Training and Competency: They’re the Same Thing, Right?

As a fitting end to my previous 3-part series on how to prepare for and survive your regulatory inspections, one of the hospitals we provide consulting services to was just visited by The CAP. Overall we did great and I’m proud of everyone there, but the inspectors found a weak area for us to improve upon that others may be struggling with as well: documentation of training and competency.

It is a common misnomer that training and competency are equivalent and essentially the same thing. Whether you’re subject to CLIA, CAP or your local state DOH requirements, you will be required to provide proof (documentation) of both training AND competency for each employee, for each task that they perform. This is not just limited to your technical staff, but also includes non-technical personnel (phlebotomists, lab assistants, LIS personnel,transport couriers, etc.), as well as staff outside of the immediate laboratory testing area (respiratory clinics with blood gas analyzers, Point of Care testing, etc.).

Simply put, training is coaching, mentoring, and teaching someone step-by-step how to perform a specific task. Proper documentation of this training includes:

  • Objectives for the training (i.e., “After completing training, staff will understand howto successfully perform maintenance tasks on the hematology CBC analyzer.”)
  • Identification of the methods to be used during the training (direct observation, monitoring recording & reporting of results, review of worksheets & preventive maintenance records, evaluation of problem solving skills)
  • Identification of the materials to be used during the training (cleaning agents, QC samples, previously tested & scored proficiency testing material)
  • Criteria used to assess the effectiveness of the training (minimum score of 90% on critical thinking quiz, ±10% correlation with previously tested sample)
  • Signature of both the trainee and trainer confirming that training was completed, and when

In addition to the obvious routine tasks a lab professional will need to perform (running QC, instrument maintenance, running patients), don’t forget to document their training for the low frequency tasks performed as well. Based on an employee’s job description, they may be involved in additional tasks such as specimen handling, safety precautions, packing and shipping of samples to reference labs, computer system training, telepathology training, and supervisory functions. These tasks too will require documentation of training.

Documentation of all of these tasks can be organized through the use of a departmental orientation checklist. This will help you keep track of what each staff members’ specific job junctions will include that they need to be trained on, and which tasks have been completed by each trainer. Depending on the task, training can be completed quickly after several minutes of demonstration (waived urine hCG testing), or may take several weeks for staff to fully understand and master the task (flow cytometry leukemia work-up). Keep in mind that until a staff member has documented training followed by successful assessment of competency of that task, they should not be permitted to perform or result patient testing independently of their trainer.

Once training has been completed and documented, you must then assess each staff member’s ability to successfully perform these tasks. This is their competency, where you assess if the training was successful and staff are able to perform each assigned task correctly. To fully demonstrate successful competency of non-waived tests, all 6 of the following elements must be documented for each employee, for each task:

  1. Direct observation of patient test performance, including patient identification, specimen collection, handling, processing and testing.
  2. Monitoring the recording & reporting of test results, including when appropriate the handling of critical results.
  3. Review of testing worksheets, QC records, proficiency testing results, and preventive maintenance records.
  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 proficiency testing samples.
  6. Evaluation of problem-solving skills.
  7. Observation of compliance with safety protocols (based upon your specific local state DOH regulations).

The documentation of your competency elements should include the date each item was evaluated, as well as a way to identify and recreate the test performance if asked by an inspector. This is most easily accomplished with the specimen ID number, or PT survey name so records can be located or reprinted.

Be mindful of your local state regulations regarding the specific requirements for who can perform a competency assessment. In many cases, assessors will need an additional supervisor competency for themselves to confirm they are able to successfully assess the performance of their peers. If weaknesses are identified during the competency assessment, additional training should be performed with appropriate corrective actions documented. Competency should be reassessed to ensure staff are correctly performing all duties, prior to them resuming patient testing.

So to summarize:

During training, I am showing you how to do something. I will document all aspects of the training steps that I reviewed with you. When I assess your competency, you are showing me that you know how to do the task correctly. You will document your results as you were trained how to do, and I will validate the accuracy of your work.

-Kyle Nevins, MS, MLS(ASCP)CM is one of ASCP’s 2018 Top 5 in the 40 Under Forty recognition program. She has worked in the medical laboratory profession for over 18 years. In her current position, she transitions between performing laboratory audits across the entire Northwell Health System on Long Island, NY, consulting for at-risk laboratories outside of Northwell Health, bringing laboratories up to regulatory standards, and acting as supervisor and mentor in labs with management gaps.

Flexibility within Structure: Towards Competency-Based Clinical Pathology Training

Since I previously blogged about introductory surgical pathology training, I thought that I’d switch gears and focus this week’s post on introductory CP training. Based on my limited experiences during medical school rotations and at two different residency programs, I can say that developing a targeted CP curriculum (both introductory and more advanced) to train pathology residents can be difficult. Often many of the CP services can function without a resident so clinical laboratory scientists (CLSs) may be in a quandary as to what to do with residents when we are present.

I found that I’ve had the best and most educational experiences when I spent time at a CP lab bench with a CLS who likes to teach and does it well. Lab directors should either identify techs who excel at or train their CLSs how to teach. It’s not as easy as it sounds. The technologist has to not only complete their usual daily workload but at the same time break down the important and most clinically relevant parts of what they do to residents as well as to deliver all this information in an engaging manner.

Having a written syllabus with a logical flow of requirements that builds on previously learned concepts helps to provide structure for those who need it. The syllabus should include rotation objectives, important contact information, and topics and tests necessary to cover by rotation-end. But within CP, I see more of an opportunity for us to train in a competency-based manner at our own pace and toward our individual interests. For someone like me with extensive, hands-on lab and research experience, I need less (sometimes none) of my time spent learning how tests are set up (I basically told my attendings that it wouldn’t be useful for me to watch the CLSs pipetting; by reading up quickly on an unfamiliar permutation of a test based on a concept I already know, I usually can understand it as well). Also, since I learn more by doing, letting me act as a first consult for referring physician calls about test issues really accelerated my learning because if I didn’t know about the test/issue, you can bet I did by the time I called the physician back with a response. And I also learned that a good clinical work-up is key to good care but that applies in any area of pathology that we work in.

But I understand that not everyone has experience or comfort in the lab setting. At my current program, they do two months of an introductory ‘wet lab’ rotation during their first and second years. They have competency/credentialing checklists of tasks they must perform during these rotations. The first month is spent in chemistry, special chemistry, microbiology, hematology, and blood bank becoming acquainted with the staff as well as understanding the theory and performing hands-on applications and analysis of the repertoire of tests available in each section. This is not because we will be expected to do things like a Gram stain in the future but so we have some context to understand what we will be explaining often to referring physicians when they call about a particular test. I think it also helps us to understand the time frame of task completion to help explain when we do serve as the intermediary with referring physicians. And most importantly, you get friendly with technologists who honestly really will help you a lot. Being competency-based, I was allowed the flexibility to decide my competency level (ie – I skipped the ‘perform a Gram stain’ portion of my checklist because I already had done many of these in the past). The second month is spent in more specialized areas such as molecular diagnostics, cytogenetics, advanced microbiology, and special coagulation.

Telling residents to just ‘go sit at a bench with a tech’ is not all that useful, especially if the tech is busy or not interested in or good at teaching. That’s why it is so pivotal that medical directors identify technologists who can serve in this role or do in-service trainings so they understand how to participate in resident teaching. Also, telling residents to just ‘go read up on X’ is also not the most helpful because we learn more by actively doing than just passively reading. For residents in specialties with more patient contact, they have no choice but to participate in direct patient care. At times, it seems more difficult to remember to train pathology residents to feel that same urgency they would if they had the patient in front of them and also to train them in a manner that more actively engages them, but it’s possible. It just requires more effort and thought during the curriculum design phase.

Another thing that I like here at my current program is how during July they have separate orientations to each service regardless of the fact that the first years are on intro to SP and I’m on a hybrid intro to wet lab/comprehensive CP (chemistry and microbiology) rotation with some grossing time to learn the nuances of how grossing is done at this institution. We all have to attend these AP and CP orientation sessions that are geared toward preparing us for situations we will see on call – grossing late Friday prostates for the Saturday call person, how to accession and handle a frozen, transfusion reaction calls, and so on. First years also participate in supervised CP day call with an attending to learn how to handle specific situations so that they are pros by the time they have night/weekend/holiday call as a senior resident. Here, we cover both AP/CP call at the same time as senior residents.

So, how do they teach intro to CP at your institution? How do you think is the best way to train residents during introductory CP rotations? I would love to hear your opinions.

 

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.