D.38 Point of Care Testing and Provider Performed Microscopy.pdf

DEPARTMENT OF VETERANS AFFAIRS Policy Memorandum 113-14-13 South Texas Veterans Health Care System San Antonio, Texas 78229-4404 September 11, 2014

POINT OF CARE TESTING AND PROVIDER

PERFORMED MICROSCOPY

1. PURPOSE: The purpose of this policy is to define Medical Center policy on Point-of-Care testing and provider performed microscopy (PPM)/provider performed testing (PPT) performed within the South Texas Veterans Health Care System (STVHCS) and to define the responsibilities of individuals who perform, document or oversee such testing.

2. POLICY: It is the policy of the STVHCS to ensure that fully qualified and trained individuals perform Point-of-Care and/or PPM/PPT testing with documented competencies for designated personnel. Testing in the STVHCS will be in full compliance with Veterans Health Administration (VHA), College of American Pathologists (CAP), The Joint Commission and Clinical Laboratory Improvement Act (CLIA) ’88 Regulations. Waived testing may be used as a definitive test or for screening purposes and is defined for each test.

3. ACTION:

a. Privileged providers are members of the medical staff and licensed practitioners privileged through the medical staff credentialing process.

b. Point-of-Care testing is performed at the bedside of the patient, in the clinic or other site remote from the laboratory.

c. PPM/PPT is a category of testing performed outside the laboratory that may be performed as part of the patient’s physical examination by privileged providers.

d. Approved Point-of-Care and PPM tests, see Attachment A.

4. PROCEDURES:

a. When a service wishes to perform testing outside of the main laboratory, a request to perform Waived/ Point-of-Care Testing must be submitted to The Ancillary Testing and Laboratory Utilization Committee in Pathology & Laboratory Medicine Section (P&LMS) (See Attachment B). The committee will review the request and the Chief of P&LMS will either approve or disapprove the testing.

b. The Ancillary Testing Coordinator/Pathology & Laboratory Medicine Section (ATC/P&LMS) will contact the requesting service and assist them to ensure the appropriate instrument/reagent is obtained. The ATC/P&LMS will assure that the instrument(s) is validated and all users are trained before patient testing commences. The ATC/P&LMS will monitor for compliance with the following: Appropriate policy and procedures in place; qualified and trained staff; documentation or test data and quality controls; Equipment maintenance logs; and ongoing competency assessments for designated staff.

D.38 36C25721R0043

POLICY MEMORANDUM 113-14-13

c. The ATC/P&LMS will determine the proficiency testing needs, where appropriate, to ensure full compliance with The Joint Commission, CAP and CLIA, and VHA Handbook

1106.01 requirements. The ATC/P&LMS will distribute proficiency testing surveys in a timely manner to the test sites upon receipt in P&LMS. The ATC/P&LMS will review proficiency testing results as they are received, and communicate these results to the testing sites, as well as to ensure appropriate corrective actions are initiated and documented for all instances of unacceptable performance.

d. The competency of each Point of Care Testing person to perform the duties assigned must be assessed following training before the person performs patient testing. Thereafter, during the first year of an individual’s duties, competency must be assessed annually. Retraining and reassessment of employee competency must occur when problems are identified with employee performance. Elements of competency assessment include but are not limited to:

(1) Direct observations of routine patient test performance, including, as applicable, patient identification and preparation; and specimen collection, handling, processing and testing.

(2) Monitoring the recording and reporting of test results, including, as applicable, reporting critical results.

(3) Review of intermediate test results or worksheets, quality control records, proficiency testing results, and preventive maintenance records.

(4) Direct observation of performance of instrument maintenance and function checks, as applicable.

(5) Assessment of test performance through testing previously analyzed specimens, internal blind testing samples of external proficiency testing samples; and

(6) Evaluation of problem solving skills

5. ACCOUNTABILITY:

a. It is the responsibility of each service performing Point-of-Care and/or PPM /PPT:

(1) To assess the use of each test performed and to determine the extent to which it will be used for diagnosis, treatment or screening, with or without follow-up using confirmatory testing.

(2) To identify the staff responsible for the testing activity. These identified staff must receive training specific to the testing activity; receive orientation specific to the needs of the service; and have documented annual competency evaluations.

b. It is the responsibility of the ATC/P&LMS:

(1) To administer and document specific training to qualified staff identified as responsible for performing Point-of-Care testing.

(2) To ensure a current written procedure for each Point-of-Care test and/or PPM/PPT testing is readily available at the testing site. The procedure elements will include appropriate specimen collection and preservation guidelines; instrument calibration; quality control and remedial actions; equipment performance evaluation; and performance of the test.

c. It is the responsibility of each staff member performing Point-of-Care and/or PPM testing:

(1) To perform and document quality control checks as defined in the test procedure.

(2) To document patient test results in the electronic record or chart if they are not entered electronically.

d. It is the responsibility of each service performing Point-of-Care testing to maintain quality control records, equipment maintenance logs and any other documentation related to this testing according to applicable VA guidelines.

e. It is the responsibility of any service intending to initiate Point-of-Care testing and/or PPM/PPT to first notify the ATC/P&LMS of its intentions, so that the proposed test can be brought before P&LMS for review and approval.

6. REFERENCES: VHA Handbook 1106.01, Chapter 1, Hospital Accreditation Standards for Hospitals, The Joint Commission, Code of Federal Regulations: 42 CFR part 493.

7. RESPONSIBILITY: Chief, Pathology & Laboratory Medicine Service (113)

8. RESCISSIONS: STVHCS Policy Memorandum 113-12-13 dated February 6, 2012.

9. RECERTIFICATION: September 2019

(Signature on file)

MARIE L. WELDON, FACHE

Director

Attachment (2)

DISTRIBUTION: C

The following tests are approved Point-of-Care tests and may be performed by approved staff and/or privileged providers at the STVHCS:

Point of care testing offered

Locations performed (as medically required)

Timed defined

Performed by staff providers or staff

Complexity

Bedside blood glucose

STVHCS, Kerrville, All CBOPCs

Monitoring Approved staff Waived

Fecal Occults STVHCS (Urgent care only)

Screening Approved staff Waived

Urine Pregnancy FTOPC, SBOPC, BHOPCs, SPOPC, VOPC

Screening Approved staff Waived

Arterial blood gas STVHCS, Kerrville Definitive Approved staff Non-waived

Activated clotting time (ACT)

Cath Lab, OR Perfusionist, Anesthesia Lab

Definitive Approved staff Non-Waived

Blood oximetry Anesthesia lab/Cath lab

Screening Approved staff Non-waived

KOH, Scabies, Tzanck Dermatology clinic Definitive Staff providers PPM

Thromboelastometry Anesthesia Lab Definitive Approved staff Non-waived

Attachment A

South Texas Veterans Health Care System

Request for Point-of-Care/PPM Testing

Service/Care Line: _____________________________________________________________

Location of Testing Site: ________________________________________________________

Site Supervisor: _______________________________________________________________

Test/s Performed and Instrument and/or Reagents to be used: ________________________

Reason for Testing _____________________________________________________________

Will this test be a screening or definitive test? ___________________

If it is a screening test, what follow-up procedures will be performed? __________________

Testing Personnel: _____________________________________________________________

How will personnel be certified? _________________________________________________

How will competency be checked? __________________________________________

Who will purchase equipment/reagents/supplies? ___________________________________

Will results be documented in Vista? Yes/No

Will appropriate Quality Control records be kept and be available for review? Yes/No

Signature of Service Chief Date

________________________________ Approved/Disapproved __________________ Chief, P&LMS Date

Attachment B

DEPARTMENT OF VETERANS AFFAIRS Policy Memorandum 113-14-13