PROFICIENCY TESTING A BRIEF OVERVIEW. CPT Anne Sterling LTC Paul Mann. OUTLINE. WHAT IS PT? & WHY DO WE DO IT? WHO DOES IT & HOW OFTEN? HOW IS IT EVALUATED? WHAT DO RESULTS MEAN? WHAT HAPPENS WHEN WE FAIL? HOW TO INVESTIGATE PT. PROFICIENCY TESTING.
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CPT Anne Sterling
LTC Paul Mann
- Uses commercially available materials & evaluations
- CAP Surveys
- Develops confidence in the accuracy and reliability of results
- ALL TESTING LOCATIONS PERFORMING
MODERATE OR HIGH COMPLEXITY TESTING
- ALL TESTING LOCATIONS PERFORMING MODERATE OR HIGH COMPLEXITY TESTING + Waived (Minimal Complexity) labs are required to be enrolled in a PT program if one is commercially available.
- WAIVED & PPM SITES
- Can be more stringent than CLIA/CLIP. This is what TJC/CAP will hold you to.
- ALL REGULATED ANALYTES
- ALL ANALYTES
- THREE TIMES A YEAR (MINIMUM OF 5 SAMPLES FOR ALL REGULATED ANALYTES)
Unregulated analytes usually have fewer challenges, fewer samples per challenge
- Alternate method (Split Testing) will be performed at least every 6 months
- GUESS AGAIN
- PROBABLY, BUT MAYBE NOT
- MEAN +/- 2 SD
- EVALUATE BIAS
- EVALUATE CV
- EVALUATE TRENDS
- INTENDED RESPONSE
- MAJORITY OF RESULTS
- determine why
- prevent 2nd unsatisfactory performance
A rigorous systematic approach to answering:
- What happened & Why?
Why did it happen?
What do you do to prevent it from happening again?
How do we know we made a difference?
Techs know what happens at the microprocess (bench) level
Will give them a sense of accomplishment/contribution
Involve in both the investigation and solution development
Techs will be the ones that implement the solution
Defective Survey Material
Wrong Survey Material
Machine / Equipment
SOP written , current, & available
Review Process4Ms of a RCA
Unacceptable results may be classified as follows:
Problem with proficiency testing materials
Problem with evaluation of results
No explanation after investigation
PROVE ACCURACY & PRECISION OF METHOD
- SURVEY MATERIAL HANDLING & PROCESSING
Review patient data from the time of the unacceptable PT result, to determine whether the problem could have affected patient care
If so, appropriate follow-up action should be documented
Ensure the validity of patient results by verifying on two consecutive occasions that the corrective action taken has resolved the problem
This maybe done by reanalysis and/or retesting of frozen or additional PT material, purchase of supplemental PT material, or blind, split-sample testing of patient material with another certified laboratory
Document investigation, conclusions, and corrective actions taken
Maintain documentation for at least 2 years to include worksheets, instrument tapes, reporting forms, evaluation reports, participant summaries, and documentation of follow-up, as applicable. (5 years for Immunohematology) from the date of event.
The laboratory director will review the effectiveness of the corrective actions and, if satisfied, will document his/her recommendation whether to resume testing.
- 1 of 2 or 1 of 3 unsatisfactory performance
- 2 of 2 or 2 of 3 unsatisfactory performance
- 3 of 3 or 3 of 4 unsatisfactory performance
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 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.