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Lab Manual for UCSF Clinical Laboratories

Lab Manual for SFGH

Internal Resources

Provider Performed Microscopy (PPM) Program

Provider Performed Microscopy (PPM) includes the following five tests at UCSF:

1. Urine Sediment
2. Saline Wet Mount
3. 10% KOH Preparation
4. Fern Test, and
5. PinWorm Microscopy

Federal CLIA ‘88 regulations classify all PPM as ‘moderately complex’ testing and therefore require that all individuals performing PPM, or overseeing PPM performed by trainees, successfully complete a periodic competency assessment and be credentialed and privileged by the UCSF Medical Staff. At UCSF, there are two required components – online examination(s), and a direct observation competency evaluation by a colleague. Both must be completed In order to be eligible for Medical Staff privileges to perform PPM. For practitioners new to UCSF or newly requesting PPM privileges, successful initial competency testing must be repeated within six (6) months, as required by federal regulations. Therefore, new practitioners who pass their initial competency will be asked to retake the competency assessment after six (6) months. Thereafter, competency assessment notices will be required annually.

Part One - Online Competency

The UCSF Clinical Laboratories utilizes on-line PPM competency challenge program hosted by the University of Washington. A link to this program along with additional instructions on how to log into the program will be sent via email by the UCSF Medical Staff Office once privileges are requested. Online competency testing in all five areas is available and can be administered independently of each other. Please know that there is no opportunity to review your answers at the end, so be careful and confident of your answer before moving on to the next question. Each subject has approximately five (5) questions and you must answer 80% of the questions correctly to pass. The UCSF Medical Staff Office will keep a record of the results.

Part Two - Direct Observation Evaluation

A competency assessment form will be sent to each practitioner so that the evaluations of the competencies required by The Joint Commission are documented. The six (6) required competencies are:

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, QC records, PT results, and preventive maintenance records;

4. Direct observations of performance of instrument maintenance and function checks,

5. Assessment of test performance through testing previously analyzed specimens, internal blind testing samples or external PT samples,

6. Assessment of problem solving skills.

This form can also be found at: competency assessment form

Completion of this form will require involvement by a provider fully credentialed and current on PPM competency assessment at UCSF. If assistance is need to identify a credentialed provider to assist with this task, please contact the UCSF Medical Staff Office at (415) 885.7268 for assistance.

For practitioners who practice at both UCSF and Zuckerberg San Francisco General Hospital (ZSFG), note that the PPM Part One- Online competency- test requirement at both UCSF and ZSFG are similar, so therefore, a practitioner will only need to successfully complete this aspect of competency assessment once at either location. The PPM Part Two- Direct Observation Evaluation- is unique between UCSF and ZSFG and therefore will need to be performed at each site at which PPM privileges are requested.

In the event a practitioner fails the competency assessment the following procedure will be followed:

  1. Failure of one or more on-line competency assessment modules: Practitioner is allowed to retake after one failure (notification will be sent via email after the first failure allowing the practitioner to retake the exam). On repeat failure, the practitioner must be mentored prior to being allowed to retake the examination a second time:

    1. Medical Staff Office will assist to identify a mentor who has passed the competency assessment and has current privileges in the area(s) of PPM for which the practitioner failed competency.

    2. Practitioner must correctly interpret twelve (12) patient samples with the mentor in each of the examination types that the practitioner failed.

    3. The mentor will complete an attestation that the practitioner has successfully completed the (12) sample review and forward to the Medical Staff Office.

    4. Upon acceptance of the mentor's attestation the the UCSF Medical Staff Office will reset the online competency examination website and the practitioner will be notified that he/she is allowed to re-take the online competency examination(s).

  2. Repeat failure after mentoring: Practitioner must repeat mentoring as above before being allowed to retake the examination.

Impact on PPM privileges:

Repeat failure on an exam for failure to take any exam by the notified date will result in an administrative suspension of privileges for the exam(s) in question. In addition, he or she must be mentored on PPM examinations in the area(s) where competency was failed until retaking and passing the examination.

Please contact the Point of Care Committee Chair, Dr. Anne Deucher(Anne.Deucher@ucsf.edu) or POCT Senior Supervisor, Wilford Vince Cruz( Wilford.VinceCruz@ucsf.edu) if you have any questions regarding Provider Performed Microscopy and/or if you have concerns regarding the on-line competency program.

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