ephrata community hospital- 12/2006 1 ephrata community hospitals poct competency program- then and...

Ephrata Community Hospital- 12/Ephrata Community Hospital- 12/20062006

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Ephrata Community Hospital’s POCT Competency Ephrata Community Hospital’s POCT Competency Program- Then and NowProgram- Then and Now

By By Beverly McAllisterBeverly McAllister

Laboratory Operations ManagerLaboratory Operations Manager


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DemographicsDemographics 135 bed Community Hospital135 bed Community Hospital Located in Lancaster County, PALocated in Lancaster County, PA 12 types of Point-of-care tests12 types of Point-of-care tests 6 POC tests brought in-house within the last 3 years6 POC tests brought in-house within the last 3 years Abbott P-Web brought in-house within the last 2 years- Abbott P-Web brought in-house within the last 2 years-

prior to that QM2 in use for Precision PCx prior to that QM2 in use for Precision PCx Physicians credentialed for PPT testsPhysicians credentialed for PPT tests All Anesthesiologists trained/competencied on ISTATAll Anesthesiologists trained/competencied on ISTAT Operator lists are on Excel Spreadsheets by Operator lists are on Excel Spreadsheets by

instruments/test typeinstruments/test type


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POCT Operator DemographicsPOCT Operator Demographics

Precision PCx Whole Blood Glucose Meter- 440 usersPrecision PCx Whole Blood Glucose Meter- 440 users Precision XTRA Whole Blood Glucose Users- 26 usersPrecision XTRA Whole Blood Glucose Users- 26 users Fecal Occult Blood- 150 usersFecal Occult Blood- 150 users Gastroccult- 40 usersGastroccult- 40 users Urine Pregnancy- 70 usersUrine Pregnancy- 70 users Urine Dipstick- 90 usersUrine Dipstick- 90 users Avoximeter- 6 usersAvoximeter- 6 users Coaguchek- 12 usersCoaguchek- 12 users Cholestech- 5 usersCholestech- 5 users Nitrazine paper- 50 usersNitrazine paper- 50 users ISTAT- 80 usersISTAT- 80 users


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POCT LOCATION DEMOGRAPHICSPOCT LOCATION DEMOGRAPHICS

Precision PCx- all areasPrecision PCx- all areas Precision XTRA- Ambulance Life Support UnitPrecision XTRA- Ambulance Life Support Unit Fecal Occult Blood- ED, IMCU, CCUFecal Occult Blood- ED, IMCU, CCU Gastroccult- ED, IMCU, CCUGastroccult- ED, IMCU, CCU Urine Pregnancy- ED, SSUUrine Pregnancy- ED, SSU Urine Dipstick – FMU, EDUrine Dipstick – FMU, ED Avoximeter- Cath LabAvoximeter- Cath Lab Coaguchek- Cancer CenterCoaguchek- Cancer Center Cholestech- Wellness CenterCholestech- Wellness Center Nitrazine Paper- FMUNitrazine Paper- FMU ISTAT- Anesthesia, Cath Lab, Respiratory, NICUISTAT- Anesthesia, Cath Lab, Respiratory, NICU


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REGULATIONS- JCAHO- REGULATIONS- JCAHO- Current as of 9/2006Current as of 9/2006

Standard- PC.16.30Standard- PC.16.30

Staff receive specific training and Staff receive specific training and orientation for the tests they perform, and orientation for the tests they perform, and must demonstrate satisfactory levels of must demonstrate satisfactory levels of competence. competence.


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Elements of Performance for Elements of Performance for PC.16.30PC.16.30

1.1. Staff members who perform testing have Staff members who perform testing have been oriented according to the hospital’s been oriented according to the hospital’s specific services. specific services.

2.2. Staff members who perform testing have Staff members who perform testing have been trained for each test he or she is been trained for each test he or she is authorized to perform. authorized to perform.

3.3. Those staff members who perform tests that Those staff members who perform tests that require the use of an instrument have been require the use of an instrument have been trained on the use and maintenance of that trained on the use and maintenance of that instrument. instrument.


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Elements of Performance for Elements of Performance for PC.16.30- cont. PC.16.30- cont.

4. Competence is assessed according to hospital policy at defined 4. Competence is assessed according to hospital policy at defined intervals. Testing always occurs at the time of orientation and intervals. Testing always occurs at the time of orientation and annually thereafter. annually thereafter.

5. Current competency is assessed using 5. Current competency is assessed using at least 2 of the following at least 2 of the following methods per person per testmethods per person per test: :

Performing a test on a blind specimenPerforming a test on a blind specimen Having the supervisor or qualified delegate periodically observe Having the supervisor or qualified delegate periodically observe

routine workroutine work Monitoring each user’s quality control performanceMonitoring each user’s quality control performance Having written testing that is specific to the method assessed. Having written testing that is specific to the method assessed. 6. The director named on the CLIA certificate or qualified designee 6. The director named on the CLIA certificate or qualified designee

evaluates and documents evidence of orientation, training and evaluates and documents evidence of orientation, training and competency. competency.


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CAP Regulations- CAP Regulations- Current as of 10/31/06Current as of 10/31/06

POC.06700 Phase IIPOC.06700 Phase II Is there evidence that testing personnel have Is there evidence that testing personnel have

adequate, specific training to ensure adequate, specific training to ensure competence? competence?

POC. 06800 Phase IIPOC. 06800 Phase II Is there a current list of POCT personnel that Is there a current list of POCT personnel that

delineates the specific tests that each delineates the specific tests that each individual is authorized to perform? individual is authorized to perform?


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CAP REGULATIONS- cont. CAP REGULATIONS- cont.

POC.06900 Phase IIPOC.06900 Phase II

Is there a documented program to ensure Is there a documented program to ensure that each person performing POCT that each person performing POCT maintains satisfactory levels of maintains satisfactory levels of competence? competence?


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CAP Regulations- cont.CAP Regulations- cont.

NOTE: The records must make it possible for the NOTE: The records must make it possible for the Inspector to determine what skills were assessed and Inspector to determine what skills were assessed and how those skills were measured. Some elements of how those skills were measured. Some elements of competency assessment include, but are not limited competency assessment include, but are not limited to: to:

1.1. Direct observation of routine test performance, Direct observation of routine test performance, including patient prep, specimen handling, processing including patient prep, specimen handling, processing and testingand testing

2.2. Monitoring the recording and reporting of tests resultsMonitoring the recording and reporting of tests results3.3. Review of intermediate test results or worksheets, QC Review of intermediate test results or worksheets, QC

records, PT results, and PM records. records, PT results, and PM records.


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4. Direct observation of performance of 4. Direct observation of performance of instrument maintenance and function instrument maintenance and function checkschecks

5. Assessment of test performance through 5. Assessment of test performance through testing previously analyzed specimens, testing previously analyzed specimens, internal blind testing samples or external internal blind testing samples or external PT samplesPT samples

6. Evaluation of problem solving skills6. Evaluation of problem solving skills


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Competency must be reassessed at least Competency must be reassessed at least annually. During the first year that an individual annually. During the first year that an individual is performing such patient testing, competency is performing such patient testing, competency must be assessed every 6 months. All of the must be assessed every 6 months. All of the above elements that are applicable to an above elements that are applicable to an individual’s duties must be evaluated for that individual’s duties must be evaluated for that individual. The competency of physicians who individual. The competency of physicians who perform POC tests may be established and perform POC tests may be established and reassessed through the credentialing process reassessed through the credentialing process of the institution’s medical staff. of the institution’s medical staff.


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The Journey began in 2000………The Journey began in 2000………

Staff development was doing the training for whole Staff development was doing the training for whole blood glucose testing and fecal occult blood- They blood glucose testing and fecal occult blood- They trained all RNs on both tests regardless of where they trained all RNs on both tests regardless of where they were workingwere working

I had no idea what other tests where being done in I had no idea what other tests where being done in house and who was training them or if there was house and who was training them or if there was trainingtraining

No competency program existed at the timeNo competency program existed at the time Units were hiding POC products in filing cabinets. They Units were hiding POC products in filing cabinets. They

would not admit to performing the testswould not admit to performing the tests We had just gone live with QCM2 in the fall of 1999. We had just gone live with QCM2 in the fall of 1999.

That was the only operator list I hadThat was the only operator list I had


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The journey continues….The journey continues….

First things first….First things first….

1.1. Clean up the houseClean up the house

2.2. Identify what tests were being Identify what tests were being performedperformed

3.3. Initiate competency program.Initiate competency program.

4.4. Initiate proficiency testing program Initiate proficiency testing program

5.5. Comply with regulations. Comply with regulations.


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The journey continues…..The journey continues…..

Paper, Paper and more Paper…….Paper, Paper and more Paper…….The first competency program consisted of a The first competency program consisted of a

written test and no more, for whole blood written test and no more, for whole blood glucose testing and fecal occult blood. That glucose testing and fecal occult blood. That was in 2002. The tests had to be completed was in 2002. The tests had to be completed and returned to me by the last week of and returned to me by the last week of December. That would give me enough time to December. That would give me enough time to grade them and update the operator grade them and update the operator certification in QCM2. It was a nightmare certification in QCM2. It was a nightmare getting all of the tests back. getting all of the tests back.


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This process went on for several years. I added This process went on for several years. I added more written tests for those manual tests that more written tests for those manual tests that did not have one or for those new products did not have one or for those new products brought in-house. Staff development continued brought in-house. Staff development continued with the OCB and WBG training. I trained staff with the OCB and WBG training. I trained staff for all other tests. I also initiated a proficiency for all other tests. I also initiated a proficiency testing program and developed maintenance testing program and developed maintenance forms for the Precision PCx among other forms for the Precision PCx among other things. The process was becoming very things. The process was becoming very painful-something had to give. painful-something had to give.


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2005- 2005- the straw that broke the camel’s backthe straw that broke the camel’s back

I had distributed all of the POCT competency I had distributed all of the POCT competency tests to the nurse manager’s stating that if the tests to the nurse manager’s stating that if the staff did not complete and pass them as of staff did not complete and pass them as of 12/31/05, they would be locked out of the 12/31/05, they would be locked out of the system and not be allowed to use the glucose system and not be allowed to use the glucose meter. We’ll guess what happened!!!!! meter. We’ll guess what happened!!!!!


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the straw that broke the camel’s the straw that broke the camel’s back……..back……..

I got a call around 0900 on 12/31/05 stating that no one I got a call around 0900 on 12/31/05 stating that no one could get into the glucose meter. Only one operator ID could get into the glucose meter. Only one operator ID worked and all of the staff was using it. I told the worked and all of the staff was using it. I told the nursing supervisor the reason for that was due to the nursing supervisor the reason for that was due to the staff not taking their competency exam and they were staff not taking their competency exam and they were now locked out. To make the long story short, I had to now locked out. To make the long story short, I had to come in and recertify all staff regardless of whether or 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 not they took the exam. On 1/2/06, I met with the VP of Nursing, the nurse managers and staff development. Nursing, the nurse managers and staff development. Things started to change that moment. After thorough Things started to change that moment. After thorough discussion of the regulations and the process currently discussion of the regulations and the process currently in place, we were all on the same page. We all wanted in place, we were all on the same page. We all wanted to do a good job and meet each others needs as well to do a good job and meet each others needs as well as comply with the regulations.as comply with the regulations.


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How did it all end……..How did it all end……..

In 2006- the following changes were made: In 2006- the following changes were made: 1.All of the written competency exams were transitioned to Healthstream1.All of the written competency exams were transitioned to Healthstream

No more paperNo more paper Nurse manager accountabilityNurse manager accountability POCT operator accountabilityPOCT operator accountability Staff knows they will be locked out if the exams are not completed. 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 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 QCM3update the Operators Users list in Excel and QCM3

3. Creation of Test specific Operator’s list in Excel3. Creation of Test specific Operator’s list in Excel4. Review of POC test menu by department- was able to eliminate testing in some 4. Review of POC test menu by department- was able to eliminate testing in some

areas. areas. 5. Developed written Training/Competency Program with training documents for all 5. Developed written Training/Competency Program with training documents for all

POC tests as well as a POCT Competency Assessment FormPOC tests as well as a POCT Competency Assessment Form6. Involved nursing with POCT Competency Program. Defined roles for POCT 6. Involved nursing with POCT Competency Program. Defined roles for POCT

Coordinator, Nurse manager, Staff development and Nurse educator. Coordinator, Nurse manager, Staff development and Nurse educator. 7. Addition of POCT coordinator assistant. 7. Addition of POCT coordinator assistant. 8. Development of POCT QI Report Card. 8. Development of POCT QI Report Card.


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There’s still work to be done…..There’s still work to be done…..

1.1. Need to go back and retrain the nurse educators on Need to go back and retrain the nurse educators on the manual tests- There is no training documentationthe manual tests- There is no training documentation

2.2. Get signature lists of all POCT operators performing Get signature lists of all POCT operators performing manual tests in which QC is documented manually. manual tests in which QC is documented manually. This is so we can read the initials of each POC This is so we can read the initials of each POC operator to allow them to receive credit for operator to allow them to receive credit for successfully performing QC. successfully performing QC.

3.3. Initiate performance of testing unknown specimen for Initiate performance of testing unknown specimen for manual testsmanual tests

4.4. Training of POCT coordinator assistant. Training of POCT coordinator assistant.


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What have we learned…….What have we learned…….

1.1. POCT coordinator is the leader and Leadership is the POCT coordinator is the leader and Leadership is the act of accomplishing more than the science of act of accomplishing more than the science of management says is possible!!!management says is possible!!!

2.2. Nursing and the POCT coordinator need to work as a Nursing and the POCT coordinator need to work as a team to get the job done completely- team to get the job done completely- Can’t do it aloneCan’t do it alone

3.3. Communication and understanding is key!Communication and understanding is key!4.4. Question-Why you are doing something? Is there Question-Why you are doing something? Is there

value in it? Can it be done differently? value in it? Can it be done differently? 5.5. Rome was not built in a day- A good program takes Rome was not built in a day- A good program takes

time to maturetime to mature


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POINT-OF-CARE COMPETENCY ASSESSMENT FORMNAME:__________________________________________________________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 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 DOCUMENTName:_________________________________ Date:_______________________

Department:___________________________ Operator ID: _________________GOAL: To Demonstrate competency in the use of the ISTAT System

Evaluator’s InitialsIdentifies 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:_________________


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URINE PREGNANCY TEST TRAINING DOCUMENTName: ______________________________________ 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: _______________


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POINT-OF-CARE TESTING ISTAT OPERATOR COMPETENCY LIST

YEAR: 2006 PARTIAL LISTPARTIAL LIST

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 PlanECH Environmental Safety CommitteeQI 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%/monthYellow = 1 missed/monthRed = 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%/yearYellow = 15-20%/quarterRed = <15%/quarter

25%/Quarter with 100% competent by 12/06

85% 100%100%


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Any questions?Any questions?

ephrata community hospital- 12/2006 1 ephrata community hospitals poct competency program- then and...

Documents

users istat

users cholestech

users coaguchek

users avoximeter

users gastroccult

users precision pcx

users precision xtra

users urine dipstick