# Standard Operating Procedure: Training and Competency

| Document ID | SOP-003 |
|-------------|---------|
| Title | Training and Competency |
| Revision | 1.0 |
| Effective Date | [DATE] |
| Author | [AUTHOR] |
| Approved By | [APPROVER] |
| Department | Quality Assurance |

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## 1. Purpose

To establish requirements for training and competency assessment of personnel involved in developmental pediatric services, ensuring standardized assessment administration and evidence-based clinical practices.

## 2. Scope

This procedure applies to all personnel involved in:
- Clinical assessments and evaluations
- Developmental screening
- Administrative support
- School liaison activities
- Quality assurance functions

## 3. Responsibilities

### 3.1 Clinical Director
- Identifies training needs
- Develops clinical training curriculum
- Assesses clinical competency
- Maintains assessment tool certifications
- Approves specialized assessment administrators

### 3.2 Quality Assurance Manager
- Maintains training records
- Tracks training completion
- Schedules required training
- Documents competency assessments

### 3.3 Supervisors
- Ensure staff complete required training
- Assess ongoing competency
- Identify performance gaps
- Support professional development

### 3.4 Employees
- Complete assigned training
- Maintain required certifications
- Participate in competency assessments
- Seek additional training as needed

## 4. Training Requirements

### 4.1 New Employee Onboarding

All new employees shall complete:

1. **General Training** (within first week):
   - Organization overview and mission
   - Quality policy and QMS overview
   - HIPAA and patient privacy
   - Safety and emergency procedures
   - Document control procedures
   - Electronic health record system

2. **Role-Specific Training** (within first 30 days):
   - Position-specific SOPs and protocols
   - Clinical workflows and procedures
   - Assessment tools and protocols (if applicable)
   - Multidisciplinary team coordination
   - Family communication best practices

### 4.2 Clinical Assessment Training

Clinical staff shall complete specialized training in:

#### 4.2.1 Autism Diagnostic Tools
- **ADOS-2** (Autism Diagnostic Observation Schedule, 2nd Edition)
  - Research-reliable training or equivalent
  - Annual inter-rater reliability checks
  - Module-specific training for each age/language level

- **ADI-R** (Autism Diagnostic Interview-Revised)
  - Standardized training in administration
  - Scoring and interpretation protocols
  - Annual reliability verification

#### 4.2.2 Cognitive and Developmental Assessments
- **Bayley-4** (Bayley Scales of Infant and Toddler Development)
- **WISC-V** (Wechsler Intelligence Scale for Children)
- **Stanford-Binet 5**
- **Vineland Adaptive Behavior Scales-3**
- **Leiter International Performance Scale-3**

#### 4.2.3 ADHD and Behavior Rating Scales
- Conners Rating Scales-4
- Vanderbilt Assessment Scales
- BASC-3 (Behavior Assessment System for Children)
- CBCL (Child Behavior Checklist)

#### 4.2.4 Learning Disability Assessments
- WIAT-4 (Wechsler Individual Achievement Test)
- WJ-IV (Woodcock-Johnson IV)
- KTEA-3 (Kaufman Test of Educational Achievement)

#### 4.2.5 Screening Tools
- ASQ-3 (Ages & Stages Questionnaires)
- M-CHAT-R/F (Modified Checklist for Autism in Toddlers)
- PEDS (Parents' Evaluation of Developmental Status)

### 4.3 Regulatory and Compliance Training

All staff shall complete annual training in:
- HIPAA and patient privacy
- IDEA and special education law (for school liaison staff)
- Section 504 and ADA requirements
- Mandated reporter requirements
- Cultural competency
- Trauma-informed care

### 4.4 Continuing Education

Clinical staff shall maintain:
- Professional licensure requirements
- Continuing education credits per licensing board
- Updated knowledge of DSM-5-TR criteria
- Current AAP developmental surveillance guidelines
- Evidence-based practice updates

## 5. Competency Assessment

### 5.1 Initial Competency

Before independent practice, employees shall demonstrate competency through:

1. **Observation**: Direct observation by supervisor/trainer
2. **Testing**: Written or practical examination
3. **Case Review**: Review of practice cases with feedback
4. **Simulation**: Practice scenarios or role-play

### 5.2 Assessment Tool Competency

Clinical staff administering standardized assessments shall demonstrate:

1. **Administration Fidelity**:
   - Correct setup and materials
   - Standardized instructions
   - Accurate timing and prompting
   - Appropriate rapport building

2. **Scoring Accuracy**:
   - Accurate real-time scoring
   - Correct interpretation of responses
   - Proper use of scoring criteria

3. **Protocol Adherence**:
   - Following published administration guidelines
   - Proper documentation
   - Recognizing when to discontinue or adapt

### 5.3 Ongoing Competency

Annual competency verification through:
- Case audits and documentation review
- Inter-rater reliability checks (for diagnostic tools)
- Supervisor observations
- Peer review
- Outcome metrics (e.g., report timeliness, family satisfaction)

### 5.4 Competency Documentation

Document competency assessments using:
- FRM-004 Training Record Form
- Assessment tool fidelity checklists
- Inter-rater reliability data
- Competency assessment forms

## 6. Training Records

### 6.1 Record Contents

Training records shall include:
- Employee name and position
- Training topic/course title
- Date of training
- Duration/credits
- Trainer/instructor name
- Competency assessment results
- Certifications and expiration dates

### 6.2 Record Retention

- Active employee records: Maintained in personnel file
- Former employee records: Retained for 7 years after separation
- Assessment tool certifications: Maintained with current credentials

## 7. Training Effectiveness

Training effectiveness evaluated through:
- Post-training assessments
- Performance metrics
- Error/incident rates
- Family satisfaction feedback
- Audit findings
- Competency assessment results

## 8. Retraining

Retraining required when:
- Competency assessment fails
- Significant protocol deviations identified
- New assessment tools implemented
- Regulatory changes require updated knowledge
- Annual refresher training due
- Extended absence from clinical duties (>6 months)

## 9. Related Documents

- FRM-004 Training Record Form
- Assessment tool administration manuals
- Competency assessment checklists
- Personnel files

## 10. References

- ADOS-2 Clinical Training Guidelines
- Professional licensing board requirements
- AAP developmental surveillance recommendations
- IDEA regulations (34 CFR Part 300)

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## Revision History

| Rev | Date | Description | Author |
|-----|------|-------------|--------|
| 1.0 | [DATE] | Initial release | [AUTHOR] |