During a recent CAP inspection, my facility was cited for not having an annual competency assessment performed for the Blood Bank supervisor (me).  Our lab director completes an assessment each year stating that each supervisor is competent to oversee their respective department(s) and listing specific supervisory tasks that are assessed.  Shouldn't this supervisor assessment also be sufficient to verify that I am competent to perform testing in the Blood Bank?  It seems a bit silly to me that I am deemed competent to assess the competency of the rest of my staff, but I'm not competent to perform the same tasks myself.  I must have one of my staff observe me performing critical tasks, only to turn around and complete that person's direct observation myself.   I'm also the one who writes and grades the competency exams each year, but am I also expected to take the test myself?  Please let me know your thoughts on the subject.  Thanks.

Personally, I think you should respond to CAP exactly as you did in your post.  You make a logical and compelling argument.  I could say more but I think I'll stop for now and see what other responses you get.

My manager and myself (asst manager) both complete the same competency that the staff do in order to be able to be able to fill in at the bench if the need arises.  "This year's" competency is "good" for next year's observations.  It's hard to get done - but, we both feel it's valuable - and the staff seems to appreciate that we remain "competent" since previous management had no clue what went on at the bench....

Keeps us in the loop.

On 7/10/2023 at 6:13 PM, Tympanista said:

During a recent CAP inspection, my facility was cited for not having an annual competency assessment performed for the Blood Bank supervisor (me).  Our lab director completes an assessment each year stating that each supervisor is competent to oversee their respective department(s) and listing specific supervisory tasks that are assessed.  Shouldn't this supervisor assessment also be sufficient to verify that I am competent to perform testing in the Blood Bank?  It seems a bit silly to me that I am deemed competent to assess the competency of the rest of my staff, but I'm not competent to perform the same tasks myself.  I must have one of my staff observe me performing critical tasks, only to turn around and complete that person's direct observation myself.   I'm also the one who writes and grades the competency exams each year, but am I also expected to take the test myself?  Please let me know your thoughts on the subject.  Thanks.

I have had the exact same concern for years now. This is a strange position to be in, especially if you are a manager who regularly works the bench. 

I also fill in on the bench and do the same competencies that my team does. On a slightly different note, CAP cited us recently for not having the person assessing competency evaluated for their ability to assess competency (I think that makes sense).  So now we have a document stating that the person assessing competency has been reviewed as able to assess competency (team member levels and managers)

3 hours ago, applejw said:

I also fill in on the bench and do the same competencies that my team does. On a slightly different note, CAP cited us recently for not having the person assessing competency evaluated for their ability to assess competency (I think that makes sense).  So now we have a document stating that the person assessing competency has been reviewed as able to assess competency (team member levels and managers)

We did the same, back in the Dark Ages when I was still working.

Our director completes an assessment for the supervisors each year, which states that we are competent to perform our supervisory duties, one of which is assessing the competency of our staff.  That was not sufficient for CAP, though, to show that I am competent to work the bench.  I understand their argument, because I have worked with managers in the past who were not capable of working the bench.  But, then those managers were not qualified to assess the competency of their staff, in my opinion.  

In response to the CAP deficiency, I had one of my techs sign me off using the same competency form I use for the rest of the techs.  The issue I have now, though, is that only 2 of the techs trained in our blood bank have bachelor's degrees, and they are not my strongest techs.  The best techs I have in my department only have associate's degrees, so they're not qualified per CLIA regulations to perform competency assessments, even though they have over 20 years of experience.  But, that's a whole different topic of discussion.

23 hours ago, Bet'naSBB said:

My manager and myself (asst manager) both complete the same competency that the staff do in order to be able to be able to fill in at the bench if the need arises.  "This year's" competency is "good" for next year's observations.  It's hard to get done - but, we both feel it's valuable - and the staff seems to appreciate that we remain "competent" since previous management had no clue what went on at the bench....

Keeps us in the loop.

Unfortunately, I don't have another supervisor, asst manager, or even a lead tech who can perform my competency.  And the only 2 techs who have bachelor's degrees work mainly in Micro, so they're not strong blood bankers.  But, according to CLIA, they're qualified to perform competency assessments in blood bank.  I think a lot of times these regulations look good on paper, but they don't always carry over to real world situations.  That's how people end up in supervisory positions when they have no idea how to actually do the job themselves.  There just aren't enough people who meet all of the regulatory requirements and have the knowledge and experience to do the job effectively.

Thanks for the interesting post. Are you part of a health system? Perhaps another blood bank supervisor could come assess you, or you could pay a private consultant to do so.

 

49 minutes ago, cthherbal said:

Thanks for the interesting post. Are you part of a health system? Perhaps another blood bank supervisor could come assess you, or you could pay a private consultant to do so.

 

My facility is part of a larger health system, but the hospitals within the system do not all have the same policies/procedures.  We've actually asked several times for assistance from the larger hospital that is considered the "mother ship" for the system, due to not having a Heme or Chem supervisor in our lab for almost 2 years, but they always say they're too busy.  Even if they were available to assist, though, I don't feel like someone from outside our facility would be competent to perform our assessments, because they wouldn't be familiar with our facility-specific policies/procedures.  I think the ultimate goal for the health system is to have everything be consistent from one hospital to the next, but that dream is still several years away.

Thanks everyone for your feedback!  Going forward, I will perform the same competency assessment as the rest of my staff each year, and have one of my techs sign off on it.  I was already performing CAP surveys, instrument maintenance, and everything else that is required as part of a competency assessment.  I just didn't have it officially documented and signed off by another staff member, which is what CAP was looking for.  Maybe sometime in the future I'll be lucky enough to have an assistant manager or lead tech who can perform my assessment. 

How strict is everyone on the "annual" assesment?  Does this mean every 12 months, or can it be done throughout the year?  For example, it was done in March of 2024, does it need to be done by March of 2025?  Or can it be completed throughout the year 2025?

On 4/18/2025 at 1:25 PM, DebWerner said:

How strict is everyone on the "annual" assesment?  Does this mean every 12 months, or can it be done throughout the year?  For example, it was done in March of 2024, does it need to be done by March of 2025?  Or can it be completed throughout the year 2025?

I was told by a past inspector that the annual assessment can be done any time in the following calendar year.  The 6-month assessment must be done no later than 7 months after the initial training, but there is no specific timeline for the annual assessment.

17 hours ago, Tympanista said:

I was told by a past inspector that the annual assessment can be done any time in the following calendar year.  The 6-month assessment must be done no later than 7 months after the initial training, but there is no specific timeline for the annual assessment.

I hope you got that in writing or willing to argue the point some time in the future because there is a good chance the next inspector will have a different take on it.  Over the years I received contradictory info from more than one inspector and often they were representing the same organization!   

I actually found it in writing from the CAP website undeer GEN.55500 frequently asked questions, see attachment.

 

GEN.55500 FAQ.pdf

4 hours ago, DebWerner said:

I actually found it in writing from the CAP website under GEN.55500 frequently asked questions, see attachment.

 

GEN.55500 FAQ.pdf 110.35 kB · 2 downloads

Thank you for the reference!  I'm saving this in case any future inspectors "interpret" the requirement differently.

On 7/12/2023 at 1:24 PM, Tympanista said:

Our director completes an assessment for the supervisors each year, which states that we are competent to perform our supervisory duties, one of which is assessing the competency of our staff.  That was not sufficient for CAP, though, to show that I am competent to work the bench.  I understand their argument, because I have worked with managers in the past who were not capable of working the bench.  But, then those managers were not qualified to assess the competency of their staff, in my opinion.  

In response to the CAP deficiency, I had one of my techs sign me off using the same competency form I use for the rest of the techs.  The issue I have now, though, is that only 2 of the techs trained in our blood bank have bachelor's degrees, and they are not my strongest techs.  The best techs I have in my department only have associate's degrees, so they're not qualified per CLIA regulations to perform competency assessments, even though they have over 20 years of experience.  But, that's a whole different topic of discussion.

most of blood bank testing is high complexity so someone with an associate degree would qualify as an assessor.  

On 4/18/2025 at 12:25 PM, DebWerner said:

How strict is everyone on the "annual" assesment?  Does this mean every 12 months, or can it be done throughout the year?  For example, it was done in March of 2024, does it need to be done by March of 2025?  Or can it be completed throughout the year 2025?

As some one mentioned before, the annual assessment can be completed throughout the year.  Make sure your policy reflects your process. 

On 7/10/2023 at 6:13 PM, Tympanista said:

During a recent CAP inspection, my facility was cited for not having an annual competency assessment performed for the Blood Bank supervisor (me).  Our lab director completes an assessment each year stating that each supervisor is competent to oversee their respective department(s) and listing specific supervisory tasks that are assessed.  Shouldn't this supervisor assessment also be sufficient to verify that I am competent to perform testing in the Blood Bank?  It seems a bit silly to me that I am deemed competent to assess the competency of the rest of my staff, but I'm not competent to perform the same tasks myself.  I must have one of my staff observe me performing critical tasks, only to turn around and complete that person's direct observation myself.   I'm also the one who writes and grades the competency exams each year, but am I also expected to take the test myself?  Please let me know your thoughts on the subject.  Thanks.

If u are performing patient testing, then u need to have your competency assessed.  No way around that requirement.