CAP POC.06910
Good morning,
I am wondering how others are complying with CAP POC.06910. My hospital is part of large health system and we share POC testing staff across many different locations. Our POCT procedures are the same across all the locations and there is no real difference in how the testing is performed at any location. We have IQCPs for each department at each location that performs testing. We use RALS for our data management. Wen use an on line education module that is assigned to them as part of meeting the 6 elements . I just can't figure out how to monitor that each operator performs 6 month & annual recertification at each site/CLIA.
There seems to be no value in this either. It's time consuming for the POCCs and the operators and $$$.
I would welcome anyone's suggestions.
Thanks,
Dianne
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We use Medialab for just about everything! We have all of our operating instructions on there for main lab and POCT. It serves as a good document control system. We are able to document competency assessments, initial training, color blindness testing, you name it, MediaLab can do it. It keeps track of who is due for what and when AND, it’ll send that person an email telling them that they have to get whatever tasks you assigned completed. It essentially puts the onus of getting their assessment completed on them.
Our medical director can also perform their operating instructions review and sign off. During our last CAP inspection, we were able to download the CAP checklist and answer every question right in MediaLab. We uploaded the evidence of compliance and notes as needed. When our inspectors came in, they each reviewed our checklists on MediaLab. It was a bit odd not having the huge binders full of forms and logs for them to look at (like back in the day) but it was definitely a lot easier! It takes a little bit of time to learn the system but once you figure out all the tricks, it’s a really useful too!
Angela Rivas
Langley Air Force Base
Hampton, VA
From: Don Tran via POCT Listserv (Groupsite)
Sent: Tuesday, April 28, 2020 3:01 PM
To: Rivas, Angela V CIV USAF 633 MDG (USA)
Subject: [EEMSG: Marketing][Non-DoD Source] [POCT Listserv] Re: CAP POC.06910
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That is impressive. I should look into this. We only use Medialab for continuing Ed for main lab.
Just an FYI for everyone, I was sited last year by CLIA for not performing all of the testing for competency assessment for moderately complex testing (iSTAT) because I was only utilizing one value on the test cartridge. She wanted ALL of the cartridge results to be assessed. I am CAP at my other facilities, but just remember you can still be inspected by CLIA as well.
MediaLab is really great for your CAP checklist. It is cumbersome at first, but makes life so much simply in the years to come. We have our policies in Policy Manager, so you can create a hyperlink into the checklist. That way, it always refers to the most recent policy. No more making sure you have the most recent copy in "the big fat book" you used to have.
When we were inspected 2 years ago, the inspectors were so impressed with it-they were going to look into having it at their facility.
Deana,
I am interested in your two dates for competency. If someone starts in January, they would still do their 6 month in March and their annual at Sept? If so, ever had issues with CAP inspections over this?
If they do the annual in September we still have them do their one year in January, then the following September they would have an annual and be on the same
rotation.
C
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