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GEN.55500 CAP Competency Assessment


RandAlThor

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Can anyone provide some help/insight into how they identify each "Test System" to satisfy the 6 elements of competency for CAP?  Personally, I feel like "Blood Bank" should be it's own "test system" and I should be able to assign all the different testing we do into one of the 6 elements based on the errors/problems I see throughout the year.  Then rotate all the different testing systems, using the 6 elements, annually.  

it specifically says "if there are any tests with unique aspects, problems, or procedures within the same testing platform competency must be assessed as a separate test system system to ensure staff are performing those aspects correctly"

Am I really supposed to perform all six elements for:

ABORH/ABS using echo, gel, tube 

XM using gel, tube

Antibody Identification using gel, tube, ficin, diluting 3% down to 08% for gel testing, etc,etc,etc 

Dat using Gel, tube

 

Just using the above examples that's documenting 66 elements annually and that's only scratching the surface!  

How many "test systems" have been able to narrow your blood banking down to?  I feel like I need to hire someone just to do competency assessments! 

 

 

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The simple answer is - yes, pretty much. You must assess all 6 elements for each 'test system' every year. How you do it is where is gets complicated.

I assess each tube test (crossmatch, blood type, DAT, antibody ID, etc., plus 'automation' (rather than each individual automated test but would include tasks related to preparing specimens for testing, processing tests, through resulting). I also assess problem areas and some none test related skills (like packing blood) in more detail. Remember that you can cover a lot of ground during observation by asking questions (which cover trouble shooting plus knowledge of procedures), asking them to do QC testing related to the test performed, documentation, etc. It is very time consuming and I would love to hire someone to do it, but that's not going to happen.

I have some kits I get specifically for competency assessment that require tube blood type, antibody screen, ID, antigen typing, and crossmatch. While the tech is doing the exercise they perform all the necessary QC plus documentation and I ask them questions about what they are doing and how they decide what to do. That all by itself covers a whole lot of ground. If your budget doesn't allow purchasing kits, make your own samples up with all patient samples and reagents. While they are incubating, I throw in DATs on samples I make from check cells and cord bloods with positive DATs and fetal bleed screens (use positive and negative controls from old kits for sample manufacturing). Once the kit sample is worked through, we've gone a long ways toward finishing the assessment. Depending on how fast my techs work and what they are cleared to do, it takes 4-8 hours to do observations for each tech.

I also do ongoing review of documentation, QC, etc to assess what they are doing when I'm not looking...this is part of what I'm looking at during supervisory review. If/when they handle a difficult situation during their routine shifts, I review the records to see how they handled/solved the problem and ask questions as needed, all of which can be part of competency assessment. Everyone rotates through surveys. These are ordered in our LIS like any other patient sample so I use that work for additional assessment of documentation, problem solving and computer skills.

Remember that if there is a problem uncovered during your assessment, you should be sure to document the action plan for 'fixing' the problem plus documentation for reassessment to prove that the problem was 'fixed'.

(P.S. I work on the bench a large percentage of my time as the only full time blood banker with lots of generalists, so I do understand what an obligation this all is. I just focus on the task at hand and try to keep moving. If I look at the mountain, it is overwhelming.)

Edited by AMcCord
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