CAP POC.06910

Diane,

I agree with what you have said especially the value part of it. I have a few suggestions if you want to call me. I DO perform all comps per CLIA and I have 5 hospitals.

Deanna Bogner

210-297-9657

Hi Diane,

Since the online education/training we use is exactly the same for every location, we require a separate competency checklist (paper form) be completed for each CLIA location. 

Very interested in what other locations are doing.

Annelise

I also use a separate competency checklist (paper form) for 6 month and yearly assessments.  The part that I seem to struggle with is how does everyone keep up with observation of running patient samples and QC.  I have several facilities myself and find it difficult.  Any suggestions!!

We have the same situation here:

• 10 facilities using the same system procedure, same system for mod-complex testing


• same online elearning for all.


• separate IQCP's at each facility.


• users that bounce from one facility to another.

we are under CAP.  I called them about this specific issue.  They stated that the elearning does not have to be different if the system is using the same policy/procedure/system.

BUT:

Each user must complete the observed skill-check at each facility and follow the same frequency dependent steps.  This means that a teammate that has been using the system for 10 years at facility "A" must complete the training, 6month and 12 month observation skill-check steps to start at facility "B".  All employees must have a personnel file at each facility they work at to store skill-check records performed at that facility.

This means that a new teammate that works at 3 different facilities would be required to perform the observed skill-check 9 times within their first year.... but would only have to complete the elearning 3 times.

Our POC middleware is setup facility specific meaning that a teammates's user access  can have an expiration date of 12/31/2020 at one facility and 5/1/2020 at another.

Yes, I agree completely this doesn't add value.  CAP stated that they are following CLIA which has not addressed this issue yet.

What POC middleware are you using that is able to be facility specific for the operator's recert dates?

To all,

A couple of suggestions. I have 5 hospitals. I use one knowledge based test for all 5 places-same procedures etc.

• I have those who pick up shifts/who are hired as a "Resource Pool" person in a "Resource Pool". These people come to me to be trained/recertified by appointment. No certification-no ISTAT in all 5 hospitals. When I find others who are "hopping" I place them in the same place in my middleware.


• I have 5 ISTAT-one from each hospital. Each ISTAT=one CLIA number.


• I use "Fake Blood" as my unknown. This is a combo of old PT and expired Eurotrol QC/LVM that I make up in several 50 ML tubes. I track only potassium. I tried pH but it was not stable.


• I have BS degreed nurses who have two years of experience with the ISTAT who use this fake blood and observe the end user. All I have to do is check the potassium.  They scan a barcode for ANNUALTEST or 6MONTHTEST which documents the testing in the middleware.  


• CAP told me that if someone picks up a few shifts for extra Christmas money in a different ER area, that was not a big deal. But if someone is covering another FMLA as a loan for three months, or in a Resource Pool they needed the 5 comps.


• I have RT under the same process except they use regular QC as the "unknown" if they pick up shifts in other places.

I have passed two CAP with the process above.

Deanna Bogner

210-297-9657

to all,

• All my operators are on one date of expiration and 6 month comps. September for yearly, and March for 6 months. This makes things much easier to track.

Deanna Bogner

210-297-9657

We are currently on Pweb but have a project in place to replace it.

We also have RT's and RN's with bachelors and 2 years experience performing the observed skill-check.  These individuals must be signed off to perform this function and added to our CAP list of "Technical Consultants".

We use a QC for our skill-check. 

• CAP told me that if someone picks up a few shifts for extra Christmas money in a different ER area, that was not a big deal. But if someone is covering another FMLA as a loan for three months, or in a Resource Pool they needed the 5 comps.

This doesn't seem right, sounds like "playing the odds" of having their tests pulled for an audit.  If they perform one test at the facility you should be able to provide a observed competency at that facility.

We have an annual June recertification month that all users eventually join once they have competed the first year of access:  initial training, 6 month, 12 month, every June.  We have ~800 moderately complex users on the floors throughout the system.

Deanna,

What middleware do you use that allows you to scan these ANNUAL and 6MONTH barcodes and saves the data?

Breana,

The middleware will take anything that you scan as a patient ID. I know people with all 3 middleware (UniPOC, RALS, Telcor) who are using the system.

 I inspected a place last year who I taught this system. They were using it before our team left.

The site I use to print the barcodes is barcodesinc.com. I have to have different barcodes per place due to the different patient ID that RT scans versus the ER and OR areas.

Deanna

Deanna - Thank you!! This is an awesome idea!!

I am trying to "revamp" my whole competency process for all my moderately complex testing (ACT, GEM, TEG). I am fairly new in this role and am finding lots of room for improvements. The previous POCC was also a Chemistry supervisor so I think she was just spread to thin and some of these things were left more to the nursing staff to monitor. This would be a very helpful monitor tool for sure. If you have any other helpful tricks or tips please share if you don't mind.

breana.birmingham@dignityhealth.org

We started using MediaLab a few years ago. It is an excellent way to keep up with competencies (NO PAPER). It is set up for initial, 6 month and annual for moderately complex tests, initial/annual for waived. We have a location built into the competency that the educator is to provide the blind sample information including number used (usually we use 999999 as our patient "identifier"), result obtained (we generally utilize glucose control), the range expected, and the date performed. We also have quizzes built for the moderately complex platforms (as well as a couple of the visual waived tests because the need arose).

MediaLab sends emails out 30 days before a competency is due. It notifies both the tester and the educator-whoever you have configured for it to notify. Upon completion of a competency, MediaLab will alert also our POC department of the completions Our lab also uses it for document control. We have found it a very valuable investment. We had a CAP inspection a couple of months ago. That hospital was so excited about it they were taking the information about it back to hopefully bring it on line at their location.

Debra,

I am interested in learning more about MediaLab.  Between our 2 hospitals, we have close to 1000 users who perform non-waived tests.  Do you give all users access to the MediaLab?  Thanks!

We have had MediaLab for several years.  I use it to organize my forms that I use for the staff.  For example, if I search Betty Jones, I can see all the copies of her training, competencies, etc.  I have to keep copies of their education as well, so we scan that into their electronic folder as well.

I don't have it send emails to the staff, but I get an email stating when personnel are due.  Also, in my middleware, I set up peoples competency to end at a certain date.

For example, a new employee only gets 30 days to ensure I get their diploma, they do their training and take their quiz.

Then, they receive a 6 month certification, at which point they are no longer able to use the iSTAT until they have performed the required tasks.  By creating these 6 month end dates, it prevents the user from being able to use the instrument.

I like Medialab as well, I believe price is based on the number of users you have.  It is worth the money for your mental stability...LOL