Volume 2024 | No. 2
SURVEYOR
CLINICAL LABORATORY
CHAPTER 2: LABORATORY PERSONNEL 02.02.04 Testing personnel competency and evaluation 02.02.05 Personnel competency assessment policies Overview of the requirement:
Policies and procedures establish competency assessment for all individuals who perform patient testing or who report patient test results. The technical supervisor/consultant is responsible for assessing and documenting the competency of staff to perform test procedures and report results based on required elements and intervals for evaluations. Compliance is assessed through document review, response to interview, and observation. Surveyors noted policies that did not include competency assessment for all roles, or that failed to include the six minimum requirements for evaluation. Incomplete documentation was noted with dates of assessment or signatures of assessors omitted.
Comment on deficiencies:
Frequency of citation:
02.02.04: 36%; 02.02.05: 24%
Examples of surveyor findings:
02.02.04 n The laboratory was not evaluating competency using all six required elements for each test or test system. n Two of two contracted respiratory therapists records showed no competency assessments at six months, at one year, and annually thereafter. n Competency assessments for the general laboratory staff lacked sufficient detail, e.g., assessment dates and CLIA element notations for required tasks. n Multiple laboratory and bold gas personnel competency assessment records lacked an assessor’s signature/initials. n Tube direct antiglobulin (DAT) testing was not identified as requiring competency assessment, so no blood bank personnel had been assessed for this test. 02.02.05 n The laboratory does not have policies and procedures to assess competency based on position responsibilities. n The laboratory did not define how competency would be assessed for the positions of Technical Supervisor and General Supervisor. n Create a tracking document for all testing personnel that lists each test or test system they perform. n Ensure that all six required elements are evaluated for each test system. n Ensure competency assessment twice in the first year that a particular test is performed and annually thereafter for all testing personnel. This applies to all moderate and high complexity testing even if it is performed outside of the laboratory, including point of care testing.
ACHC Clinical Laboratory accreditation covers all levels of complexity and all clinical settings from point-of-care waived tests performed in a physician office to high complexity testing in independent or hospital- based laboratories.
Testing Specialties
n Chemistry
n Hematology n Histocompatibility n Immunohematology ABO Group Rh Type Antibody Detection Antibody Identification Compatibility Testing
n Microbiology Bacteriology Mycology Parasitology Virology n Pathology Cytology
n Radiobioassay
Routine Chemistry Urinalysis Endocrinology Toxicology n Clinical Cytogenetics n Diagnostic Immunology General Immunology Syphilis Serology
Tips for complianc e:
Histopathology Oral Pathology
achc.org | (855) 937-2242 | 7
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