Training and Competency
The competency of each person to perform his/her assigned duties, based on his/her specific job description is assessed following training, and periodically thereafter. The Section Head, or designate, of each section must document Initial Training and Competency Assessment for each employee within 6 and 12 months of hire and annually thereafter. The training and assessment program must be documented and specific for each job description. For testing personnel, prior to starting patient testing and prior to reporting patient results for new methods or instruments, each individual must have training and be evaluated for proper test performance. The records must cover all testing performed by each individual. Those activities requiring judgment or interpretive skills must be included. The records must make it possible to determine what skills were assessed and how those skills were measured.
Competency assessment must include all of the following elements that are applicable to the individual's duties:
- Direct observations of routine patient test performance, including patient preparation, if applicable, specimen handling, processing and testing.
- Monitoring the recording and reporting of test results.
- Review of intermediate test results or worksheets, quality control records, proficiency testing results, and preventive maintenance records.
- Direct observation of performance of instrument maintenance and function checks.
- Assessment of test performance through testing previously analyzed specimens, internal blind testing samples or external proficiency testing samples.
- Evaluation of problem-solving skills.
The LP uses data collected about staff competence patterns and trends to respond to staff learning needs. If an employee fails to demonstrate satisfactory performance on the competency assessment, the supervisor shall initiate a plan of corrective action to retrain and reassess the employee's competency. The supervisor must document the retraining and reassessment of employees who initially fail to demonstrate satisfactory performance on competency assessment.
Note: Training records must be maintained for a minimum of two years, but should be retained for the duration of an employee's employment. After the initial two-year period, records of successful ongoing competency assessment may be used in lieu of training records to satisfy the College of American Pathologists (CAP) requirements for personnel training.
Supervisory Training and Competency
Individuals responsible for competency assessments must have the education and experience to evaluate the complexity of the testing being assessed.
The LP Delegation of Authority designates technical directors or individuals meeting general supervisor qualifications the ability to perform competency assessment for moderate- to high-complexity testing in their section.
Performance assessment of section directors / technical supervisors, general supervisors and consultant staff is assessed initially upon hire, or if there is a demonstrated necessity, using the Technical Director / General Supervisor Training Checklist tool.
Supervisory performance is assessed annually utilizing the NIH Personnel Management and Appraisal Performance (PMAP). Unsatisfactory performance must be addressed in a corrective action plan.
Professional Competency
Pathologists who sign out patient reports must have competency assessment pertaining to the type of interpretive/diagnostic services provided. Each attending pathologist should participate in at least one peer educational or intra-departmental / intra-institutional peer review program per year. Competency should be at least 80%, such as 4/5 or 8/10, successful performance on graded or peer-reviewed challenges, and should include at least 5 cases per year. Current graded educational challenges available to LP pathologists include:
- College of American Pathologists (CAP) Performance Improvement Program in Surgical Pathology (PIP) challenges, 10 challenges per shipment, 4 shipments per year
- CAP Autopsy Pathology (AUCD) Education challenges, 5 challenges per activity, 2 online activities per year
- CAP Dermatopathology (DPATH) challenge, 6 challenges activity, 2 online activities per year
- CAP Neuropathology (NP) challenge, 8 challenges activity, 2 online activities per year
- American Society for Clinical Pathology (ASCP) Anatomic Pathology (AP) Checkpath, 5 to 7 cases with clinical histories sent each quarter
- ASCP Hematopathology (HP) Checkpath, 5 to 7 cases with clinical histories sent each quarter
Other competency assessment tools include:
- Intra-departmental peer review, such as Immunohistochemistry scoring correlation between pathologists
- Clinical Center biennial peer review
- Quality management records that have metrics
Competency records must be retained in the pathologists' employee folder for a minimum of two years.
Competency Corrective Action
Retraining and reassessment of employee competency must occur when problems are identified with employee performance. If testing personnel fail to demonstrate satisfactory performance on the competency assessment, the laboratory follows a plan of corrective action to retrain and reassess competency. If it is determined that there are gaps in the individual's knowledge, the employee should be re-educated and allowed to retake the portions of the assessment that fell below the laboratory's guidelines. If, after re-education and training, the employee is unable to satisfactorily pass the assessment, then further action should be taken which may include, supervisory review of work, reassignment of duties, or other actions deemed appropriate by the medical director.
Continuing Education
Personnel have a variety of opportunities to participate in continuing clinical laboratory education to meet their needs. Examples of such opportunities include safety training, seminars, lectures, classes, writing or reading journal articles, etc. Training sessions are provided at NIH as needed; however, personnel may contact their supervisors for approval to attend other venues of educational programs. Technical employees should log at least eight (8) hours of continuing clinical laboratory education on an annual basis. Supervisors and managers should log at least sixteen (16) hours of continuing clinical laboratory education on an annual basis. Medical staff members are required to maintain personal records of continuing medical education (CME) appropriate for the State in which they are licensed. Records of continuing education are kept in each section. Employees may document training using the Continuing Education Log Worksheet.
In addition to professional continuing education opportunities, the NIH Training Center offers professional development courses to staff.
NIH Current and Upcoming Education Series
Educational opportunities are routinely offered through the NIH Clinical Center and are available to any interested LP Staff. These continuing education and training opportunities can be found on the Education and Training Department's monthly calendar of events.
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