Provider Performed Microscopy

It's easier to convince the practice managers. The microscopes are expensive to maintain, plus the cost of proficiency testing. That is how some scopes have been eliminated in some of my offices.

Yes, I had success with my dermatology docs and a large percentage of OB's. 
They got a cost analysis of the testing which showed a very low reimbursement. The QC requirement for the KOH and proficiencies was enough for most docs. A few chose to continue with Ferning. Remember to remove scopes if they say they will not perform tests anymore. Good luck and keep hair dye close by. :)

They are unconvinced when you explain the use of resources to train, audit, maintain microscope, provide supplies etc. Sometimes failed PT will do it. Providers are convinced that 1. I'm a doctor, I can do anything 2. I can make a faster diagnosis than waiting for lab and 3. depending on how your organization is structured, providers can personally bill for PPM and get revenue.  We have several offices and we found MDs, Nurse Midwifes and Practitioners constantly failed PT despite retraining. We also had them do blind readings after the lab. They were only 50/50 with Clue cells and Yeast on Wetprep. Some offices were just shamed into dropping PPM because it was widely discussed they were failing Proficiency testing so badly.

Nancy - can you tell me what your offices were using to QC the KOH (prior to discontinuation)? We were under the impression that QC wasn't generally required for KOH testing. 

There is a log to document sterility of the KOH each day that testing is performed. Who is checking to see that it's actually done, that I can't vouch for.
Here's what is in my SOP.

1.0  QUALITY CONTROL

o     With each patient test visually examine the KOH reagent for: 

o   clarity-reagent should appear clear 

o   reagent must be within manufacturer’s expiration date

o   clearing of proteinaceous material on patient sample

o   This is documented on the patient result log for each patient tested.

o     10% KOH should not be used if:

o   There is evidence of dehydration

o   The color has changed

o   The manufacturer’s expiration date has passed

o   The solution appears cloudy or contaminated 

Note: KOH is caustic.  It causes eye and skin burns.  May be harmful if swallowed.  May cause severe respiratory tract irritation with possible burns.  Avoid contact with skin. Areas of accidental skin contact should be washed immediately with soap and water.  It can damage a microscope stage. Care should be taken not to spill reagent

        With each patient test, visually examine the 0.85% saline prior to use. 

o           Check the expiration date and clarity of the 0.85% saline prior to use.

Saline must be clear and within manufacturer’s expiration date 

We were able to substitute microscope for testing done in the lab for family sites. Specialty sites are an issue. Currently looking at waived BV and waived STI cassette with Trich. Been working on action plans for PPM since 2017. The CLIA rule where the CLIA holder has to assess competency in PPM labs may  cause more POCT labs to drop testing.....Good luck. 

Our experience and outcome was nearly identical to Glen's summation, couldn't have said it better.

Glad to know I am not alone in this frustration. I keep hoping an inspector will dig deep and notice that competency is next to impossible to complete each year. As Glen said, providers don't think they need to prove anything because they are a provider, and my emails, and downright PLEAS for completing competency go unread by at least 50% of them. I don't see it ever being dropped (Fern Test) unless an inspector cites a deficiency, and we take the microscope away.

The day I removed the microscope from our L&D floor was glorious! Our providers behaved exactly like Glen and Patricia's experiences. Also, they were only certified to perform Fern Testing which they ignored and called everything else too. I nearly lost my voice trying to get through to them they can't PPM diagnose without the POC certifications - and attitude ensued. SO, I happened to have a great CAP inspector that year who after hearing my concerns, cited us. It gave our lab the ammo to say "enough," you'll send to the lab, but you won't be performing ANY PPM. 
My suggestion is to use your 'tools' and have your lab inspector cite them. 

Citations. As many as necessary to get movement towards compliance. If you can recite the regulations and get those citations, you just need strong support from your Medical Director and way too much persistence. I know this one far too intimately. 

Ask your Inspector if you need help getting attention on important regulatory items that aren't being covered during your inspections. 

I am happy to rejoin this conversation and say that I am now able to pull Fern Testing from the providers after a CAP inspection gave me ammunition with several deficiencies cited. However, the concession was that we still provide Fern Testing on demand in the laboratory. (Yes, we do currently perform Amnisure also in the lab).
Coming here to ask how other facilities may do that....
Do providers prepare the slide and send to the lab, or do they send a swab and lab prepares the slide? If they are preparing the slide outside of the lab, are there checks on if it is being prepared correctly (letting it air dry)? 
The comments in the OB Quality committee meeting from the providers during this discussion were just as I expected - they would do it anyway (no...I will pull the microscope) and some were performing it but never documenting it (which explains the reports I would run and only get a handful of results). So glad to have this (almost) behind me!

First, congrats on getting rid of the PPM!
At our facility the providers prepare the Fern slides bedside then send them to the lab. 
These are the instructions that we provide to providers for slide prep:

"Required:
slide with appropriate sample and labeling-

The MLSs in the lab are also instructed to check for complete drying and contamination with blood, mucous or lube and inform the patients nurse of a delay or, the need for a recollection.
All of our Fern test results go out with the following comment attached: "

Fern test results may be confirmed with ROM+ test which detects IGFBP-1 (also known as PP12) and AFP protein markers of amniotic fluid in vaginal secretions. 

The test is for use by healthcare professionals to aid in the detection of ROM in pregnant women when patients report signs, symptoms or complaints suggestive of ROM".

 I would recommend working with your lab director on the process of ensuring quality slides. 

I am currently going through this with two of my clinics right now.

We heavily sighted them in our most recent self inspection. 
We found out recently that competency can't be delegated to a technical or general supervisor it has to be a CLIA defined Medical director.
We have a medical director designee who spent hours in the clinic trying to do direct observations with little success so my Medical director had me send the clinics an email saying we need them to find a designee to take this on going forward or they will have to get their own CLIA license to continue performing PPM