CAP Checklist POC.06920
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Hello, everyone!
Our window just opened for the CAP inspection 2019. One of the items in my checklist is POC.06920, and it is "qualifications of individuals assessing competency" I just wanna know if there's anyone out here also preparing for their inspection - what evidence of compliance have you come up with for this? Should I, as the POCC, have "trained" the educators who are giving comps to the RNs?
Any input would be greatly appreciated!
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You should document their education level, training, and competency of the person assessing competency.
Jeremy Williford, PBT(ASCP)CM
Laboratory Services Coordinator
Laboratory
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South Georgia Medical Center
2501 North Patterson Street
Valdosta, Georgia 31602
229-433-4804 (O) | 229-563-2292 (M)
jeremy.williford@SGMC.ORG | sgmc.org
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From: Mary Stewart via POCT Listserv (Groupsite)
Sent: Wednesday, October 16, 2019 5:20 PM
To: Williford, Samuel 'Jeremy'
Subject: [POCT Listserv] CAP Checklist POC.06920
WARNING: This email originated outside the SGMC’s email system.
DO NOT CLICK: Links or attachments unless you recognize the sender and know the content is safe.
Hi,
We just added to our policy that “nursing trainers”, those who train staff on our behalf, will be initially trained by the POC Coordinator. The POCC will observe their first
training session and then every 2 years. We keep this on a form to track their initial competency and when we observe their training sessions.
Kathy Andrews
MLT, RT
Point of Care Coordinator /
Coordinatrice des Analyses Hors Laboratoire
Moncton & Miramichi Area /
Régions de Moncton et Miramichi
Horizon Health Network / Reseau de Sante Horizon
Tel: (506)-857-5315 Fax: (506) 857-5325
kathy.andrews@horizonnb.ca
“In order to succeed, we must first
believe that we can.”
Nikos Kazantzakis
From: Mary Stewart via POCT Listserv (Groupsite) [mailto:users+1250894@poct.groupsite.com]
Sent: October-16-19 6:35 PM
To: Andrews, Kathy (LAB) (HorizonNB)
Subject: [POCT Listserv] CAP Checklist POC.06920
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Our policy on competency assessment defines the qualifications for evaluators. For moderately complex tests: BS in a chemical, physical or biological science (diploma confirmed), 2 years’ experience with the test method, and annual competency
assessment performed by a POCT medical laboratory scientist. For waived testing: 1 year experience with the test and competency assessment performed by POCT MLS. We audit compliance with this policy as one of our monthly QI indicators.
Thank you soooo much for your responses, Jeremy, Kathy, and Terry! Appreciate it a lot!
I have it in our policy, but I didn't know if the other required evidence meant "copy of competencies they did with the RNs(operators of the meter), or competencies/training I as the POCC did with them, the educators. I actually havent comped them, so, yikes. (I just started as a POCC 3 months ago - came from a very long bench life in Chem, Hematology, BB)
Anyway, thanks again!!! Have a great day to all!
'Hey' all,
Do we need to bring up creating and maintaining a document showing the CLIA Lab Director delegates Jane Smith (and all others delegated and their dates of competency to be the assessor) to conduct the moderately complex competency assessments (elements including observation signoff)? It would state that the employees listed meet the CLIA qualifications for the role of observer/technical consultant.
I know I just caused someone to frown. Sorry!
Peggy
Better to frown now than when an inspection is happening!
Yes, Peggy. We need to do that and define that process in a Delegation Policy too.
We have a Technical Personnel Policy that names/delegates me as the Technical Consultant.
Every Six months, I give the Lab Director a list of those who are authorized to do lab testing and he signs it. It includes waived tests list ( for the benefit of the unit directors) but I have a separate list of non-waived testing/moderate complexity tests personnel.
Peggy,
Yes, you did make me frown☹
We have a list of 300+ “superusers” who are evaluated directly by the POCT lab team each year. The list contains their name, badge#, the date they were evaluated by POCT, specific tests they are qualified to evaluate, and a note that their
credentials have been checked if they teach/evaluate moderately-complex testing. Our medical director does not sign the actual spreadsheet. He signs the policy which says we maintain such a list.
We think this meets the intent of the standard.
Terry Hawkins, C(ASCP)
Point-of-Care Testing Laboratory
Christiana Care Health System
4755 Ogletown-Stanton Road
Newark, DE 19718
302-733-4684