Clinical Education Matrix: A Guide to Accreditation and Competency Management
March 13, 2023 — Marissa Lemley Brown, MSN, RN, NE-BC, NPD-BC, CPN
Over the last 18 years, I have often turned to the Association for Nursing Professional Development (ANPD) to garner informational support for new projects, resources to spark ideas, and toolkits to refine my skill set. The ANPD Resources for Nursing Professional Development Practitioners page of the ANPD website has proven to be an instrumental collection of tools that can complement anyone’s professional journey. When I venture to the page, I find myself working through the sections to ensure I am up to date on the latest professional information and trends. Although I have referenced many of these resources over the years, such as the NPD Practice Model, Environmental Scanning Toolkit, and Known Costs Table, the Clinical Education Matrix is my most frequently visited section.
In 2015, I began supporting the human resources file review process for accrediting and regulatory visits at a large academic medical center. An employee file review is often part of an overseeing body’s scheduled or unscheduled visit. Many of the components of the file review are the primary responsibility of our Human Resources Department, including the job description, background check, and annual performance evaluation. However, in those visits as a nursing professional development (NPD) specialist, I provide a complementary overview of the initial and annual competencies, learning transcript, and compliance portal. Partnering with our Human Resources Department allows me to speak to competency processes and programs in a complete and in-depth manner if questions arise.
Over the course of those years, I have reviewed hundreds of files. With each visit, I am proud to lean back on our work as an organizational competency team, which has utilized the Clinical Education Matrix as a guiding principle. The matrix outlines educational requirements set by regulatory and accrediting bodies. Highlighted organizations include the Centers for Medicare & Medicaid Services (CMS), Det Norske Veritas Healthcare, Inc. (DNV), The Joint Commission (TJC), The Occupational Safety and Health Administration (OSHA), and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Each section consists of guidelines for required education that should be provided to designated audiences working at the facility. Although this is not an inclusive list, as individual state requirements are not incorporated into the document, it is an exceptional resource to utilize as you are having conversations interdepartmentally and with leaders when planning your next competency and compliance cycle.
We have also found this resource helpful when seeking initial accreditation through a specific organization. Many organizations have access to the individual guidance resources of each organization. This document offers something unique: an “at a glance” summary that can assist practitioners in their planning. I appreciate that each section includes the reference section indicator and/or page number. If you are interested in reviewing the accrediting body’s larger document, you can quickly pinpoint the requirement and section instead of searching through massive documents.
Updated annually by ANPD Implementation Committee volunteers, it has been a pleasure to participate in revising the document I have utilized so frequently. Committee members have tirelessly combed through many documents to ensure topics, requirements, effective dates, initial training, and annual training are adequately represented so this tool can continue to be a trusted source.
Marissa Lemley Brown, MSN, RN, NE-BC, NPD-BC, CPN
Marissa Lemley Brown began her pediatric nursing career at Vanderbilt University Medical Center in 2001 after graduating from Aquinas College. She progressed in her career as a charge nurse and department educator before becoming the director of clinical education for Children's Hospital. Marissa is proud to be a fourth-generation nurse. She believes in the benefits of professional development, staff mentoring, and a supportive transitional environment for new professionals.
She received her MSN degree from the University of Phoenix and holds certification in Nursing Professional Development (NPD-BC) and as a Nurse Executive (NE-BC) from the American Nurses Credentialing Corporation (ANCC). Marissa also holds a specialty certification as a Certified Pediatric Nurse (CPN) from the Pediatric Nursing Certification Board.