This scenario presents a professional challenge due to the inherent complexity of managing anticoagulation therapy in a pediatric patient with a rare disease, requiring a nuanced understanding of both the disease’s pathophysiology and the pharmacokinetics of anticoagulants in a developing physiology. The need to balance efficacy with the significant risk of bleeding, especially in a vulnerable population, necessitates a highly individualized and evidence-based approach. Furthermore, the rarity of the condition may mean limited published data, increasing reliance on expert consensus and careful extrapolation of existing knowledge. The best approach involves a comprehensive assessment of the patient’s specific clinical status, including the severity of the rare disease, current bleeding risk, and any co-morbidities. This assessment should then inform the selection of an appropriate anticoagulant, considering its safety profile, route of administration, and monitoring requirements in pediatric patients. Close collaboration with the patient’s multidisciplinary care team, including hematologists and pediatric specialists, is paramount to ensure a coordinated and safe treatment plan. This approach aligns with ethical principles of beneficence and non-maleficence, prioritizing patient safety and well-being through informed decision-making and shared expertise. Regulatory guidelines for pediatric drug use and off-label prescribing, where applicable, would also be carefully considered, emphasizing the need for robust justification and informed consent. An incorrect approach would be to solely rely on adult dosing guidelines for anticoagulants, disregarding the significant physiological differences in pediatric patients. This fails to account for altered drug metabolism, distribution, and elimination in children, potentially leading to supratherapeutic or subtherapeutic levels and increasing the risk of adverse events. Such an approach would violate the principle of individualized care and could contravene regulatory expectations for pediatric drug management. Another incorrect approach would be to initiate therapy based on anecdotal evidence or the preferences of a single clinician without consulting relevant literature or seeking input from specialists. This bypasses the critical process of evidence-based medicine and expert consultation, increasing the likelihood of suboptimal treatment and potential harm. It neglects the ethical obligation to provide care that is informed by the best available knowledge and expertise. A further incorrect approach would be to delay treatment due to uncertainty about the optimal anticoagulant, without actively seeking expert advice or exploring available evidence. While caution is warranted, undue delay in managing a condition requiring anticoagulation can lead to significant morbidity or mortality. This inaction, without a proactive strategy to resolve the uncertainty, could be seen as a failure to act in the patient’s best interest. Professionals should employ a systematic decision-making process that begins with a thorough understanding of the patient’s condition and risk factors. This should be followed by a comprehensive literature review, consultation with relevant specialists, and consideration of available guidelines. The selection of therapy should be a collaborative process, with clear communication regarding the rationale for the chosen treatment, potential risks and benefits, and the monitoring plan. Ongoing reassessment of the patient’s response and adjustment of therapy as needed are crucial components of safe and effective anticoagulation management.

Scenario Analysis: This scenario presents a professional challenge because it requires a pharmacist to navigate the complexities of advanced competency assessment within a pan-regional framework, specifically concerning anticoagulation. The core difficulty lies in ensuring that the assessment process accurately reflects the pharmacist’s readiness for advanced practice, adheres to established regulatory standards for such assessments, and maintains patient safety as the paramount concern. Misinterpreting the purpose or eligibility criteria could lead to either under-qualified individuals undertaking advanced roles or unnecessarily hindering qualified professionals, both of which have significant implications for patient care and regulatory compliance. Careful judgment is required to align the assessment’s intent with its practical application and eligibility requirements. Correct Approach Analysis: The best professional practice involves a thorough understanding that the Advanced Pan-Regional Anticoagulation Pharmacy Competency Assessment is designed to evaluate a pharmacist’s demonstrated expertise, critical thinking, and practical skills in managing complex anticoagulation therapy across a defined regional scope. Eligibility is contingent upon meeting pre-defined criteria that typically include a foundational level of anticoagulation experience, successful completion of prerequisite training or education, and a commitment to ongoing professional development within the specialized field. This approach is correct because it aligns with the fundamental purpose of competency assessments: to assure the public and regulatory bodies that practitioners possess the necessary skills and knowledge to provide safe and effective care at an advanced level. Adherence to established eligibility criteria ensures a standardized and equitable process, preventing individuals who lack the requisite background from undertaking responsibilities they are not prepared for, thereby upholding patient safety and professional standards. Incorrect Approaches Analysis: One incorrect approach involves assuming that simply having a general pharmacy license and a few years of practice automatically qualifies an individual for advanced competency assessment. This fails to recognize that advanced competency requires specialized knowledge and skills beyond general pharmacy practice, particularly in the nuanced field of anticoagulation management. Regulatory frameworks for advanced practice assessments typically mandate specific experience, training, and demonstrated proficiency in the area of specialization, not just general licensure. Another incorrect approach is to believe that the assessment is primarily a formality or a bureaucratic hurdle to overcome, rather than a rigorous evaluation of advanced capabilities. This mindset can lead to a superficial preparation and an underestimation of the depth of knowledge and skill required. Ethically and regulatorily, competency assessments are critical gatekeepers for advanced practice, ensuring that only those who have met stringent standards are recognized, thereby protecting patients from potential harm due to inadequate expertise. A further incorrect approach is to interpret eligibility solely based on personal interest or a desire for career advancement without considering the established, objective criteria set by the pan-regional body. While personal motivation is important, eligibility for advanced competency assessment is determined by adherence to pre-defined, evidence-based standards designed to ensure a consistent level of expertise across the region. Ignoring these objective criteria risks compromising the integrity of the assessment process and the assurance of advanced practice competence. Professional Reasoning: Professionals should approach competency assessments by first meticulously reviewing the official documentation outlining the purpose, scope, and eligibility requirements of the specific assessment. This involves understanding the underlying rationale for the assessment – to ensure advanced competence and patient safety. They should then objectively evaluate their own qualifications against these criteria, seeking clarification from the assessing body if any aspect is unclear. This systematic approach ensures that their participation is both appropriate and aligned with regulatory and ethical expectations, fostering a culture of accountability and continuous improvement in specialized pharmacy practice.

The control framework reveals a common implementation challenge in pan-regional anticoagulation therapy: ensuring consistent, evidence-based prescribing and monitoring across diverse healthcare settings and patient populations. This scenario is professionally challenging because it requires balancing established clinical guidelines with the practical realities of local resource availability, prescriber familiarity, and patient adherence, all while adhering to strict regulatory requirements for medication safety and efficacy. Careful judgment is required to navigate these complexities without compromising patient care or regulatory compliance. The best approach involves a proactive, multi-faceted strategy that prioritizes education, standardization, and robust monitoring. This includes developing clear, accessible protocols for anticoagulation initiation, monitoring, and management that are aligned with current pan-regional guidelines and regulatory expectations. Crucially, this approach emphasizes ongoing professional development for healthcare providers, ensuring they are up-to-date on best practices, potential drug interactions, and the specific nuances of different anticoagulants. Furthermore, it mandates a systematic approach to patient education and engagement, empowering patients to understand their treatment, recognize signs of complications, and adhere to monitoring schedules. This comprehensive strategy directly addresses the core knowledge domains by promoting evidence-based practice, patient safety, and effective communication, all within the established regulatory landscape. An approach that relies solely on individual prescriber discretion without a standardized framework is professionally unacceptable. This fails to ensure consistent application of best practices and can lead to variations in care, potentially increasing the risk of adverse events or suboptimal therapeutic outcomes. It neglects the regulatory imperative for standardized medication management and quality assurance. Another professionally unacceptable approach is to implement a new anticoagulation protocol without adequate training or support for healthcare providers. This creates a significant risk of prescribing errors, incorrect monitoring, and poor patient adherence, as providers may not fully understand the protocol or its rationale. This disregards the ethical obligation to ensure competence and the regulatory requirement for safe medication use. Finally, an approach that focuses only on the availability of different anticoagulants without addressing the critical aspects of patient selection, monitoring, and education is insufficient. While drug availability is a factor, it does not, in itself, guarantee safe and effective anticoagulation. This overlooks the core knowledge domains related to patient assessment, therapeutic drug monitoring, and patient safety, which are paramount for regulatory compliance and optimal patient outcomes. Professionals should employ a decision-making framework that begins with a thorough understanding of the pan-regional guidelines and relevant regulatory requirements. This should be followed by an assessment of the current local implementation, identifying gaps and challenges. The development and implementation of solutions should be collaborative, involving all relevant stakeholders, and should prioritize evidence-based practices, patient safety, and continuous quality improvement. Regular review and adaptation of protocols based on outcomes data and evolving regulatory guidance are essential.

This scenario presents a professional challenge due to the inherent complexity of integrating clinical pharmacology, pharmacokinetics, and medicinal chemistry principles into routine anticoagulation management, particularly when faced with unexpected patient responses. The need for a systematic, evidence-based approach is paramount to ensure patient safety and optimize therapeutic outcomes, while adhering to professional standards and regulatory expectations for advanced practice. Careful judgment is required to differentiate between expected variability and potential drug-related issues. The best approach involves a comprehensive review of the patient’s pharmacokinetic profile, considering factors such as renal and hepatic function, drug-drug interactions, and genetic polymorphisms that might influence drug metabolism and response. This should be followed by a detailed examination of the medicinal chemistry of the prescribed anticoagulant, understanding its mechanism of action, half-life, and potential for accumulation or rapid clearance. By correlating these pharmacological and chemical properties with the observed clinical data (e.g., INR values, bleeding events, thrombotic episodes), a targeted adjustment to the anticoagulant regimen can be made. This aligns with the principles of evidence-based practice and the professional obligation to provide individualized patient care, ensuring that therapeutic decisions are grounded in a deep understanding of the drug’s behavior in the patient’s body and its chemical characteristics. This systematic integration of knowledge is crucial for safe and effective anticoagulation management. An incorrect approach would be to solely adjust the anticoagulant dose based on the most recent INR value without considering the underlying pharmacokinetic and medicinal chemistry factors. This fails to address potential root causes of the aberrant INR, such as impaired drug metabolism due to a new interacting medication or altered drug clearance secondary to changes in organ function. Such a reactive approach risks perpetuating suboptimal anticoagulation and increasing the likelihood of adverse events, potentially violating professional standards of care that mandate a thorough investigation of treatment deviations. Another incorrect approach is to immediately switch to a different anticoagulant class without a comprehensive assessment. While switching may eventually be necessary, doing so without understanding why the current agent is failing to achieve therapeutic goals ignores the opportunity to learn from the patient’s specific response and may lead to similar issues with a different drug if the underlying pharmacokinetic or medicinal chemistry challenges are not identified. This impulsive decision-making bypasses the critical step of diagnostic investigation and can lead to unnecessary treatment changes and potential patient harm. Finally, relying solely on patient self-reported adherence without objective assessment or further investigation is insufficient. While adherence is a critical factor, assuming it is the sole cause of an unexpected response without exploring other pharmacological and chemical influences is a significant oversight. This approach neglects the complex interplay of factors that can affect anticoagulation and may lead to incorrect conclusions about the patient’s management. Professionals should employ a structured decision-making process that begins with a thorough assessment of the patient’s clinical presentation and laboratory data. This should be followed by a systematic review of the drug’s pharmacokinetic and pharmacodynamic properties, considering individual patient factors and potential drug interactions. The principles of medicinal chemistry should inform the understanding of how the drug functions and why variations in response might occur. This integrated knowledge base allows for the development of a rational, evidence-based plan to optimize anticoagulation therapy, prioritizing patient safety and therapeutic efficacy.

Scenario Analysis: This scenario presents a common challenge in advanced pharmacy practice: integrating new technology and data streams while ensuring patient safety and adhering to evolving regulatory expectations. The professional challenge lies in balancing the potential benefits of enhanced monitoring with the risks of data misinterpretation, system errors, and non-compliance. Pharmacists must exercise critical judgment to ensure that informatics tools support, rather than compromise, medication safety and regulatory adherence. The rapid pace of technological advancement and the complexity of pan-regional anticoagulation protocols necessitate a proactive and informed approach to compliance. Correct Approach Analysis: The best approach involves a systematic, multi-faceted strategy that prioritizes patient safety and regulatory compliance. This includes establishing clear protocols for data validation, ensuring interoperability with existing electronic health records (EHRs), and implementing robust training for all clinical staff on the new system’s functionalities and limitations. Crucially, it requires a continuous monitoring and auditing process to identify and address any discrepancies or potential safety issues arising from the informatics system. This approach aligns with the principles of good pharmacy practice, emphasizing diligence, accuracy, and a commitment to patient well-being, as well as the regulatory expectation for systems to be validated and used in a manner that safeguards patient care. Incorrect Approaches Analysis: Implementing the new informatics system without a comprehensive validation process to confirm data accuracy and system reliability poses a significant risk. This failure to verify the integrity of the data could lead to incorrect clinical decisions, directly impacting patient safety and violating regulatory requirements for accurate record-keeping and medication management. Relying solely on the vendor’s assurances of system compliance and functionality without independent verification is also problematic. While vendors provide support, the ultimate responsibility for ensuring that a system meets the specific needs and regulatory standards of the healthcare setting rests with the pharmacy. This oversight could lead to undetected errors or non-compliance with pan-regional guidelines. Adopting a reactive approach, where issues are only addressed after they have been identified by patients or through adverse event reporting, is unacceptable. This approach fails to meet the proactive expectations for medication safety and regulatory compliance, which demand the implementation of systems and processes designed to prevent errors before they occur. It also neglects the ethical imperative to safeguard patients from preventable harm. Professional Reasoning: Professionals should adopt a risk-based, proactive approach to implementing and managing health informatics systems. This involves a thorough understanding of the regulatory landscape, including specific guidelines related to medication safety, data privacy, and the use of technology in healthcare. A critical step is to conduct a comprehensive risk assessment before implementation, identifying potential failure points and developing mitigation strategies. Continuous education and training for staff are paramount, ensuring they are competent in using the technology and understand its implications for patient care and compliance. Regular audits and performance monitoring are essential to ensure ongoing effectiveness and adherence to standards. When challenges arise, a systematic investigation process, involving root cause analysis, should be employed to implement corrective actions and prevent recurrence.

This scenario is professionally challenging because it requires the pharmacist to navigate the complexities of medication management across different care settings, specifically the transition from hospital discharge to home. The critical element is ensuring continuity of care and patient safety, particularly with anticoagulation therapy, which carries a high risk of serious adverse events if not managed appropriately. The pharmacist must balance the need for timely intervention with the limitations of information access and the patient’s capacity to manage their own care. Careful judgment is required to identify potential gaps in therapy, assess patient understanding, and implement necessary interventions without overstepping professional boundaries or creating new risks. The best approach involves proactively identifying patients at high risk for anticoagulation-related complications upon discharge and initiating a structured follow-up process. This includes reviewing the patient’s discharge medication list against their home regimen, identifying any discrepancies or potential drug interactions, and assessing the patient’s understanding of their new or continued anticoagulation therapy. Crucially, this approach emphasizes direct patient engagement, education, and coordination with the primary care physician or prescribing specialist to address any identified issues before they lead to adverse events. This aligns with professional ethical obligations to ensure patient safety and promote optimal therapeutic outcomes, as well as regulatory expectations for medication therapy management services that promote continuity of care. An incorrect approach would be to assume that the discharge summary and prescription are complete and accurate without independent verification or patient consultation. This fails to acknowledge the potential for errors during the discharge process and neglects the pharmacist’s responsibility to identify and mitigate risks. Relying solely on the patient’s recall of instructions, especially for complex regimens like anticoagulation, is also professionally unsound due to the high likelihood of misinterpretation or omission, leading to potential under- or over-dosing. Furthermore, delaying intervention until a scheduled follow-up appointment with the prescriber, without any interim pharmacist assessment or patient education, creates an unacceptable risk of harm, particularly for patients on high-risk medications. Professionals should employ a systematic decision-making process that prioritizes patient safety and continuity of care. This involves: 1) Risk assessment: Identifying patients on anticoagulation who are transitioning between care settings as high-risk. 2) Information gathering: Proactively reviewing discharge summaries, medication lists, and patient profiles. 3) Patient assessment: Engaging directly with the patient to assess understanding, adherence, and identify potential barriers to effective management. 4) Intervention and collaboration: Implementing necessary medication therapy management strategies, including education, reconciliation, and timely communication with the prescribing physician to resolve any identified issues. 5) Documentation and follow-up: Maintaining thorough records and ensuring appropriate follow-up to confirm resolution of issues and ongoing safety.

Scenario Analysis: This scenario presents a professional challenge stemming from the need to balance the integrity of a competency assessment with the practical realities of candidate performance and the institution’s commitment to professional development. The core tension lies in determining how to address a candidate’s failure to meet the blueprint weighting and scoring requirements without compromising the assessment’s validity or unfairly penalizing the individual. Careful judgment is required to ensure fairness, adherence to policy, and the ultimate goal of fostering competent anticoagulation pharmacists. Correct Approach Analysis: The best professional practice involves a thorough review of the candidate’s performance against the established blueprint weighting and scoring criteria, followed by a structured discussion with the candidate. This approach acknowledges the candidate’s effort while directly addressing the identified gaps. The justification for this approach lies in its adherence to the principles of fair assessment and professional development. The blueprint weighting and scoring are the established benchmarks for competency; therefore, deviations must be understood and addressed. A structured discussion allows for clarification of expectations, identification of potential learning needs, and the development of a targeted remediation plan. This aligns with the ethical obligation to support professional growth and ensure that only demonstrably competent individuals are certified. The retake policy, when invoked, should be clearly communicated and applied consistently, ensuring transparency and fairness. Incorrect Approaches Analysis: One incorrect approach involves immediately failing the candidate and barring them from any further attempts without a detailed review or discussion. This fails to uphold the principle of providing constructive feedback and opportunities for remediation, potentially leading to an unfair outcome and discouraging professional development. It bypasses the crucial step of understanding the reasons for the performance gap. Another incorrect approach is to pass the candidate despite clear evidence of not meeting the blueprint weighting and scoring requirements. This undermines the integrity and validity of the assessment process, potentially leading to the certification of individuals who lack the necessary competencies, which is a significant ethical and professional failure. It compromises patient safety and the reputation of the assessment program. A third incorrect approach is to offer a retake without any form of review or feedback on the initial performance. This treats the retake as a mere formality rather than an opportunity for learning and improvement, failing to address the root cause of the candidate’s shortcomings and potentially leading to repeated failures. Professional Reasoning: Professionals facing this situation should employ a decision-making framework that prioritizes fairness, transparency, and the pursuit of competency. This involves: 1. Adhering strictly to the established blueprint weighting and scoring policies as the primary basis for evaluation. 2. Conducting a comprehensive review of the candidate’s performance data to identify specific areas of deficiency. 3. Engaging in open and constructive communication with the candidate to discuss the assessment results and the implications for their competency. 4. Developing and communicating a clear, actionable remediation plan if necessary, in accordance with the established retake policies. 5. Ensuring consistent application of policies to all candidates to maintain the credibility of the assessment.

Scenario Analysis: This scenario presents a professional challenge stemming from a potential conflict between a pharmacist’s clinical judgment and a patient’s expressed preference, particularly when that preference might deviate from standard care or established guidelines for anticoagulation management. The pharmacist must navigate patient autonomy, the duty of care, and the imperative to ensure safe and effective treatment, all within the framework of professional standards and regulatory expectations for advanced practice in anticoagulation. The complexity arises from the need to balance shared decision-making with the pharmacist’s responsibility to recommend the most appropriate therapeutic course. Correct Approach Analysis: The best professional practice involves a thorough, patient-centered discussion to understand the rationale behind the patient’s preference for a specific alternative anticoagulant. This approach prioritizes open communication, patient education, and collaborative decision-making. The pharmacist should explain the evidence supporting the current recommendation, discuss the potential risks and benefits of the patient’s preferred alternative, and explore any underlying concerns or misconceptions the patient may have. This aligns with ethical principles of informed consent and patient autonomy, while also fulfilling the pharmacist’s professional obligation to ensure the patient receives evidence-based care. Regulatory frameworks for advanced practice often emphasize patient engagement and shared decision-making as core competencies. Incorrect Approaches Analysis: One incorrect approach involves immediately deferring to the patient’s preference without a comprehensive discussion or clinical assessment. This fails to uphold the pharmacist’s professional responsibility to provide expert clinical advice and ensure patient safety. It bypasses the critical step of evaluating the clinical appropriateness of the patient’s request and could lead to suboptimal or even harmful treatment. This approach neglects the pharmacist’s duty of care and the regulatory expectation that pharmacists will exercise their professional judgment. Another incorrect approach is to dismiss the patient’s preference outright and insist on the initially recommended anticoagulant without exploring the patient’s reasoning or concerns. This demonstrates a lack of respect for patient autonomy and can erode trust in the pharmacist-patient relationship. It also fails to identify potential barriers to adherence or underlying issues that might be driving the patient’s preference, thus hindering effective management. This approach is ethically unsound and may contravene professional guidelines that advocate for patient-centered care. A further incorrect approach involves unilaterally changing the prescription to the patient’s preferred anticoagulant without adequate clinical justification or consultation with the prescribing physician. This action oversteps the pharmacist’s scope of practice and could have serious clinical consequences if the alternative is not clinically appropriate or if it interacts negatively with other medications. It also undermines the collaborative nature of patient care and disregards established protocols for medication management. Professional Reasoning: Professionals should approach such situations by first activating a patient-centered communication framework. This involves active listening to understand the patient’s perspective, followed by clear and concise education regarding the clinical rationale for the recommended treatment and the implications of alternative choices. The pharmacist should then engage in a shared decision-making process, where the patient’s values and preferences are considered alongside clinical evidence and professional expertise. If a significant divergence remains, consultation with the prescribing physician is a crucial next step to ensure a unified and safe care plan.

Scenario Analysis: This scenario presents a common challenge for pharmacists preparing for advanced competency assessments. The core difficulty lies in balancing the need for comprehensive knowledge acquisition with the practical constraints of time and available resources. Without a structured and evidence-based approach to preparation, candidates risk inefficient study habits, burnout, or incomplete coverage of critical topics, potentially impacting their ability to demonstrate the required competencies. The “Advanced Pan-Regional Anticoagulation Pharmacy Competency Assessment” implies a need for up-to-date, region-specific knowledge, adding another layer of complexity. Correct Approach Analysis: The best approach involves a systematic, multi-faceted strategy that prioritizes evidence-based resources and allows for iterative learning and self-assessment. This includes identifying and utilizing official assessment blueprints or syllabi provided by the assessing body, which directly outline the expected knowledge domains and learning objectives. Supplementing this with peer-reviewed literature, reputable professional guidelines (e.g., from national pharmacy organizations or relevant regulatory bodies within the specified pan-regional framework), and engaging in practice questions or case studies allows for both breadth and depth of understanding. A structured timeline, incorporating regular review and spaced repetition, is crucial for knowledge retention. This approach aligns with principles of adult learning and professional development, ensuring that preparation is targeted, efficient, and effective in meeting the assessment’s requirements. Incorrect Approaches Analysis: Relying solely on anecdotal advice from colleagues or a single, outdated textbook represents a significant failure. Anecdotal advice, while sometimes helpful, lacks the systematic rigor and comprehensiveness of official guidance and may be biased or incomplete. An outdated textbook may not reflect current best practices, evolving guidelines, or the specific nuances of the pan-regional anticoagulation landscape, leading to knowledge gaps or misinformation. This approach is ethically questionable as it fails to ensure the candidate is prepared with the most current and relevant information, potentially jeopardizing patient care if the assessment relates to clinical practice. Focusing exclusively on memorizing facts without understanding the underlying principles or clinical application is another flawed strategy. While some factual recall is necessary, advanced competency assessments typically evaluate the ability to apply knowledge in complex clinical scenarios. This approach neglects critical thinking and problem-solving skills, which are essential for demonstrating true competency. Ethically, this demonstrates a superficial engagement with the material, prioritizing passing the assessment over genuine understanding and the ability to translate that understanding into safe and effective patient management. Adopting a “cramming” approach, where intensive study occurs only in the immediate period before the assessment, is highly ineffective for long-term knowledge retention and deep understanding. This method often leads to superficial learning and increased stress, making it difficult to recall information accurately or apply it flexibly. It fails to build a robust knowledge base and is not conducive to developing the sustained competency required for advanced practice. This approach is professionally irresponsible as it prioritizes expediency over thorough preparation. Professional Reasoning: Professionals preparing for advanced competency assessments should adopt a structured, evidence-based approach. This involves: 1) Thoroughly reviewing the official assessment blueprint or syllabus to understand the scope and depth of expected knowledge. 2) Identifying and prioritizing authoritative resources, including current professional guidelines, peer-reviewed literature, and official assessment preparation materials. 3) Developing a realistic study schedule that incorporates spaced repetition and regular self-assessment through practice questions and case studies. 4) Actively seeking to understand the application of knowledge in clinical contexts, rather than merely memorizing facts. 5) Regularly evaluating progress and adjusting the study plan as needed. This systematic process ensures comprehensive preparation, promotes deep understanding, and fosters the development of true professional competency.