[Histonet] RE: Competency for Anatomic and Clinical Pathology

Lee & Peggy Wenk lpwenk <@t> sbcglobal.net
Thu Jul 18 05:14:16 CDT 2013

On Wednesday (yesterday), there was a CAP teleconference on the 
to-be-updated (to be posted end of July 2013) AP checklist.

Someone asked a question about this, mentioning that "someone" from CAP had 
said competency assessment does not apply to histology.

The reply from the presenter and the CAP "office" people who could also 
respond was that competency assess does apply to histology, but that some of 
the 6 components that have to be checked for may not apply for some or most 
of the histotech jobs. So if a component of competency doesn't apply, then 
it doesn't have to be evaluated.

Below is part of the standard:

GEN.55500 Competency Assessment Phase II
The competency of each person to perform his/her assigned duties is 
NOTE: The competency of each 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 at least semiannually. After an 
individual has performed
his/her duties for one year, competency must be assessed annually. 
Retraining and reassessment
of employee competency must occur when problems are identified with employee 
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 
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

These are the 6 components, all of which must be assessed for every task 
done by histotech - except if it doesn't apply. So, for example, if you are 
assessing the competency of sectioning, then #2 - reporting of critical 
values, and #5 - blind testing samples - doesn't apply, so you don't need to 
assess via #2 and #5. But you would have to assess the person microtoming 
via the other 4 types of assessment. (But if you are participating in 
HistoQIP, microtomy is being assess via external proficiency testing sample, 
so if some of your people's slides were evaluated, you actually have #5 
covered for microtomy).

So every aspect of the histotech's job (and the lab assistant) must be 
assessed by as many of the 6 elements above as apply to each task.

CAP says we must assess competency, Joint Commission says we must assess 
competency, and CLIA says we must assess competency, and the 6 elements come 
from CLIA. So we must assess competency.

Peggy A. Wenk, HTL(ASCP)SLS
William Beaumont Hospital
Royal Oak, MI 48073

The opinions expressed are mine, and do not reflect on my hospital.

-----Original Message----- 
From: Michelle Lamphere
Sent: Wednesday, July 17, 2013 9:10 AM
To: 'histonet <@t> lists.utsouthwestern.edu'
Cc: Elma Cortinas
Subject: [Histonet] RE: Competency for Anatomic and Clinical Pathology

I think a few people might find this interesting....

I recently attended a class about Competency Assessments in the lab.  The 
class was given by Ken Byrd (fairly certain that is how you spell his name), 
a Senior Inspector at CAP. When this particular question came up, I asked 
him to give examples of how the histology lab was supposed to use the 6 
elements to assess competency.  He informed the entire class that the 
competency assessment question with the six elements did not apply to the 
histology lab because histology did not report test results.  It is the one 
question on the Gen Lab checklist that did not apply to ANP.  Kinda 
shocking, I know.

It does not mean that we scrapped our entire competency program, we simply 
removed some of the six elements.

Michelle Lamphere
Senior Tech, Histology
Anatomic Pathology
Children's Medical Center
O: 214.456.2318 | Fax: 214.456.0779
E: michelle.lamphere <@t> childrens.com
1935 Medical District Drive | B1.06  | Dallas, Texas  75235

Message: 9
Date: Tue, 16 Jul 2013 07:14:08 -0400
From: "Histology" <histo <@t> pathlab.us>
Subject: [Histonet] Competency for Anatomic and Clinical Pathology at
To: <histonet <@t> lists.utsouthwestern.edu>
<9C0B151B30AC5F4ABFD1B69D915F84CF33E6D4 <@t> dc01.DominionPath.local>
Content-Type: text/plain; charset="us-ascii"


I would love to see your competency spreadsheet for histology.  We just 
finished our first CAP inspection and got a deficiency here.  He said the 
direct observation was great, but that we need to have all 6 elements.  I am 
having trouble trying to come up with a way to evaluate some of these and 
would love any help.

Thanks in advance,

Mehndi Helgren

Dominion Pathology Laboratories

733 Boush St.

Suite 200

Norfolk, VA  23510


histo <@t> pathlab.us

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