Despite our best efforts in the laboratory, Competency Assessment remains one of the most cited deficiencies at regulatory inspections. Guidelines, education, and articles can help us to know what our competency assessments must entail, but actually being successful in implementing and maintaining a successful competency program still seems like a lofty goal for most clinical laboratories.
what are the roadblocks that stand in our way? Why can’t we seem to
get this right?
meaningful, complete assessments
Again, the 6 CLIA requirements for competency assessment have been drilled into our heads over the last few years. Somehow, this head knowledge does not always translate to real-life practices. Perhaps this is due to paper forms and documents being outdated, in desperate need of update. Perhaps it is due to misunderstanding the 6 requirements. Do I really need to watch you perform this test? Yes! Do I really need to document that I watched you perform this test? Yes!
Ensure that your documentation, whether paper or electronic, adequately captures each competency requirement. Ensure that this documentation is standardized across the department or lab section—to the extent that it is capable of being used amongst diverse testing areas. Review the documentation regularly, and make updates as needed to ensure that you continue to capture the required information clearly and concisely—demonstrating that you are always “inspection ready”.
Unqualified staff conducting competency assessment continues to be a common regulatory citation. Get in front of this by reviewing the regulatory requirements for assessors, and then designating qualified persons, in writing, to assess competency routinely throughout the laboratory. Only Technical Consultants, Technical Supervisors, and General Supervisors may assess competency. Ensure that you designate assessors who meet these qualifications to save yourself from running into one of those competency roadblocks.
It’s fall. The end of the year is approaching, and at this very moment, you may be experiencing the end-of-year rush to complete everyone’s competency assessments. Save yourself from hitting this roadblock by staggering competency assessments throughout the year. Consider a monthly or quarterly schedule for assigning platforms or bench assessments. Spread out your assessments as much as possible to alleviate that crunch time in December.
and annual competency
This is a tough one. That first year with your new employee requires double the amount of competency assessment, and therefore double the documentation. Ensure that your documentation, again either paper or electronic, has the means of adequately capturing two assessments for an employee’s first year. Both assessments should include all six competency elements. If you’re not using an automated competency assessment software, you may have to rely on an Outlook or Google calendar to set reminders and notifications for when your employees are due. Take the time to schedule their assessments and ensure that you document them completely!
I’ve said it before, and I’ll say it again. If you didn’t document it, it didn’t happen. Don’t get stuck in the position of…I KNOW I did his competency assessment, I just can’t find it! Make sure that you have a template that allows for complete documentation of all test systems and testing platforms. Ensure that all six competency requirements are listed on this documentation—even if there’s a “Not Applicable” component, keep all six requirements on there! Store your documents appropriately. If you are not electronically recording competency, find a file folder or binder system that allows you to organize each staff member’s training and competency information.
Drowning in paperwork
This is another roadblock that can physically bog down the competency program. The amount of paperwork required to adequately record all six competency elements, on every testing platform for which an employee is trained — it quickly becomes overwhelming! Depending on the size of your organization and your test menu, keeping up with the paperwork may be nearly impossible. If you have to use paper, keep it as simple and streamlined as possible. Again, as I mentioned above, a standardized approach can only help in this situation. If you are able, consider a competency software solution, like StaffReady, that will automate and store competency documentation.
It’s not impossible to be
successful in assessing competency—it’s just a lot of hard work!
Check out the blog for other tips and tools in standardizing and
streamlining your competency program.