Non-Waived Competency

Does your organization have all POCT under CAP? Our program is split, with non-waived falling under CAP and waived under Joint Commission. For the non-waived testing, the 6 month and annual competency is completed at the physical location where the operators work. Each unit/department as a Nurse Educator or assigned unit trainer(s) that meets all education and experience requirements that have been trained and signed off by the POCC in our department responsible for that test system. We still have oversight and send reminders when competencies are coming due and/or overdue, but this system works very well. 

All POCT is under CAP.

Below is an outline I sent to CAP.

New operators for waived and non-waived point of care (POC) devices receive orientation at our main hospital network campus. Our Point of Care technical consultant will do initial training and skills check off at the main facility.

A. For waived tests After initial training (at the main campus) the operator is entered into the POC system for the device they received training. The operator will then be monitor via our POC middle ware (TELCOR) as they work at their assigned location to complete their competency. This is done by successfully completing a predetermined number of QC and patients. The operator will then auto-recertify via our POC middle ware annually when the requirements are met. All training and competency is retrievable at all locations. Auto recertification reports will be pulled for each location/hospital monthly.

 B. Non-Waived (ISTAT only) Initial training (at the main campus) the operator is entered into the POC system for ISTAT. All of competency elements except for two are checked off. Monitoring the recording and reporting of test results.. Review of intermediate quality control records. The operator will be monitored using our POC middle ware (TELCOR) while working at their assigned locations to complete their initial competency within 60 days. 6 month and annual competency is completed at operator's assigned location/hospital via skills fairs. I want to make sure that we meet all requirements with competency because each facility has a different CLIA number.

CAP Response.

 Dear Mrs. Lowery,

Per CMS, each CLIA laboratory must complete competency assessment for all employees performing non-waived testing at each facility. Laboratories may not share competency assessment documentation, even if laboratories are related and share the same instrumentation, LIS and procedures.

The laboratory director may determine how training and competency will be assessed for personnel performing waived testing at multiple test sites (same CAP/CLIA number) or laboratories within the healthcare system (different CAP/CLIA numbers). If there are variations on how a test is performed at different test sites or laboratories, those variations must be included in the competency assessment specific to the site or laboratory.

For the 6 elements of competency for non-waived tests, for the elements that state direct observation, you must actually perform an observation at the specific CAP/CLIA number.

 Your training and competency policy should be clear as to your process for waived and non-waived testing.