I am in need of templates specific to the CLIA Competency Assessment requirements (6).  This is a rather daunty task even just for Blood Bank.  I would GREATLY appreciate any insight into how to handle, but especially any templates in use or being developed so I have a tool to refer to as I begin the process.  Thanks in advance.  Have a great day and I look forward to seeing what other labs are using to meet the CLIA Competency Assessment.

 

 

Attached is the checklist I borrowed from another institution.

BB Competency Check List.pdf

We have a simple Excel spread sheet with the 6 CLIA requirements across the top of the page and then the tasks we selected going down the first column.  Off the top of my head, I believe our tasks included:

ABO/Rh (tube)

Gel testing (antibody screens and IDs)

Tube testing (antibody screens and IDs)

Antigen testing (tube)

DAT testing (tube)

Crossmatches and other blood components

Derrivatives (Rh IgG, tissue/bone, Leuko-reduction filters)

 

There are a few boxes that we X out as N/A, such as Derrivatives, we can check "Work Record" but there are not "Results" per se.   There are also some things that we double dip on.  The Instrument Maintenance for Tube testing, Ag testing and DATs are all the same.

 

We opted to keep it simple, but it is still a lot of work!

Here is a copy of our Level 2 Annual Blood Bank Competency form.  We also have a Level 1 (for just label checking and issuing blood), and a Level 3 for advanced Blood Bank competencies.

Q0230F06 Level2BBKComp 11-11.doc

Here is a copy of our Level 2 Annual Blood Bank Competency form.  We also have a Level 1 (for just label checking and issuing blood), and a Level 3 for advanced Blood Bank competencies.

Q0230F06 Level2BBKComp 11-11.doc

Could you please attach the level 1 & 3 competency forms here? Thanks in advance.

Similar to Itelchin, we have devised an Excel spreadsheet for Competency.  We list the 6 CLIA elements across the top and the first column lists each reportable test.  Some are listed multiple times, one for each platform such as Antibody screen Automated, Manual Gel, Manual Tube.  Section 2 lists other tasks that are not reportable test such as thawing plasma, issuing blood, etc.  For these we list 2 or 3 of the 6 elements that we will use for assessment of that task.  It's a work in progress and we are using just a part of it this year and plan to have it fully implemented by Jan 1, 2014. 

The real challenge is how to accomplish the direct observation for every Clinical Lab Scientist on every shift for every test/platform.  How to perform direct observation for Eluate preparation and testing when our night shift CLS's may only do two or three a year?  We will probably need to combine Direct Observation of those infrequent tests with unknown testing.  Still this will be our biggest challenge.

We were told by an inspector that they will not allow any N/A for any element. I asked, so for instrument maintenance for example, that night shift would never perform, what do I do. She suggested to explain that but not just put N/A. For example:

All routine scheduled maintenance is perfomed by the day shift. Night shift employee is competent with the use of the equipment, equipment failure protocols, and troubleshooting techniques, as well as the procedure for communicating problems with equipment to other staff/supervisor.

Terri, just curious... which inspecting agency told you no N/A?  We are expecting TJC this spring and I have just a couple N/As in blood bank, but I know chem and heme have more N/As!

 

Just an example of my instrument maintenance for the cell washers, I am having the off shift techs show me how they check saline delivery if they change a box of saline.  They don't do any regular cell washer maintenance on the off shifts. 

 

I guess we'll find out this spring if that is good enough!

 

Terri, just curious... which inspecting agency told you no N/A?  We are expecting TJC this spring and I have just a couple N/As in blood bank, but I know chem and heme have more N/As!

 

Just an example of my instrument maintenance for the cell washers, I am having the off shift techs show me how they check saline delivery if they change a box of saline.  They don't do any regular cell washer maintenance on the off shifts. 

 

I guess we'll find out this spring if that is good enough!

 

It was our Joint Commission inspector; but it was just a conversation of things that she recommended. Not sure they could cite you for N/A if the tech really does not ever perform that task.

Thanks Terri.  We'll find out in the spring!

Here is a copy of our Level 2 Annual Blood Bank Competency form.  We also have a Level 1 (for just label checking and issuing blood), and a Level 3 for advanced Blood Bank competencies.

Q0230F06 Level2BBKComp 11-11.doc

I really like your competency form, very comprehensive. However, my question would be if and has  an inpector ask for any specific records to the competency that you have listed for a any employee. The one I am currently working on has for example the actual date that the employee did QC, or profeciency testing.

Does anyone else have competency forms to share?

And how on earth is everyone performing these on evey tech...observations, quizes, etc on every test done in the BB????

 

Does anyone else have competency forms to share?

And how on earth is everyone performing these on evey tech...observations, quizes, etc on every test done in the BB????

 

We're doing it, but with 23 techs, it's taking a great deal of my time. I spend about 3 hours to do one. I chose not to do a written quiz, as if they get a question wrong you have to show retraining. Instead I have a "scenario based question" for each task/test...a "what would you do if....". Works very well, and we have some good discussions.

 We're doing it, but with 23 techs, it's taking a great deal of my time. I spend about 3 hours to do one.

 

Terri are you saying that you're able to do a full competency assessment for one tech in three hours?

 

Terri are you saying that you're able to do a full competency assessment for one tech in three hours?

 

Yes. Takes lots of planning, samples ready so I can observe them perform each method (tube testing, gel, solid phase, etc), issue units, etc. We review a lot of policies, I ask a lot of questions...so far the feedback has been positive from staff, they said it was a good review and not as painful as they thought it would be.

Edited June 13, 201411 yr by tbostock

 

 

We're doing it, but with 23 techs, it's taking a great deal of my time. I spend about 3 hours to do one. I chose not to do a written quiz, as if they get a question wrong you have to show retraining. Instead I have a "scenario based question" for each task/test...a "what would you do if....". Works very well, and we have some good discussions.

Willing to share your competency form?  I am not happy with mine.

Edited June 13, 201411 yr by ANORRIS