Ephrata Community Hospital

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Ephrata Community Hospitals POCT Competency
Program- Then and NowBy Beverly
McAllisterLaboratory Operations Manager
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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
  years- prior 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

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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

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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

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REGULATIONS- JCAHO- Current 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.

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Elements of Performance for PC.16.30

1. Staff members who perform testing have been
   oriented according to the hospitals 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.

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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 users 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.
  

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CAP Regulations- Current 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?

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CAP REGULATIONS- cont.

• POC.06900 Phase II
• Is there a documented program to ensure that
  each person performing POCT maintains
  satisfactory levels of competence?

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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
• Direct observation of routine test performance,
  including patient prep, specimen handling,
  processing and testing
• Monitoring the recording and reporting of tests
  results
• Review of intermediate test results or
  worksheets, QC records, PT results, and PM
  records.

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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

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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
  individuals 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 institutions medical staff.

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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

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The journey continues.

• First things first.
• Clean up the house
• Identify what tests were being performed
• Initiate competency program.
• Initiate proficiency testing program
• Comply with regulations.

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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.

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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.

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The journey continues..

• 2005- the straw that broke the camels back
• I had distributed all of the POCT competency
  tests to the nurse managers 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.
  Well guess what happened!!!!!

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the straw that broke the camels 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.

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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 Operators 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.

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Theres still work to be done..

• 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.

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What have we learned.

1. POCT coordinator is the leader and Leadership is
   the act of accomplishing more than the science of
   management says is possible!!!
2. Nursing and the POCT coordinator need to work as
   a team to get the job done completely- Cant do
   it alone
3. Communication and understanding is key!
4. Question-Why you are doing something? Is there
   value in it? Can it be done differently?
5. Rome was not built in a day- A good program takes
   time to mature

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• POINT-OF-CARE COMPETENCY ASSESSMENT FORM
• NAME_____________________________________________
  _____________
• DEPT.____________________ OPERATOR
  ID____________________
• COMPETENCY ASSESSMENT FOR YEAR___________________
  ______
• 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.
• As you complete a competency assessment method,
  date and initial the completion. If you are being
  observed, the observer MUST date and initial
  observation.
• If you do not perform one of the test procedures
  listed, document N/A indicating Not Applicable.
  
• Please keep this record in your files. Inspectors
  may ask for it.

Test Method Completed Healthstream Module- MANDATORY 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
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ISTAT TRAINING DOCUMENT Name_____________________
____________ Date_______________________ Depart
ment___________________________ Operator ID
_________________ GOAL To Demonstrate competency
in the use of the ISTAT System Evaluators
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 _______________ Explai
ns 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_________________
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URINE PREGNANCY TEST TRAINING DOCUMENT Name
______________________________________ Date
______________________ Department
____________________________ GOAL To
Demonstrate competency in the use of the
ImmunoCard Stat HCG Advantage Pregnancy Test


Evaluators 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
__________________ Descri
bes invalid test results
__________________ Explains hook effect and
what to do if it is suspected
__________________ Reviews procedure
__________________ EVALUATOR
___________________________________ DATE
_______________
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POINT-OF-CARE TESTING ISTAT OPERATOR COMPETENCY LIST POINT-OF-CARE TESTING ISTAT OPERATOR COMPETENCY LIST POINT-OF-CARE TESTING ISTAT OPERATOR COMPETENCY LIST POINT-OF-CARE TESTING ISTAT OPERATOR COMPETENCY LIST
YEAR 2006 PARTIAL LIST
  ISTAT ISTAT  
      COMPETENCY ASSESSMENT TYPES      
NAME DEPT OP ID WRITTEN TEST REVIEW OF QC UNKNOWN SPEC DIRECT OBS
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 x
RAMBO, DALE CATH LAB 8983 X   x x
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Equipment Management Plan ECH Environmental
Safety Committee QI Initiative/Goals Report Card
- FY 2007
Indicator Target 7/06 8/06 9/06 10/06 11/06 12/06 1/07 2/07 3/07 4/07 5/07 6/07
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 inspected in specified 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 lt15/quarter 25/ Quarter with 100 competent by 12/06 85 100
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Any questions?