Organization and Personnel Version 5.0, August 2012 This project has been funded in whole or in part with Federal funds from the Division of AIDS (DAIDS), National Institute of Allergy and Infectious Diseases, National Institutes of Health, Department of Health and Human Services, under contract No. HHSN272201200009C, entitled NIAID HIV and Other Infectious Diseases Clinical Research Support Services (CRSS). Objectives 2 Define the elements of a quality organization. Describe the requirements for maintenance of organizational, personnel and training records. List the requirements for effective employee training programs. Objectives (cont’d) 3 Define the difference between training and competency. Describe the different methods to use in evaluating competency. Define the essential elements of an effective competency development program. Pre-Assessment Question #1 Which of the following is the most important asset to an organization? A. B. C. D. 4 Well defined policies and standards State of the art laboratory equipment Adequately trained staff None of the above Pre-Assessment Question #2 Curriculum vitae (CVs) should document evidence of: A. B. C. D. Theoretical knowledge Training received Practical experience Minimum educational qualifications required for the current job E. A, B, and C F. A and C only 5 Pre-Assessment Question #3 Training that maintains, enhances, or increases the proficiency of employees is considered: A. Initial Training B. Continuing Training C. Retraining 6 Pre-Assessment Question #4 Competence compares an employee’s performance against: A. B. C. D. 7 The Training Plan Standards Policies/procedures B and C Pre-Assessment Question #5 Which of the following methods can be used for competency evaluation? A. B. C. D. E. F. 8 Blinded testing External Quality Assurance (EQA) Quality Control (QC) testing Direct observation Review of temperature monitoring records All of the above Pre-Assessment Question #6 Which of the following is an element of an effective competency development program? A. Methods for performing competency evaluation B. Documentation of competency assessment C. A Standard Operating Procedure (SOP) for competency evaluation D. All of the above 9 Organizations and Personnel Concepts: A laboratory is defined by the people who work in it. A laboratory’s success depends on the management and staff who maintain continuity and ensure that all procedures are conducted adequately. Personnel and organizational policies must be documented. Quality People 10 = Quality Service = Quality Organization Organization 11 Organizational Structure Laboratory Scope Job Profiles Assignment of Responsibilities Organizational Charts Effective way to communicate organizational, employee, and enterprise information 12 Should list all positions and how they relate to each other Allows for organizing the laboratory team with clear responsibilities, titles, and lines of authority Organizational Charts (cont’d) Laboratory Director Haematologist Consultant Laboratory Manager QA Manager Haematology Laboratory Laboratory Supervisor Flow Cytometry Laboratory Supervisor Line Lateral Staff Functional Supervisor Departmental Advisory role. No Incumbent Specialist positions relationship authority and other areas PCR Laboratory Supervisor (Safety Officer) Techs (2) Techs (2) Assistants (2) Techs (3) 13 Assistant (1) Laboratory Scope All testing activities should be listed. 14 Assignment of Responsibilities 15 Job profiles List of Job specifications, such as: Qualifications Experience Licensing Other desirable qualities needed Should be available for all positions (including Laboratory Director) Could be incorporated in the job description Job Descriptions Assignment of Responsibilities (cont’d) 16 Lists of the general tasks or functions and responsibilities of a position Also includes to whom the position reports Holds personnel accountable for performing assigned activities Should be signed/dated by job-holder and supervisor Personnel The laboratory is required to demonstrate that its personnel is adequately… Trained Qualified Competent Educated …to perform their assigned activities. 17 Personnel Records Maintain records of Education Qualifications Skills Competency Training Applicable licenses Professional registrations 18 Education and Qualifications Curricula Vitae As well as…. Maintenance of Copies of Certificates and Diplomas 19 Transcripts Valid professional licenses or registrations, where applicable Skill Check The sponsor has requested to review personnel records in order to verify that the laboratory employees are adequately qualified, trained, and proficient in performing their assigned duties. What records should the Laboratory Manager provide? A. B. C. D. E. F. 20 Job descriptions Salary packages CVs Training and competency records Written warnings A, C and D only Training Records Institutional and Facility Training Important that laboratories identify: Job Training Task-Specific Training 21 Training Plan Stage 22 Description Training needs identified • Procedures for which training is needed are identified Training guides developed • Identification of: • Objectives • Methods • Materials Training is implemented • Trainers are identified • Training is conducted Training outcomes are evaluated • Initial competence evaluation • Evaluation of learner’s experience • Training is documented Training Categories Initial Training Continuing Training Retraining 23 Training that develops trainee’s knowledge and skills to initially perform specific jobs Training that maintains, enhances, or increases the proficiency of employees The process of providing remediation or tutoring for employees deficient in specific job functions Training Methods Lecture Computer based Self-study Observance of demonstrations 24 Practice under supervision Testing of specially-provided samples What would you do? Matt Gray, an expert in flow cytometry received training on the FACSCalibur many years ago before quality systems were implemented in his laboratory. His training was not documented. He has trained all other technicians that passed through in his laboratory. In a recent annual audit, the auditor made a citation for the absence of documented evidence of training for Matt Gray. 25 How should the laboratory respond to this finding? A. Take no action, but document in the action item report to the sponsor that Matt Gray is well trained in this procedure as evidenced by his ability to train other staff members B. Complete a training log and pre-date it to the time when training was conducted C. Conceal all records suggesting that Matt Gray is employed at the facility for future audits as there is no documented evidence of training D. Complete a file note documenting the dates when training was performed and the name of the trainer and then have the file note signed and dated by the Laboratory Director 26 Competency Application of knowledge, skills, and behaviors in performance Compares employee performance against a standard Competent personnel 27 = Quality and accurate results Competency (cont’d) Assessments should: 28 Verify employees are competent to perform testing and report accurate and timely results Be able to effectively evaluate competency as well as identify areas for improvement Be meaningful and instructive Competency (cont’d) Evaluation Methods: 29 Direct observations of specimen handling, processing, and testing Direct observation of instrument performance, maintenance, and function checks Monitor the recording and reporting of test results Competency (cont’d) Evaluation Methods (cont’d): 30 Review of intermediate test results, worksheets, QC records, Proficiency Testing (PT) results, and preventive maintenance records Assess test performance: Through testing blinded samples or PT samples Assess problem solving skills Competency (cont’d) Frequency Every 6 months during the first year; and annually thereafter Retraining and reassessment of competency should be conducted for unsatisfactory performance 31 Records must show what skills were assessed and how those skills were measured Competency (cont’d) Competency Development Program: 32 Define the areas/sections and activities requiring competency assessment. Identify methods of competency evaluation. Determine who will assess competency. Define the documentation of competency assessment Develop a competency evaluation SOP. Specify the following criteria in the SOP: Evaluation frequency, Evaluation method, and Remedial plan for inadequate performance. Personnel Competency ACTIVITY Enrique works in microbiology. His only duty is to inoculate (set up) cultures • List two methods that can be used to evaluate Enrique’s competency 33 Personnel Competency (cont’d) ACTIVITY Jill’s competency evaluation was completed last week. The assessment showed she has difficulty differentiating immature white blood cell (WBC) cell lines (e.g., myelocytes, metamyelocytes, etc.) • What should Jill’s manager do next? 34 Personnel Competency (cont’d) Assess 35 • Document Re-train (if necessary) • Document • Retraining must occur when problems are identified with employee performance Re-assess (if necessary) • Document Records Maintenance Maintenance of the following Records - Organizational Charts - Position Profiles - Staff Signature Lists - Job Descriptions - Academic/ Professional Records - Professional Licenses - Training and Competency Records 36 Records Maintenance (cont’d) Readily available Records should be: Maintained through the use of a record keeping system Maintained for all laboratory employees Reviewed regularly 37 Post-Assessment Question #1 Which of the following is the most important asset to an organization? A. B. C. D. 38 Well defined policies and standards State of the art laboratory equipment Adequately trained staff None of the above Post-Assessment Question #2 CVs should document evidence of: A. B. C. D. Theoretical knowledge Training received Practical experience Minimum educational qualifications required for the current job E. A, B, and C F. A and C only 39 Post-Assessment Question #3 Training that maintains, enhances, or increases the proficiency of employees is considered: A. Initial Training B. Continuing Training C. Retraining 40 Post-Assessment Question #4 Competence compares an employee’s performance against: A. B. C. D. 41 The Training Plan Standards Policies/procedures B and C Post-Assessment Question #5 Which of the following methods can be used for competency evaluation? A. B. C. D. E. F. 42 Blinded testing External Quality Assurance (EQA) Quality Control (QC) testing Direct observation Review of temperature monitoring records All of the above Post-Assessment Question #6 Which of the following is an element of an effective competency development program? A. Methods for performing competency evaluation B. Documentation of competency assessment C. An SOP for competency evaluation D. All of the above 43 References 44 DAIDS Guidelines for Good Clinical Laboratory Practice Standards Sharp, Elder 2004: Competency assessment in the Clinical Microbiology Laboratory; Clinical Microbiology Reviews College of American Pathologists Commission on Laboratory Accreditation, Laboratory General Checklist, April 2006 Clinical and Laboratory Standards Institute. Developing a Training Verification Program. NCCLS document SC16-L, Clinical and Laboratory Standards Institute, Wayne, PA USA, 1996 CLSI: GP21-A2: Training and Competence Assessment 42 CFR § 493.1413 42 CFR § 493.1451 Wrap Up 45