Ephrata Community Hospital’s POCT Competency
Program- Then and Now
By
Beverly McAllister
Laboratory Operations Manager
Ephrata Community Hospital12/2006
1
Demographics





135 bed Community Hospital
Located in Lancaster County, PA
12 types of Point-of-care tests
6 POC tests brought in-house within the last 3 years
Abbott P-Web brought in-house within the last 2 yearsprior to that QM2 in use for Precision PCx
 Physicians credentialed for PPT tests
 All Anesthesiologists trained/competencied on ISTAT
 Operator lists are on Excel Spreadsheets by
instruments/test type
Ephrata Community Hospital12/2006
2
POCT Operator Demographics











Precision PCx Whole Blood Glucose Meter- 440 users
Precision XTRA Whole Blood Glucose Users- 26 users
Fecal Occult Blood- 150 users
Gastroccult- 40 users
Urine Pregnancy- 70 users
Urine Dipstick- 90 users
Avoximeter- 6 users
Coaguchek- 12 users
Cholestech- 5 users
Nitrazine paper- 50 users
ISTAT- 80 users
Ephrata Community Hospital12/2006
3
POCT LOCATION DEMOGRAPHICS
 Precision PCx- all areas










Precision XTRA- Ambulance Life Support Unit
Fecal Occult Blood- ED, IMCU, CCU
Gastroccult- ED, IMCU, CCU
Urine Pregnancy- ED, SSU
Urine Dipstick – FMU, ED
Avoximeter- Cath Lab
Coaguchek- Cancer Center
Cholestech- Wellness Center
Nitrazine Paper- FMU
ISTAT- Anesthesia, Cath Lab, Respiratory, NICU
Ephrata Community Hospital12/2006
4
REGULATIONS- JCAHOCurrent as of 9/2006
 Standard- PC.16.30
Staff receive specific training and
orientation for the tests they perform, and
must demonstrate satisfactory levels of
competence.
Ephrata Community Hospital12/2006
5
Elements of Performance for
PC.16.30
1. Staff members who perform testing have
been oriented according to the hospital’s
specific services.
2. Staff members who perform testing have
been trained for each test he or she is
authorized to perform.
3. Those staff members who perform tests that
require the use of an instrument have been
trained on the use and maintenance of that
instrument.
Ephrata Community Hospital12/2006
6
Elements of Performance for
PC.16.30- cont.
4. Competence is assessed according to hospital policy at defined
intervals. Testing always occurs at the time of orientation and
annually thereafter.
5. Current competency is assessed using at least 2 of the following
methods per person per test:
 Performing a test on a blind specimen
 Having the supervisor or qualified delegate periodically observe
routine work
 Monitoring each user’s quality control performance
 Having written testing that is specific to the method assessed.
6. The director named on the CLIA certificate or qualified designee
evaluates and documents evidence of orientation, training and
competency.
Ephrata Community Hospital12/2006
7
CAP RegulationsCurrent as of 10/31/06
POC.06700 Phase II
Is there evidence that testing personnel have
adequate, specific training to ensure
competence?
POC. 06800 Phase II
Is there a current list of POCT personnel that
delineates the specific tests that each
individual is authorized to perform?
Ephrata Community Hospital12/2006
8
CAP REGULATIONS- cont.
 POC.06900 Phase II
Is there a documented program to ensure
that each person performing POCT
maintains satisfactory levels of
competence?
Ephrata Community Hospital12/2006
9
CAP Regulations- cont.
NOTE: The records must make it possible for the
Inspector to determine what skills were assessed and
how those skills were measured. Some elements of
competency assessment include, but are not limited
to:
1. Direct observation of routine test performance,
including patient prep, specimen handling, processing
and testing
2. Monitoring the recording and reporting of tests results
3. Review of intermediate test results or worksheets, QC
records, PT results, and PM records.
Ephrata Community Hospital12/2006
10
CAP Regulations- cont.
4. Direct observation of performance of
instrument maintenance and function
checks
5. Assessment of test performance through
testing previously analyzed specimens,
internal blind testing samples or external
PT samples
6. Evaluation of problem solving skills
Ephrata Community Hospital12/2006
11
CAP Regulations- cont.
Competency must be reassessed at least
annually. During the first year that an individual
is performing such patient testing, competency
must be assessed every 6 months. All of the
above elements that are applicable to an
individual’s duties must be evaluated for that
individual. The competency of physicians who
perform POC tests may be established and
reassessed through the credentialing process
of the institution’s medical staff.
Ephrata Community Hospital12/2006
12
The Journey began in 2000………
 Staff development was doing the training for whole
blood glucose testing and fecal occult blood- They
trained all RNs on both tests regardless of where they
were working
 I had no idea what other tests where being done in
house and who was training them or if there was
training
 No competency program existed at the time
 Units were hiding POC products in filing cabinets. They
would not admit to performing the tests
 We had just gone live with QCM2 in the fall of 1999.
That was the only operator list I had
Ephrata Community Hospital12/2006
13
The journey continues….
First things first….
1. Clean up the house
2. Identify what tests were being
performed
3. Initiate competency program.
4. Initiate proficiency testing program
5. Comply with regulations.
Ephrata Community Hospital12/2006
14
The journey continues…..
Paper, Paper and more Paper…….
The first competency program consisted of a
written test and no more, for whole blood
glucose testing and fecal occult blood. That
was in 2002. The tests had to be completed
and returned to me by the last week of
December. That would give me enough time to
grade them and update the operator
certification in QCM2. It was a nightmare
getting all of the tests back.
Ephrata Community Hospital12/2006
15
The journey continues…..
This process went on for several years. I added
more written tests for those manual tests that
did not have one or for those new products
brought in-house. Staff development continued
with the OCB and WBG training. I trained staff
for all other tests. I also initiated a proficiency
testing program and developed maintenance
forms for the Precision PCx among other
things. The process was becoming very
painful-something had to give.
Ephrata Community Hospital12/2006
16
The journey continues…..
2005- the straw that broke the camel’s back
I had distributed all of the POCT competency
tests to the nurse manager’s stating that if the
staff did not complete and pass them as of
12/31/05, they would be locked out of the
system and not be allowed to use the glucose
meter. We’ll guess what happened!!!!!
Ephrata Community Hospital12/2006
17
the straw that broke the camel’s
back……..
I got a call around 0900 on 12/31/05 stating that no one
could get into the glucose meter. Only one operator ID
worked and all of the staff was using it. I told the
nursing supervisor the reason for that was due to the
staff not taking their competency exam and they were
now locked out. To make the long story short, I had to
come in and recertify all staff regardless of whether or
not they took the exam. On 1/2/06, I met with the VP of
Nursing, the nurse managers and staff development.
Things started to change that moment. After thorough
discussion of the regulations and the process currently
in place, we were all on the same page. We all wanted
to do a good job and meet each others needs as well
as comply with the regulations.
Ephrata Community Hospital12/2006
18
How did it all end……..
In 2006- the following changes were made:
1.All of the written competency exams were transitioned to Healthstream
 No more paper
 Nurse manager accountability
 POCT operator accountability
 Staff knows they will be locked out if the exams are not completed.
2. Receive a Terms/Hires document from HR every month so I can keep track of and
update the Operators Users list in Excel and QCM3
3. Creation of Test specific Operator’s list in Excel
4. Review of POC test menu by department- was able to eliminate testing in some
areas.
5. Developed written Training/Competency Program with training documents for all
POC tests as well as a POCT Competency Assessment Form
6. Involved nursing with POCT Competency Program. Defined roles for POCT
Coordinator, Nurse manager, Staff development and Nurse educator.
7. Addition of POCT coordinator assistant.
8. Development of POCT QI Report Card.
Ephrata Community Hospital12/2006
19
There’s still work to be done…..
1.
2.
3.
4.
Need to go back and retrain the nurse educators on
the manual tests- There is no training documentation
Get signature lists of all POCT operators performing
manual tests in which QC is documented manually.
This is so we can read the initials of each POC
operator to allow them to receive credit for
successfully performing QC.
Initiate performance of testing unknown specimen for
manual tests
Training of POCT coordinator assistant.
Ephrata Community Hospital12/2006
20
What have we learned…….
1.
2.
3.
4.
5.
POCT coordinator is the leader and Leadership is the
act of accomplishing more than the science of
management says is possible!!!
Nursing and the POCT coordinator need to work as a
team to get the job done completely- Can’t do it
alone
Communication and understanding is key!
Question-Why you are doing something? Is there
value in it? Can it be done differently?
Rome was not built in a day- A good program takes
time to mature
Ephrata Community Hospital12/2006
21
POINT-OF-CARE COMPETENCY ASSESSMENT FORM
NAME:__________________________________________________________
DEPT.:____________________
OPERATOR ID:____________________
COMPETENCY ASSESSMENT FOR YEAR:_________________________
1.All employees must have at least 2 competency assessment methods to be deemed competent for each test method performed. Healthstream Module is mandatory;
therefore one of the other 5 methods MUST be completed.
2.As you complete a competency assessment method, date and initial the completion. If you are being observed, the observer MUST date and initial observation.
3.If you do not perform one of the test procedures listed, document N/A indicating “Not Applicable”.
4.Please keep this record in your files. Inspectors may ask for it.
Test Method
Completed Healthstream ModuleMANDATORY
Direct Observation
Monitor documenting test results
Perform quality control
Perform
unknown
specimen
Perform
proficiency
test sample
Precision PCX
glucose meter
Precision XTRA
glucose meter
Fecal Occult
Blood
Gastric Occult
Blood
Urine Dipstick
Urine Pregnancy
Nitrazine Test
ISTAT
Avoximeter
Ephrata Community Hospital12/2006
22
ISTAT TRAINING DOCUMENT
Name:_________________________________ Date:_______________________
Department:___________________________
Operator ID: _________________
GOAL: To Demonstrate competency in the use of the ISTAT System
Evaluator’s Initials
Identifies components of the ISTAT System
_______________
Identifies patient using 2 patient identifiers
_______________
Describes proper specimen collection
_______________
Handles the specimen properly
_______________
Fills and closes the cartridge correctly
_______________
Inserts and removes the cartridge correctly
_______________
Describes proper cartridge storage requirements
_______________
Accurately enters data into the ISTAT
_______________
Explains all prompts and displays
_______________
Demonstrates access to stored patient results
_______________
Describes what to do with patient results
_______________
Describes the use of the Electronic Simulator
_______________
Describes the care of the system
_______________
Demonstrates docking the ISTAT
_______________
Reviews Procedure
_______________
EVALUATOR:__________________________________
DATE:_________________
Ephrata Community Hospital12/2006
23
URINE PREGNANCY TEST TRAINING DOCUMENT
Name: ______________________________________ Date: ______________________
Department: ____________________________
GOAL: To Demonstrate competency in the use of the ImmunoCard Stat HCG Advantage Pregnancy Test
Evaluator’s Initials
Identifies proper storage requirements of the test card
__________________
Identifies and describes correct QC material and usage
__________________
Identifies patient using two patient identifiers
__________________
Describes proper specimen collection
__________________
Handles specimen properly
__________________
Identifies correct specimen volume
__________________
Knows how to handle a cloudy urine specimen
__________________
Accurately dispenses specimen into test card
__________________
States incubation time
__________________
Accurately interprets results
__________________
Correctly identifies result documentation form
__________________
States situations that may call for retesting
__________________
Describes invalid test results
__________________
Explains “hook effect” and what to do if it is suspected
__________________
Reviews procedure
__________________
EVALUATOR: ___________________________________ DATE: _______________
Ephrata Community Hospital12/2006
24
POINT-OF-CARE TESTING ISTAT OPERATOR COMPETENCY LIST
PARTIAL LIST
YEAR: 2006
ISTAT
COMPETENCY ASSESSMENT TYPES
NAME
DEPT
OP ID
WRITTEN TEST
REVIEW OF QC
BARR, MAGGIE
ANESTHESIA
8679
X
X
X
BEECH, ROBERT
ANESTHESIA
6893
X
X
X
BERKOWITZ, ALAN
ANESTHESIA
8541
X
X
X
COOK, ARLENE
ANESTHESIA
438
X
X
X
FAVORITE, SUE
ANESTHESIA
6969
X
X
X
MCKANE, ROBERT
ANESTHESIA
6827
X
X
X
NOLL, DAWN
ANESTHESIA
7471
X
X
X
BUCEK, JEANINE
ANESTHESIA
3568
X
X
X
CASSANO, DON
ANESTHESIA
6888
X
x
x
CICERO, LARRY
ANESTHESIA
8453
X
X
X
CULP, DAVID
ANESTHESIA
4005
X
X
X
JURGENSEN, MARCUS
ANESTHESIA
7160
X
X
X
ZANG, DICK
ANESTHESIA
1970
X
X
X
GARVIN, ROBERT
ANESTHESIA
4685
X
X
X
HILL, KATHY
ANESTHESIA
3942
X
X
X
KLICK, ROBERT
ANESTHESIA
5847
X
ON FMLA
ON FMLA
LEE, CHANG
ANESTHESIA
6529
X
X
X
MELAMED, BRIAN
ANESTHESIA
9119
X
X
X
MITCHELL, MARY
CATH LAB
8631
X
x
x
OBER, RAY
CATH LAB
8535
x
x
RAMBO, DALE
CATH LAB
8983
x
x
X
Ephrata Community
HospitalX
12/2006
UNKNOWN SPEC
DIRECT OBS
25
Equipment Management Plan
ECH Environmental Safety Committee
QI Initiative/Goals Report Card - FY 2007
Indicator
Target
7/06
8/06
9/06
1. Monthly preventative maintenance
will have electrical checks completed
according to schedule. 11 beds
scheduled per month - 122 beds.
Measurement: % of beds inspected in
their appropriate month (7/1/06 –
6/30/07 (ES)
Green = Average of 100% of beds
completed in their specified month .
Yellow = Average 90% of beds
completed in their specified month.
Red = ,Average of 80% of beds
completed in their specified month.
100%
of beds
inspecte
d in
specifie
d month
100
%
100%
100%
2. Rental equipment will have a
current, accurate and separate
inventory. Measurement: Numerator:
# of items rented (equipment) vs the
number of items with inspection
sticker. (ES, DP)
Green = 100%/month
Yellow = 1 missed/month
Red = 2 missed/month
100%
per
month
3. ISTAT users completing annual
competency. Measurement:
Numerator: Number of trained ISTAT
users completing 2 forms of JCAHO
approved competency requirements.
Denominator: Total number of trained
ISTAT users. (DG, BMc)
Green = 25%/quarter, 100%/year
Yellow = 15-20%/quarter
Red = <15%/quarter
25%/
Quarter
with
100%
compet
ent by
12/06
85%
10/06
11/06
12/06
1/07
2/07
3/07
4/07
5/07
6/07
100
%
Ephrata Community Hospital12/2006
26
Any questions?
Ephrata Community Hospital12/2006
27