Vaginal pH testing

OH ok I see PPM.

Thank you!

I have also heard that about trying to go the "procedure" vs. "test" route.  Even though it is not a specimen that can be collected in a container, per se, JC still considers it a test.

I thought it's a part of their credential because it's just a waived test with no instruments involved. Did I read it wrong?

http://www.jointcommission.org/assets/1/18/Waived_Testing_Source_Article.pdf

3 Include providers in orientation, training,
and competency assessment. "Many organizations
do a good job of training nurses and
medical assistants, but not providers [physicians,
nurse practitioners, physician assistants],"
says Afrow. "If the test doesn't require
an instrument, then the organization can
assess provider competency as part of credentialing
and privileging. If it does require an
instrument, the provider needs to go through
the same orientation and training process as
the staff members, and competency should be
reassessed annually. It's also important to note
that provider-performed microscopy is not
considered a waived test and does not fall
under this standard. That requires a separate
CLIA certificate."

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

Kompan.Hallman@kp.org

Bonnie, no, pH paper is a 'waived complexity lab test' and not a CLIA PPMP. PPMPs are not waived complexity, they are moderate complexity testing. Yes if you held a CLIA Certificate PPMP then you could perform this waived complexity test under that PPMP CLIA but a pH test is not included on the CLIA list of PPMPs.  

https://www.cms.gov/regulations-and-guidance/legislation/clia/downloads/ppmplist.pdf

Perhaps some providers consider the following as 'a procedure': a pelvic exam, collecting for a KOH/wet prep and testing that sample with pH paper.   

Hope this helps explain there could be several ways to look at 'procedure'. Peggy

PT on pH paper? We do not subscribe to a PT Program for waived testing.

For waived testing we perform QC two levels and do lab comparisons. 

I have the package insert for acutest pH paper (acutest.net). I just tried finding it online but it's not posted. I won't be in my office tomorrow but will try to remember to take it along and scan it to a file I can post if I can get access to one of our outpatient printers.

Kompan, you're correct - JC allows for physician/mid-level credentialing for a waived (no instrument) test.  CAP used to as well, but has since revoked that allowance.

Just to share our experience, we were also planning to pursue the credentialing route, but as part of a very large health system, we were finding that the path toward making that happen proved nearly as difficult as having them participate in competency assessment.  Lots of obstacles finding the person willing and able to put the credentialing documentation into practice.  And when CAP disallowed credentialing anyway, there was no point in pursuing.

Wow...thanks for the info!

To all,

I have done credentialling for TJC for two large hospital systems. It can be a challenge to find who "blesses" the comp...but I would suggest that you go to Physician Services and talk to the boss. That person can place you on the path for the process to present to the Medical Executive Board (MEB) which would have to approve that type of a change to the charter. Also, involve your TJC over sight person (In both systems it was a she and she was the "TJC Whisperer".) They will need to be able to speak to the change during a TJC Hospital inspection.

We used this mainly for occult bloods in the ER and dipstick urines in clinics where the doc was doing them.

Deanna 210-297-9657