Provider Performed Testing

I was wondering what everyone's process is for making sure Provider Performed Microscopy and Waived testing is in compliance. I have very recently taken over as POCC and it has come to my attention hemoccult testing is being performed by providers without ANY regulation, official training documentation or competencies... I'm at a loss as to how to handle it. I have already received some resistance just asking about it. I have a feeling it is done at a larger scope than just one department and am still investigating. Any Advice?

Thank you.

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Hello, Hannah, welcome (I think!) to POCC world.

I am not justifying in any way that providers are performing hemoccult testing (there) 'without no regard to regulations/competecies'. My suggestion is to 'go to' standards you are complying with based on the accreditation you are running your waived testing program under. For example, with TJC WT Chapter (CAMH) we do not put providers through the same competency/assessments for *non-instrument* POC tests that we do for nursing staff. It's allowable 'going by those standards and elements of performance' to consider hemoccults as part of the providers 'jobs/training' within their scope of practice during patient visits.

One example of going back to accreditation standards.

I should also mention:

My POCT Program is under both CAP and Joint Commission.

Hemoccult and PPM are two different things. Hemoccult is waived testing, and providers can typically be credentialed to perform that test and only require initial training, no ongoing competency assessment is needed after. So, we were in that same boat initially, for a very large organization where occult bloods were performed in all of our 17 ED's. We created a new provider credentialing form to be used when onboarding new providers into our healthcare organization and worked with the staffing office for our healthcare system to get the form approved and integrated into their process. The form included not only a declaration page listing the most common POC tests performed by providers, both waived and PPM, where they checked the box next to the tests they intended on performing, but also a quick guide on how to perform all of the waived tests offered in our system. That way, they had received initial training, signed their credentialing, and done and done. That was all great and fine for any new hires, but we did then have to go retroactive and capture that on all existing physicians, and in order to do that we had to convince their boss, the Chief MD, that they all will need to fill out that piece of paper and get it back to us if they intended to keep performing those tests. It sounded harder than it was, because truly the only people this affected was the ED docs, and they all just did it during their monthly meeting.


Would you be willing to share the form that was created?

For the PPM, what did you do for annual competency or does the form mean it was all under the credentialing? Our Clinics are under state licensure, not CAP.


As a new POCC the PPM is a task I need to get a handle on.


Tonya Free

Point of Care Coordinator

Valley Medical Center


I no longer work for that organization so I can't share the form, but you would need to design one that is in accordance to your facility specific forms policies anyways.

CLIA does not require ongoing competency assessment of providers for waived testing, they are only required to have initial training. I was just saying that I integrated that initial training into their onboarding forms, so that it was completed at hire. The staffing office was responsible for adding the forms to the physician onboarding packet, and ensuring it was filled out. Most providers would sign that they do not intend on performing any of the tests listed, which was nice too, so we had a record that they had opted out of POC.

Sorry, I just re-read your question concerning PPM - that one is harder. What we are doing at my new organization is creating an annual Survey Monkey with the CAP photomicrographs from the previous year for the specific microscopy that provider performs, and email it to that provider through our secured network in the form of a quiz. We save the copies of the completed quiz in a file, and retrain any providers that fail the quiz.

Agreed with Peggy and Silka,

Check your accreditation standards. For non-instrument waived testing an organization can use the provider credentialing process to document competency in lieu of an annual assessment. 

PPMP is considered moderate complexity and requires the 6 elements of competency.


Who does the direct observation?

Hi Silka....Just to clarify, according to CAP regulations, providers are required to perform annual competency for waived tests...correct?  The CAP POCT 2018 Checklist has the following section concerning waived tests, and I don't see that providers are exempt.  Is there an exemption stated somewhere else, or just CLIA doesn't require it but CAP does?

 **REVISED** 08/21/2017

 POC.06875 Competency Assessment - Waived Testing Phase II

The competency of personnel performing waived testing is assessed at the required frequency.

 NOTE: Prior to starting patient testing and prior to reporting patient results for new methods or instruments, each individual must have training and be evaluated for proper test performance as required in POC.06850. After an individual has performed his/her duties for one year, competency must be assessed annually. Retraining and reassessment of competency must occur when problems are identified with an individual's performance.

Ester, the providers fit into CAP checklist questions POC.09500 - There are records demonstrating that all providers have satisfactorily completed training on the performance of the specific tests performed.  and POC.09600 - Competency Assessment (Note: This requirement does not apply to waived testing performed by providers).


Gayle - that is tricky with regard to PPM - I wish I could say that we had this all figured out, but we do not. We are grading their blind sample interpretation via the quiz, we are reviewing their log where they record the results of any microscopy they perform along with any microscopy QC if it exists, and we include them in PT where we personally bring them the current photomicrograph and "observe" them interpret that. But we are definitely not going to each individual provider and watching them do a real patient test, because that would actually be inappropriate and a violation of the privacy of the patient (think fern testing here, I am certainly not going to go into the room with the doc!). Our CLIA inspector suggested rotating the PT among the providers after grading, but that is basically our process with the quiz. 

Thanks, Silka!

Thank you, Silka!!!!! 

See CLIA regulation at 493.15(e) for what labs must do for performing waived tests.  If you are an 
accredited lab, you must follow Accredited Organization standard (requirement) for performing 
waived testing.  Initial training and competency assessment on waived testing is not required under
 the CLIA regulation.  CLIA requirement on waived testing is “Follow manufacturers’ instructions for 
performing the test.”

Interpretive guidelines at 493.15(e) is helpful.

Fran Lehr
Lehr Science LLC

Sent from my iPad

I do annual direct observations with each provider for each PPM test that they perform. This looks different for each provider. For our OB/GYNs I usually will just go up to the unit to catch while they are on-call. For our residents I coordinate scheduling assessments with the residency program. Sometimes they all come to me and we get it done in a conference room in a hour, sometimes they schedule a time to come down to the lab and use one of our scopes. For our outpatient clinics I usually have to make a visit there once or twice to get them all signed off.

I use fake patient slides for the direct observation. I have them prepare the slide and tell me how they would collect it. I check off the direct observation at that time and also have them complete two quizzes: one microscope problem solving quiz for troubleshooting and another quiz with images for 'blind' testing.

Hope this helps!

Joint Commission allows a skills demonstration as an acceptable option for direct observation in a point of care setting. We use this for PPMP.

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