Understanding PPM and what is necessary
Our gyn providers perform wet prep in their clinics. 2 of these clinics are located at our hospital sites so they fall under the lab CLIA license. Questions:
1. They perform PT testing 3 times a year here at the hospital and take an e-learning quiz. Do I need to do more? Is this considered moderately complex?
This same group has 3 offsite clinics located in the same space as our endocrine clinics. Endo already had a CLIA certificate of waiver in place for HA1C testing and they have their medical director on the license.
2. Can the gyn providers perform wet prep under this or do they need a PPM certificate? Currently they do not do proficiency testing or any other competency assessment at these sites. What is required and would they need to do whatever is needed at each clinic site? There are 3 sites.
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Hi Danyel,
1. Wet preps performed by providers are PPM and are considered moderately complex testing. Because they are MC they require 6 methods of evaluation annually for competencies. Any new providers need a competency assessment initially with training, in 6 months, one year, and annually thereafter.
2. A PPM CLIA certificate must be in place to perform microscopy. If they are doing this under a certificate of waiver they are out of scope. Proficiency testing is not 'required' per say under TJC for PPM, but I think it is a good idea. I receive PPM proficiency samples three times per year. I answer the challenges and once the results come back I use them for competency evaluations and site to site correlations. They will need a complete competency using the 6 methods of evaluations. Each site is required to have a PPM certificate unless you apply for certificate for multiple locations.
Shoot me an email if you have more questions: ruth.harmala@mghs.org
Ruth Harmala
POC Coordinator
UP Health System Marquette
Danyel,
On the out of the hospital, performed in endocrinology clinics off of a waived certificate - the medical director (CLIA LD) would 're-apply' using form 116 using that same CLIA# but on the application, check off the box for 'change in certificate type'. Resend the MD's state license and the CV showing evidence of that person's 'experience' as the LD.
You'll have to add proficiency testing on the KOH in the 3 clinics outside of the hospital. It's elective if you do or do not add PT for the A1c since that is WT and it's very possible that it's not a good time to 'fight to add it' with the medical director for WT until after you are over the hump of the changes that have to take place on those 3 certificates.
And yes, the competency assessment 6 elements and documentation has to be set up for each CLIA# site - so even if the MDs in the hospital are 'good to go' on the competency documentation, each provider/MD performing in the 3 offsites need comp assessment where they will perform testing (the CLIA# for the testing). Some POCCs have found shortcuts to 'duplicating' the comp assessment but my understanding is that the observations must be done at the testing site for nonwaived testing/PPMPs.
Lastly - going into the weeds here but this is a hot topic when your accreditation comes through clinic environment - add a microscope cleaning log and consider that the MD/providers won't bother to document so whomever is performing the A1cs (medical assistants?) may have to be asked by the medical director (or worse yet, you) to keep up the cleaning of the area where the microscope sits in the shared space and document it. Also take a look at the shared space since now it's only used for the A1c. Add an easily available sharps container for disposal of the glass slides otherwise ...well, you can see where I'm going with that!
Peggy
Thanks both of you! That Endo provider is not going to want to deal with that so I'm guessing Gyn is going to have to do this themselves. We'll see what they say after being informed about the competency part...they won't like that.