[Histonet] FW: CAP Competency Question

From:"Luck, Greg D."

> Subject:	CAP Competency Question
> Ok everyone, here is the CAP question that I am most concerned about.
> I'd like to see an example of how each of you intend to answer this
> question by Friday, Feb. 15.  I do not want a reply by email...I do
> want actual documentation that I can put into my manual to help answer
> the inspector's question.  Thanks.
> GEN.55500             Phase II	N/A   YES   NO
> Has the competency of each person to perform his/her assigned duties
> been assessed?
> NOTE:  The manual that describes training activities and evaluations
> must be specific for each job description.  Those activities requiring
> judgment or interpretive skills must be included.  The records must
> make it possible for the inspector to determine what skills were
> assessed and how those skills were measured.  The competency of each
> person to perform the duties assigned must be assessed following
> training, and at least annually thereafter.  During the first year
> that an individual tests patient specimens, competency must be
> assessed at least every six months.  Retraining and reassessment of
> employee competency must occur when problems are identified with
> employee performance.  Competency assessment for each individual must
> include all of the following elements that are applicable to the
> individual's duties:
> 1.	Direct observations of routine patient test performance,
> including patient preparation, if applicable, specimen handling,
> processing and testing
> 2.	Monitoring the recording and reporting of test 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
> 5.	Assessment of test performance through testing previously
> analyzed specimens, internal blind testing samples or external
> proficiency testing samples; and
> 6.	Evaluation of problem-solving skills
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