To meet JCAHO and CLIA '88 regulations, all UCSF practitioners who perform microscopic examinations as part of clinical care, must annually take and pass a web based competency assessment. This competency assessment must be successfully completed before a practitioner may initially apply for PPM privileges AND prior to requesting renewal of these privileges upon re-credentialing.

PPM includes the following five tests:

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

The UCSF Clinical Laboratories utilizes on-line PPM competency challenge program hosted by the University of Washington to fulfill the annual competency requirement. The Clinical Labs is given a list of providers by the Medical Staff Office. The Clinical Labs then sends out an email notice to the providers informing them of the testing requirement, providing the URL for the testing site, and providing a user name and a password for the testing site. Testing in all five areas is available and the tests can be taken independently of each other. There is no opportunity to review your answers at the end, so make sure that you are confident of the answer before moving on to the next question. Each subject has approximately 5 questions. You must answer 80% of the questions correctly to pass. Please note that at this time, there is no Apple Macintosh compatibility. You will need access to a Windows PC or Virtual PC to utilize the competency challenge site. The online results are reviewed periodically by the Clinical Laboratories and the results forwarded to the Medical Staff Office.

Competency testing occurs on an annual basis and the testing cycle begins each year July 1. Providers taking the initial test mid-cycle are required to retake the test on July 1.

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: Practioner 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 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 laboratory will be notified to reset the competency examination and the practitioner will be notified that he/she is allowed to re-take the on-line competency assessment

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

Impact on PPM privileges:

As PPM Privileges are for a two year period, a failure on the competency exam in the year between re-credentialing events would not impact a provider's privileges in PPM. However, the provider must take and pass the competency evaluation to be eligible to request PPM privileges in the next credentialing cycle. 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 Enrique Terrazas, MD (voice 353-1375 or email terrazas@labmed2.ucsf.edu) or Betty Yalich (voice 353-9319 or email Betty.Yalich@clinlab.ucsfmedctr.org) if you have any questions regarding Provider Performed Microscopy and/or if you have concerns regarding the on-line competency program.