I just joined the site, and have some questions about competency assessments. We have staff that rotate between two different campuses of the same hospital, but the labs have different CLIA numbers. So we were recently informed that we have to demonstrate competency at each site where our staff works. (Even though we use the same procedures, follow the same standard work, and have standardized things completely.) So I am trying to put this into practice without overwhelming our staff, but I still want to make sure we are doing a thorough check. We have a high percentage of new staff right now, so I don't want to half-a$$ it.
Question 1: Competency must be assessed for every "test system," but what are the Blood Bank test systems you assess? Do we need to assess competency for every method of testing we use every year? Or would I be able to assess IAT as a test system and rotate yearly on what method we use? I cannot seem to find any Blood Bank-specific listing of test systems that require annual competencies! It seems pretty clear for other areas, but I am getting a bit stressed out trying to make sure we are fulfilling the requirements for CAP/AABB. And I also don't want to overwhelm our staff with 17 yearly competencies.
In my lab, we perform the following tests:
ABO/Rh - automated gel and tube testing Antibody screens - automated gel, manual gel, and tube testing DATs - manual gel and tube testing Antibody titration - manual gel and tube testing Antibody identification Antigen typing Elutions Fetal bleed screens Question 2: How do you handle items that you want to do a competency assessment on that are not tests? For example, we do quite a bit of component preparation, so we generally try to do an annual competency assessment and direct observation of our staff splitting a platelet into a pediatric dose. I am familiar with the 6 elements of competency assessment (show below), but I struggle with how to apply these to processes.
"The following six (6) procedures are the minimal regulatory requirements for assessment of competency for all personnel performing laboratory testing:
Direct observations of routine patient test performance, including patient preparation, if applicable, specimen handling, processing and testing; Monitoring the recording and reporting of test results; Review of intermediate test results or worksheets, quality control records, proficiency testing results, and preventive maintenance records; Direct observations of performance of instrument maintenance and function checks; Assessment of test performance through testing previously analyzed specimens, internal blind testing samples or external proficiency testing samples; and Assessment of problem solving skills."
Thank you in advance!
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!
According to CLIA (and I think Joint Commission and CAP), evaluating and documenting competency of personnel responsible for testing is required at least semiannually during the first year the individual tests patient specimens.
How do you define 'semiannual'? Is this 6 months into employment? 6 months after the completion of initial competencies?
Furthermore, how many sets of competency assessments do you have after 1 year of service? 3: initial, semiannual and annual? or just 2 semiannual and annual?
I haven't seen much discussion relating to competency assessment on these forums. I find this odd because it is such an albatross at our institution. (This post is focused on USA regs, I can't even imagine what others might have to put up with.)
Are there any facilities out there that have a successful competency assessment plan that meets the CLIA requirements? (i.e. Assess the six applicable elements of competency, with EVERY test system, for EACH associate, EVERY year)
How are you documenting your competency assessment activities? Are you including copies of result entry/review, copies of worksheets, profiency results, direct observation checklists, copies of problem solving quizzes/scores?
Are you including transfusion service activities that aren't testing into your competency assessment plan? (i.e. receipt/logging in blood products, issuing blood products, component processing, etc.)
How do you handle competency assessment with part timers, zero hour/PRN associates, weekenders, and overnighters?
How are you delegating competency assessment activities among your staff?
We have a plan that I'm pretty happy with but there's a lot of contention with the specifics. I'm hoping to hear from other institutions and have a better understanding how the community as a whole handles this process. My previous experience was with military blood banks and we had a very rigorous training and competency assessment program, which I have been told was unnecessarily rigorous simply because it was military.
I'm also curious if anyone is willing to share any of your assessment plans/checklists/documentation. I need to blank out one of our template cover sheets and maybe include an example of our excel sheet tracking tool.