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How To Interpret CAP Proficiency Testing Evaluations. Elaine Staley, MT(ASCP) Compliance Officer St. Luke’s Hospital – Mayo Clinic Jacksonville. Objectives. Identify performance issues by evaluating data provided on the PT evaluation and Participant Summary

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how to interpret cap proficiency testing evaluations

How To Interpret CAP Proficiency Testing Evaluations

Elaine Staley, MT(ASCP)

Compliance Officer

St. Luke’s Hospital – Mayo Clinic Jacksonville

objectives
Objectives
  • Identify performance issues by evaluating data provided on the PT evaluation and Participant Summary
  • List investigational techniques for responding to Proficiency Testing Exception Summary (PTES)
  • Assemble a quarterly review of PT scores by using the All Analyte Scorecard
e lab solutions
e-Lab Solutions
  • The best way to view CAP evaluations is to use e-Lab Solutions
    • Request access from your institution’s administrator
cap evaluations 101
CAP Evaluations 101
  • Printed Evaluation
    • Exception Codes
  • Interactive Evaluation
  • Participant Summary
cap evaluation what should you review
CAP Evaluation What Should You Review?
  • Evaluate each analyte and specimen for negative/positive bias, trends or shifts
  • Evaluate ungraded challenges
      • If an evaluation criteria is not listed in the Participant Summary you can use information provided by manufacturer or use Rhoads http://www.dgrhoads.com/db2004/ae2004.php
education challenges code 26
Education Challenges Code 26

POC.03275 Phase II N/A YES NO

Is there evidence of evaluation and, if indicated, corrective action in response to "unacceptable" results on the proficiency testing reports and results of the alternative performance assessment system?

NOTE: The evaluation must document the specific reason(s) for the "unacceptable" result(s) and actions taken to reduce the likelihood of recurrence. This must be done within one month after the POCT program receives its evaluation. In addition, each ungraded challenge, each educational challenge, and each episode of nonparticipation must be reviewed and corrective action instituted as appropriate.

proficiency testing exception summary ptes
Proficiency Testing Exception Summary (PTES)
  • Unsatisfactory PT performance
    • Failure to attain the minimum satisfactory score for an analyte, test, subspecialty, or specialty for a testing event.
  • Unsuccessful PT performance (2 of 3 testing events)
    • Failure to attain the minimum satisfactory score for an analyte, test, subspecialty, or specialty for two consecutive or two of three consecutive testing events.
  • Critical PT performance (3 of 4 testing events)
    • Failure to attain the minimum satisfactory score for an analyte, test, subspecialty, or specialty for three consecutive or three of four consecutive testing events. A laboratory must immediately cease testing for that analyte or the discipline.
ptes response
PTES Response
  • College of American Pathologists How to Respond to Unsatisfactory Proficiency Testing Events
  • Example
all analyte score card what is it and how can it help
All Analyte Score Card What is it and How Can it Help?
  • The all analyte score card can be filtered various ways
  • Results can be downloaded into PDF or Excel format
  • Provides a cumulative summary for quality team
cap accepted pt providers
CAP Accepted PT Providers
  • AccuTest (Healthmetrx Digital PT)
  • American Association of Bioanalysts (AAB)
  • American Proficiency Institute (API)
  • American Society of Histocompatibility and Immunogenetics (ASHI)
  • College of American Pathologists (CAP)
  • Control Laboratory PT Program
  • South-Eastern Organ Procurement Foundation (SEOPF)
  • Wisconsin State Laboratory of Hygiene Proficiency Testing Program (WSLH)
cap lap audioconference
CAP LAP Audioconference

POCT and CAP Accreditation

Selwyn J. Baptist, MD, FCAP

September 20, 2006

1:00 – 2:00 pm

Free enrollment to institutions accredited by CAP

aacc southeast poc chapter
AACC Southeast POC Chapter

Point-of-Care-Testing: Evidenced Based Practices and Regulatory Issues

November 2-4, 2006

Francis Marion HotelCharleston, South Carolina

http://www.pointofcare.net/AACC_Southeast_POC_Meeting.htm

central florida poc network
Central Florida POC Network

6th Annual Health First Point-of-Care Conferenceand Exhibition

Friday, November 17th, 2006

Cape Canaveral Hospital inCocoa Beach, FL

http://www.pointofcare.net/Central_Florida/November2006Meeting.htm

references
References
  • GP27-A Using Proficiency Testing (PT) to Improve the Clinical Laboratory
  • College of American Pathologists How to Respond to Unsatisfactory Proficiency Testing Events
  • What to do With PT Providers – 2004 LAP Audioconference – Gerald Hoeltge, MD
  • CAP Laboratory Accreditation Program Manual
thank you
Thank You

Contact Information

Elaine Staley, MT(ASCP)

E-mail – staley.elaine@mayo.edu