Initial, six months, and annual competencies- CAP regulations -Nonwaived testing

16 followers
1 Likes

For the trainers who do not perform testing how do you cap them on nonwaived testing? They are POC personnel. Would a blind test work or an proficiency sample satisfy it ?

6 Replies

PT would probably be your best option but could use a patient as a blind sample and compare to results obtained by a different operator already deemed "competent" or compare back to lab analyzer results.

Do they just oversee training and competency? If so, they only need performance assessment as a technical consultant. Competency assessment is for testing personnel. Attaching what we use at my hospital.
Supervisor Performance Assessment.docx

They only train and follow up on the competencies. Do not perform testing 

Here is the CAP Requirement: 

Key takeaway: make sure the staff are delegated. Make sure lab policy indicates how Technical Consultants are assessed, make sure you are following policy.


GEN.55525
Performance Assessment of Supervisors/Consultants
The performance of section directors/technical supervisors, general supervisors, technical consultants, and clinical consultants is assessed and satisfactory.

Note:All responsibilities of section directors/technical supervisors, technical consultants, general supervisors, and clinical consultants must be delegated in writing.   
The frequency for assessments must be defined in laboratory policy and be appropriate to the size, test menu, and complexity of the facility. The assessment may take the form of a checklist or other record of performance of responsibilities, as defined by the individual's job description. Unsatisfactory performance must be addressed in a corrective action plan.   If assessment of these individuals is not performed or there are inadequate or inconsistent records, a deficiency should also be cited for DRA.11425 (Director Responsibility - Delegation of Functions) in the Director Assessment Checklist. If the individuals in these roles are also performing nonwaived testing, competency assessment requirements for testing personnel (GEN.55500) also apply, including all six elements of competency at the required frequencies.

Evidence of Compliance:   
      
   *  Job descriptions that list regulatory responsibilities AND   
   *  Records of performance assessment

I spend 99% of my time with competency, QA and training.  But because I fill in if someone is sick or have to jump in and release, I need to have competency as well (for JCAHO).  I usually do 1 of each of CAP samples for the PT part.  

You actually don't NEED to do all of the things in the file I posted above. I am in NY though, and we have more requirements.

Reply
Subgroup Membership is required to post Replies
Join POCT Listserv now
Fatimah Ali
2 months ago
6
Replies
1
Likes
16
Followers
691
Views
Liked By:
Suggested Posts
TopicRepliesLikesViewsParticipantsLast Reply
CLIA Lab Director Site Visit Form/Checklist
Lori Pattison
1 day ago
00208
Lori Pattison
Rapid molecular tests for Covid, FluAB, RSV and Strep A
Alexandr Markevich
5 days ago
80336
Alexandr Markevich
about 6 hours ago
Hemosonics Quantra CPT Code
Mary Garcia
5 days ago
40117
Mary Garcia
5 days ago