1. Developing a Comprehensive POCT Competency Assessment Program
Marcy Anderson, MS MT(ASCP) Medical Automation Systems, Inc.
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2. Agenda Define the problem. Who regulates competencies?
CLIA 88, JCAHO and CAP
What are the steps to develop ones own program?
How does one measure success?
Examples of competency tools.
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3. What is the problem? Too many operators to keep track of.
Communication between nursing and lab (POC) is incomplete.
Documentation is not standardized and/or hard to keep track of.
Operators are expired but still performing POC testing.
Hard to determine what method to use/what is most effective.
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4. Who regulates competencies?
CLIA 88 (semi-annually and yearly thereafter)
-Direct Observation
-Monitoring recording and reporting
-Review of results
-Observation of instrument maintenance
-Testing previously analyzed specimens
-Problem solving skills
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5. Who regulates competencies?
JCAHO must show training, orientation, and competence
-Testing of unknown specimen
-Observation of routine work
-Quality Control performance
The JCAHO emphasizes skills testing for individuals who perform testing infrequently
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6. Who regulates competencies
Some examples of evidence of performance of the standards include but are not limited to:
Personnel records
Orientation and competence policy and procedures
Ongoing data collection (talking to staff, observation, analyzing trends)
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7. Who regulates competencies?
CAP
-Direct observation
-Monitoring of records
-Review of test results
-Observation of instrument maintenance
-Test performance using previously analyzed specimens
-Problem solving skills
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8. Achieving competence 1. WHO Who needs to be trained? 2. WHAT
What tests do they do that need to have a competency assessment?
These must be answered for the scope and competency assessment program to be developed!!
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9. Next Questions?
3. Who is responsible for implementation and management of operator competencies within the institution?
Is this documented in an institutional policy?
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10. Next Questions?
4. What methods are used for achieving competency assessment?
Does one method prevail over others?
Are the positive and negative aspects of each method accessible to the person responsible for competencies?
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11. Administering a written test
Make sure you include the pre-analytical, analytical and post analytical aspects.
Quiz
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12. Hands on Testing
How many of you distribute and watch the performance of proficiency at the floors?
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13. Tutorial based computerized program
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14. Next Questions?
5. What is the acceptable threshold level of compliance for competency within the institution?
Is the threshold being achieved? If not, what are the possible causes and corrective actions?
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15. Next Questions?
6. Is there a mechanism for the end user to be made aware when his/her competency is due? Are there corrective actions for non-compliance?
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16. Remember to reward for a job well done
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17. Conclusion Develop a program that is fine tuned for your institution.
Keep communication lines open with nursing.
Remember to assess your competency program. Make changes if needed.
Reward for a job well done.
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