people collaborating in modern office.

    Patient Safety Topics

    We can make a difference on your journey to provide consistently excellent care for each and every patient.

  1. Home >
  2. Standards >
  3. Standards FAQs >
Competency Assessment vs Orientation
Print

The Human Resource (HR) chapter of the accreditation manuals include requirements for 'orientation' and 'competency assessment'. How do these activities really differ from each other?

Back to FAQs
Any examples are for illustrative purposes only.

Orientation
The Joint Commission's glossary defines orientation as "A process used to provide initial training and information while assessing the competence of clinical staff relative to job responsibilities and the organization's mission and goals." 

Orientation may be further described as an introductory program and/or activities intended to guide a person in adjusting to new surroundings, employment, policies/procedures, essential job functions, etc. Each organization is responsible for determining when and how long a person is considered to be in orientation. 

The requirements found at HR.01.04.01 outline specific topics to be included in an employee's orientation process and documented. For example, orientation to Key Safety Content that must be completed before staff provides care, treatment, and services often include:
  • Fire Safety and response
  • Infection prevention and control
  • Emergency response (code blue, rapid response, etc.)
  • Active shooter
  • Bomb threats
  • Personal safety
  • Emergency Management (internal/external disaster plans)
  • Medical equipment failure and reporting process
  • Utility system disruptions and reporting process
Additional examples may include:
  • Work schedule
  • Employee attendance, time and resource management expectations
  • Employee responsibilities in the event of an internal or external disaster
  • Managing a patient's pain
  • Sensitivity to cultural diversity
  • Patient Rights
  • Code of conduct expectations
  • Infection prevention and control
  • Maintaining privacy and security of protected health information; sometimes referred to as HIPAA training.
Competency
While not formally defined, competency may be described as a combination of observable and measurable knowledge, skills, abilities and personal attributes that constitute an employee's performance.  The ultimate goal is that the employee can demonstrate the required attributes to deliver safe, quality care.

Competency assessment timeframes may vary greatly based on the individual's entry skill level and the complexity of the task(s) the individual will be required to safely perform.  For example,  demonstrating competency on performing a bedside glucometer test will take less time to achieve than caring for a patient who has just undergone an open heart procedure that involves managing/monitoring complex equipment and highly refined assessment skills.
 
Because of the variability involved in both the number and complexity of competencies an individual must be deemed competent, organizations often give consideration to these factors rather than assigning a finite period of time in which competency must be achieved, however, this would be an organizational decision.

While The Joint Commission does not define required competencies that must be completed, when determining competency requirements, consideration should be given to needs of its patient population, the types of procedures conducted, conditions or diseases treated, and the kinds of equipment it uses. Competency assessment then focuses on specific knowledge, technical skills, and abilities required to deliver safe, quality care.

Competency assessments for knowledge and technical skills intrinsic to an individual's professional education are generally not required. For example:
  • Administration of oral, IM or sub-q medications may be intrinsic to professional education, but the use of a programmable infusion pump for IV administration may be a required competency.
  • Basic assessment skills, such as heart/lung sounds may be part of education, but assessment skills required to care for patients on a neuro-surgical unit may require advanced competency assessments in evaluating a patient's neurological status.
  • Basic infection prevention and control knowledge may be part of education, however, knowledge and skills related to sterile technique, sterilization, and high-level disinfection would be competencies expected of an OR Nurse, surgical assistants and sterile processing staff.
Survey activities will focus on the organization's requirements, compliance with evidence-based guidelines, standards of practice and regulatory requirements. The accreditation requirements that address orientation and competency are found in the Human Resource (HR) chapter of the accreditation manual. Each Joint Commission-accredited organization has a copy of the manual containing these requirements.
Manual: Ambulatory
Chapter: Human Resources HR
Last reviewed by Standards Interpretation: April 18, 2022 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: August 28, 2017 This Standards FAQ was first published on this date.
This page was last updated on April 18, 2022 with update notes of: Review only, FAQ is current Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.
Back to FAQs

If no, please comment on how we could improve this response.

If you have additional standards-related questions regarding this topic, please use the Standards Online Submission Form
A group of nurses in a hospital hallway

Go Above and Beyond with Certification

Reduce variation and risk while improving quality care. Certifications from The Joint Commission represent the most stringent, comprehensive and evidence-based proof of the success of your program available.
Certification
A group of medical professionals seen on a video call on a laptop computer

Ambulatory Health Care Webinars

Get the latest on the Comprehensive Accreditation Manual for Ambulatory Care, including all you need to know for a successful survey, tips for implementation, preparing your team, in addition to sustaining your accreditation.
Webinars
A business professional reads off a laptop computer and takes notes on a notepad

PolicySource: P&Ps for Compliance with Joint Commission Requirements

Get access to dozens of downloadable, sample policies and procedures required by Joint Commission standards on this easy-to-navigate web-based portal.
PolicySource
Chat Bot Icon
Joint Commission Virtual Assistant
This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. Get more information about cookies and how you can refuse them by clicking on the learn more button below. By not making a selection you will be agreeing to the use of our cookies.
  • Joint Commission International
  • Joint Commission Resources
  • Visit us on Facebook facebook
  • Visit us on Twitter twitter
  • Visit us on LinkedIn linkedin
  • News Room
  • Careers
  • E-Alerts
  • Contact Us
  • Accessibility
  • Terms of Use
  • Privacy & Cookies Statement
©2023 The Joint Commission, All Rights Reserved

The Joint Commission is a registered trademark of the Joint Commission enterprise.