How to do Observations at six-month

I have been relying on the test performance observation done after initial training and then at six months doing a look back at all testing, error codes, etc for the six month assessment.  However, our CAP inspector said I must do the observation at six months. I made up a form for them to use but am challenged with how to get compliance.  We have a great education department that does most of the nursing staff for initial and annuals but getting the staff back to them in six months won't be easy.  How are larger facilities handling this? I have anywhere from 15 - 30 people every month.  Plus, the confusion in that half of the year, their six months falls during annual skills so figuring out all the documentation is challenging me. Any and all help is welcomed.  Ivy

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I thought you could do the competency throughout the 6 months period. I had my charge nurse observed their staff throughout the year for the annual competency. So the 6 elements are not on exactly the same date but within the time frame.


Kompan (Opal) Hallman, MBA, MLS (ASCP)

Area Laboratory Manager / POCT Coordinator
Riverside Medical Center & Moreno Valley Medical Center Areas
Phone: 951-251-6152 or Tie line 8-299-6152
Fax: 951-251-6151               

I think someone from our lab confirmed with CAP that it could be done between 3-6 mos. after initial training. But with how things change, I'd recheck with CAP to be sure.

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The CAP checklist, item POC.06910 states in the notes: "Many of the elements of competency assessment are performed during routine review of personnel throughout the year. Records of these elements, including adherence to laboratory policies and procedures, observation of test performance, results reporting, instrument maintenance, review of worksheets, recording QC, performance of PT, and demonstration of taking appropriate corrective actions are examples of daily activities that can be used to demonstrate competency. If elements of competency are assessed during routine review by an individual qualified to assess competency for the complexity of testing performed, the competency procedure must outline how this routine review is used to evaluate competency. Competency assessment during routing review may be recorded using a checklist."

This says to me that the assessment can be done as needed, as long as the final report of assessment is complete within the 6 month period. 

Evaluation of various things over the course of the six months what what I was doing and the inspector was okay with that EXCEPT the observation part.  On the deficiency form it was written "no direct observations testing done for 6 month competencies".  When I discussed with the inspector, all indications were to observe at the 6 months mark.  My plan for now with the first half of this year's six monthers is to record the day they did their 2018 annual assessment as the observation, even though not exactly done at six months and I guess the last half they will have to come by and check off with me.  

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