Need your ideas....

[Brenda K Hutson]

We are re-evaluating the Lab process for annual competencies (created many years ago; before my time). There are a lot of issues with the current process. This is for all of the Lab depts., though the protocol may vary some from dept. to dept. with our new protocol.

Currently, I have Direct Observation Checklists that I use for training for new employees and Med. Tech. students. One thing "I" would like to do is evaluate every Tech. that works in the Transfusion Service by "me" observing them on these checklists annually. In addition, I have tried in the past to find "creative" ways to have them perform annual review of the Procedure Manuals (one year I actually made a crossword puzzle using words from various SOPs; they might be "fill in the space" such that they had to go to the SOP to find out the word missing). This takes a lot of time though so is not going to be done every year.

I would like to know of any fun, creative and productive methods any of the rest of you use to assess Annual Competency of your staff.

Thanks,

Brenda Hutson, CLS(ASCP)SBB

[JOANBALONE]

Hi Brenda,

I have no creative suggestions but one question - is annual review of procedures by lab staff required by AABB, CAP or any other agency? We also require annual review by lab staff but can not find any reference. I think I might drop it. CAP does require annual review by medical director or designee though.

[Brenda K Hutson]

Hi Brenda,

I have no creative suggestions but one question - is annual review of procedures by lab staff required by AABB, CAP or any other agency? We also require annual review by lab staff but can not find any reference. I think I might drop it. CAP does require annual review by medical director or designee though.

That question came up in a Management Meeting yesterday. Some of us believe it is a requirement by "one" of the regulatory agencies, but cannot recall which one (so we are supposed to try to find out). It has been required everywhere I have ever worked (and not just because "I" implemented it there), but I can also say that it has pretty much been a "joke" everywhere I have worked (in that most staff do not in fact sit down and read each SOP thoroughly; some probably not at all). Having a way to assess that they have in fact done what they said they did (and signed a document to that affect) is the tricky part. With the crossword puzzle I created at one Institution, it was fun so they did it (but even then, obviously it will not cover everything).

Brenda

[L106]

CAP item # TRM.31190: "Does the laboratory have a system documenting that all personnel are knowledgeable about the contents of procedure manuals (including changes) relevant to the scope of their testing activities?"

Then CAP's commentary NOTE adds: This does not specifically require annual procedure sign-off by testing personnel. The form of this system is at the discretion of the laboratory director.

To me, this means that you could fulfill the requirement by doing something like a written quiz just spot-testing different topics/areas of the procedure manuals.

As for Brenda's orginial question: I don't have any creative ideas on how to make competency testing a fun activity (but would love to hear if others have suggestions.)

[KKidd]

We put out an annual quiz. The techs may use any resource but a supervisor for the answer. I already developing the quiz for 2011. Whenever we have an issue that has been addressed, it is included on the next annual quiz. THere is a separate competency sheet that goes in the techs records for 5 years. At the bottom, is a comptency statement with any exceptions noted. For example, we perform therapeutic phlebotomies, but only 3 of us are trained to do them. The competency "quizes" are used in each area. This has met with approval from Joint Commission and AABB.

:writersbl:writersbl:pcproblem

[Brenda K Hutson]

CAP item # TRM.31190: "Does the laboratory have a system documenting that all personnel are knowledgeable about the contents of procedure manuals (including changes) relevant to the scope of their testing activities?"

Then CAP's commentary NOTE adds: This does not specifically require annual procedure sign-off by testing personnel. The form of this system is at the discretion of the laboratory director.

To me, this means that you could fulfill the requirement by doing something like a written quiz just spot-testing different topics/areas of the procedure manuals.

As for Brenda's orginial question: I don't have any creative ideas on how to make competency testing a fun activity (but would love to hear if others have suggestions.)

Thanks! I wonder if it used to read differently such that Hospitals were required to do it annually (and many just never changed)??

Anyway, just something that I will throw out (though I am still looking for ideas) is the crossword puzzle. If anyone is interested, here is how I approached it:

1. First, write down a lot of Blood Bank words that you know are in the manuals (antibody; tube;Duffy; LISS; etc).

Just write and write as you never know when you could use a word to fill in part of the puzzle.

2. Start with one of your words (write it horizontally); then start building some words off of it. It is kind of like

scrabble I guess.

3. Once you have the puzzle in place, you can start writing the questions: i.e. SOP 1.0 states to perform [blank]

testing if all Gel Testing is positive due to a warm auto (answer; LISS).

Anyway, the staff really enjoyed it. I did it around the Hoidays at another Instittution and actually had to make 2 puzzles; 1 for the Techs. and 1 for the Lab Assistants. I will probably do that once at my current Institution but it is too time-consuming for "me" to make them more than that.

Brenda Hutson

[JOANBALONE]

Hi L106,

I take this CAP requirement to mean that staff read and sign off on new and revised procedures, which they do. They aslo have a chance to ask any questions about the procedure before they sign. Anything else would be above and beyond what is required. Sorry for getting off track again.

[Brenda K Hutson]

Hi L106,

I take this CAP requirement to mean that staff read and sign off on new and revised procedures, which they do. They aslo have a chance to ask any questions about the procedure before they sign. Anything else would be above and beyond what is required. Sorry for getting off track again.

Yes, I could see how it could leave a lot of room for interpretation. And as I said, perhaps years ago it was a clear reference to all staff reviewing all SOPs on an annual basis; I don't know. I have been doing this for 27 years now and as I said, that is just the way it has been everywhere I have worked (6 places).

I personally don't think an annual review is such a bad idea though (if in fact staff really did do it) You have had new staff coming through (who yes, read it; but probably just once); you have per diem staff; you have procedures that are not performed frequently; and then you have people who have just kind of adapted "their way" of doing things and need to be reminded of the protocol every once in awhile. But that is just my experience and opinion.

Brenda

[Malcolm Needs ☆]

Thanks! I wonder if it used to read differently such that Hospitals were required to do it annually (and many just never changed)??

Anyway, just something that I will throw out (though I am still looking for ideas) is the crossword puzzle. If anyone is interested, here is how I approached it:

1. First, write down a lot of Blood Bank words that you know are in the manuals (antibody; tube;Duffy; LISS; etc).

Just write and write as you never know when you could use a word to fill in part of the puzzle.

2. Start with one of your words (write it horizontally); then start building some words off of it. It is kind of like

scrabble I guess.

3. Once you have the puzzle in place, you can start writing the questions: i.e. SOP 1.0 states to perform [blank]

testing if all Gel Testing is positive due to a warm auto (answer; LISS).

Anyway, the staff really enjoyed it. I did it around the Hoidays at another Instittution and actually had to make 2 puzzles; 1 for the Techs. and 1 for the Lab Assistants. I will probably do that once at my current Institution but it is too time-consuming for "me" to make them more than that.

Brenda Hutson

Brenda, this is a quite brilliant idea.

I'm going to use it in my laboratory (with your permission) to train and educate my staff to recognise the more esoteric (and the more "simple") antibodies and combinations of antibodies that we see on a day to day basis.

I think it will be a wonderful way to get the staff to learn how to choose what tests and what sera/red cells should be used to elucidate problems that they will enjoy doing, without actually thawing out rare antisera/cells.

FANTASTIC!!!!!!!!!!

:D:D:D:D

[Brenda K Hutson]

Brenda, this is a quite brilliant idea.

I'm going to use it in my laboratory (with your permission) to train and educate my staff to recognise the more esoteric (and the more "simple") antibodies and combinations of antibodies that we see on a day to day basis.

I think it will be a wonderful way to get the staff to learn how to choose what tests and what sera/red cells should be used to elucidate problems that they will enjoy doing, without actually thawing out rare antisera/cells.

FANTASTIC!!!!!!!!!!

:D:D:D:D

Great! It will take you a fair amount of time to put it together (and won't look as "tight and neat" as real crossword puzzles by the experts), but it came out pretty well anyway. And as I said, the staff really enjoyed doing it (and I hope yours does also).

Brenda

[Marilyn Plett]

I'm sure you review antibody identifications. Couldn't you document somehow that each tech has adequately performed several procedures based on this review? Then you can minimize the extent of additional competency testing needed. I tend to want a quiz based on the issues that have been noted during the year. I don't see a need to have techs review every sop every year. Neither do I see a need to have Medical Director's review sops every year, but this is just a personal pet peeve with me. I think it would be much more helpful to document that you've made sure that your sops incorporate changes with a new edition of AABB Standards and staff were trained on any changes. There are days when I feel like we're paying staff to review and demonstrate competency and QC, but not to perform actual work. Oh dear, my age is showing!!!!!

[Eagle Eye]

We have our staff sign off on annual review but I might drop it too as we have a very tight system where any time there is a change in SOP we have all staff need to read and sign off on it. Anytime we have a process change we have different training plan based on the process and staff must get training on new process(including review of revised policy) before they can actually perform specific procedure.

Re: Annual review of policies by MD---I beleive this is required...as per CAP & AABB it can be designated but some State requirements are such that medical director must sign off on annual review.

[Mabel Adams]

At my current workplace we had an inspector a few years ago (CMS I think) insist that the CLIA requirements are that competency for every single procedure be verified by direct observation annually. This is amazingly time-consuming even with designated people to help.

[Malcolm Needs ☆]

There are days when I feel like we're paying staff to review and demonstrate competency and QC, but not to perform actual work.

NEVER A TRUER WORD WAS SPOKEN!

:mad::mad::mad::mad::mad:

[Michaele]

I've used a 'scavenger hunt' before on med tech students and techs alike. They find the answers to my questions in the SOP and they must give the answer and the location of the answer. That way I know they are actually looking in the procedure manual!

I do like the idea of a crossword puzzle though. May have to try that sometime, if you don't mind.

[Brenda K Hutson]

At my current workplace we had an inspector a few years ago (CMS I think) insist that the CLIA requirements are that competency for every single procedure be verified by direct observation annually. This is amazingly time-consuming even with designated people to help.

I believe there is an FDA requirement along those lines also. I need to find the reference. To "me" it seemed to say "every Tech.;" "every year;" "every major procedure performed." And you are correct; it is very time-consuming.

Brenda

[Brenda K Hutson]

I've used a 'scavenger hunt' before on med tech students and techs alike. They find the answers to my questions in the SOP and they must give the answer and the location of the answer. That way I know they are actually looking in the procedure manual!

I do like the idea of a crossword puzzle though. May have to try that sometime, if you don't mind.

Of course I don't mind! Go for it! Just sharing ideas....

Brenda

[LisaM]

Brenda--try this website:

http://www.medtraining.org/corpsite/

Where I work, we use this for twice per year competencies in all areas of the lab. They offer online quizzes that you can take and have good reading material to go along with the quizzes in each department. There's a lot on there for Blood Bank, too!

Or you could just give all your employees passwords to this forum, and start a new thread called "Stump Malcolm" where they have to go head to head with him and see if they can beat him at a "Jeopardy" style, 20-questions sort of thing!!! LOL LOL!!

Edited June 7, 2010 by LisaM

[Malcolm Needs ☆]

Or you could just give all your employees passwords to this forum, and start a new thread called "Stump Malcolm" where they have to go head to head with him and see if they can beat him at a "Jeopardy" style, 20-questions sort of thing!!! LOL LOL!!

Oh gee, thanks!!!!!!!!!!!!!!!!!!!!!!!!!!!

:eek::eek:

[L106]

Thanks, Brenda. This looks like a very interesting site and I will share this info with our Lab Director.

[Deny Morlino]

Competency is a current topic in our quality assurance focus this year. Thanks Lisa for the link. Our lab director seemed interested enough to give it a look.

[Eagle Eye]

Brenda--try this website:

ould just give all your employees passwords to this forum, and start a new thread called "Stump Malcolm" where they have to go head to head with him and see if they can beat him at a "Jeopardy" style, 20-questions sort of thing!!! LOL LOL!!

YES!!!!!!!I love this idea...Malcolm...don't worry we will add questions to your pool or rescue you once in a while.:):):tongue::tongue::tongue::tongue:

I actually suggested to Cliff lontime back that we can have separate section for questions & answers...But if we follow what you are saying (give this forum address to our techs) we need to have passcode to enter answer key/area...

[Malcolm Needs ☆]

I feel like you are all ganging up on me!!!!!!!!!!!!!!!!!!!!!!!!!!!!

:fear::fear::disbelief:disbelief:disbelief:disbelief:D

[Lynn]

Brenda--try this website:

http://www.medtraining.org/corpsite/

Where I work, we use this for twice per year competencies in all areas of the lab. They offer online quizzes that you can take and have good reading material to go along with the quizzes in each department. There's a lot on there for Blood Bank, too!

I use this site to do make up tests for the donor center and it has worked out well. Our lab dept also uses for some competencies such as customer service, safety, etc.

[LisaM]

^^Awww, we all love you, Malcolm! LOL! We could always start a game thread of sorts where you have to answer the blood bank question the person above you posted, then leave one for the next person that posts after you--could be fun and I know I'd have to most likely do research at times and look stuff up to be able to answer some things, since I'm currently dusting off the cobwebs in the Blood Bank sector of my brain!!