Waived Testing Competency at multiple sites across system TJC

We actually got cited for this on our last TJC inspection. We have now added all of the CLIA numbers of each offsite location on every competency to say that he/she is able to run this test at all of these sites. That was acceptable according to our inspector.

Hi,

I would also be interested to hear what TJC says. We are thinking of adding POCT to a clinic in Green Bay.  I know that CAP requires, competency at each location, even though the testing/analyzers are the same. They feel that there may be differences at different locations that need to be assessed (e.g. reagent storage refrigerated at one location but room temp at another, changes in expiration dates due to different storage temps etc.). I was thinking of adding the variations to the bottom of the competency form for staff that rotate to other locations. What do you think?

Thanks,

Reine

Susan, which standard was it that you got cited on?

Reine, will your clinic be CAP? All our clinics/offices are inspected by either TJC,COLA or  DHEC/CLIA. Just our main labs are CAP.

We keep our POC separate from main labs.

Was the Joint Commission std the waived chapter only or full lab standards?

Susan,

There are float staff at our facility (Hospital and 15+ group practices).  The floats have been trained to run all the POCT at each facility.  I perform a 2 point comp. assessment each year with them.  Exam through MTS and a skills assessment & procedure review or QC.

Our institution has standardized policies and procedures for each site.  No exceptions - remember it's following manufacturer's directions.  Our other P/P have to do the initial training/unusual results/annual competency/ QC & QI, etc., again the same for all sites.

Susan, I like the CLIA numbers listed on the assessments!

PS Never be afraid to contact any certifying agency - you get answers straight from the horses mouth.  Send via email so if an inspector waivers on a particular issue you can direct them to the response.

Hi,

Our clinic will be TJC, Waived chapter, so interested to hear what others have experienced by this particular inspection chapter.

Thanks,

Reine

I think it is a good idea to list the CLIA # on the competency form.  I am curious which JC standard was referenced?

Thanks

Bonnie