DIAMONDS IN THE ROUGH: Creating Star Laboratory Performers from your Staff

 Do you want to perform laboratory testing in your physician’s office, but you aren’t sure where to obtain qualified personnel?  Perhaps you already have an established lab, but your primary lab person just resigned, and you don’t know where to find a replacement.  Today’s physician office laboratory (POL) has equipment and testing methods that are often just as sophisticated as their hospital laboratory counterparts.  Often these POLs are interfaced with electronic record systems which communicate facility-wide.  It is not an easy task to staff these complex operations, and you can’t expect new, untrained personnel to simply walk in and know how to perform testing correctly.  

Where can you find personnel who are qualified and capable?  Even if the facility can afford to pay the higher salaries of trained laboratory technicians or technologists, the supply of these professional personnel is dwindling with each passing year.  Many have entered retirement or have gone into other professions, and are no longer available in the work force.  Many of the laboratory training schools have closed their programs, so that fewer people are entering this profession.  What is the alternative?

Fortunately for the POL, the federal regulations known as the Clinical Laboratory Improvement Amendments (CLIA ’88) allow alternate routes for obtaining qualified testing personnel.  Current office staff may be cross-trained, or other personnel, such as Medical Assistants, may be trained for a waived or moderate complexity laboratory.  What are these qualifications and what is the best way to train staff to become capable laboratory personnel?

Testing Personnel Qualifications

CLIA ‘88 describes the various ways an individual can qualify to perform laboratory testing. In most states, a laboratory may employ untrained, non-licensed laboratory personnel for moderate complexity testing as long as certain education criteria are met and training is provided and documented. There are no education requirements for individuals performing only waived testing, but training must be provided and documented. Be aware that certain states regulate all laboratory personnel and may require additional qualifications or licensure.

For moderate complexity, testing personnel must have at least a high school diploma or equivalent.  Documentation of education is required, such as a photocopy of high school diploma or GED (General Education Diploma), and the laboratory inspector or surveyor will ask for it at inspection time. 

You must have documentation that appropriate training occurred.  You could create checklists for each skill or test method and fill out the checklist as the training is completed.  Training completion certificates from manufacturers or courses are another way to document training; copies should be kept in each employee’s file.

Lab personnel must demonstrate competency to perform testing before reporting patient results.  Again, this can be documented in the form of checklists that document observations of adequate skills and/or accurate test results.  Written or oral quizzes are also excellent forms of competency checks. 

How to Train Laboratory Personnel

What is the best way to proceed with training?  Each facility should have written job descriptions, procedures and protocols for training and competency evaluation, and documentation of training and competency.

Start by creating job descriptions for all positions in the facility, including for the laboratory director, testing personnel, and phlebotomists.  Job descriptions should specify the minimum education requirements, who supervises each position, detailed responsibilities and duties, and limitations for each position.  Also describe the training requirements for each position and how competency will be measured.  The job description should also state how often evaluations will take place, if there are expected goals to be met, and what will happen if minimum goals are not met.  In this way, each employee knows what is expected.

Ensure you have written policies and procedures for all laboratory activities and all testing performed.  Never assume that the staff will intuitively know how to do something.  The proper way to perform each activity, from filling out a test requisition to making decisions about quality control acceptability, should be detailed in a written procedure.  These procedures should be available to staff at all times and the first step in training is to have personnel read these procedures.  This is to ensure that they understand and follow established protocol.  Laboratory errors are often the result of deviations from protocol, either by taking “short-cuts” or by ignoring proper procedure.

Establish a written plan for training to ensure training is appropriate and consistent. Management and staff need to know what is expected and how training will be carried out.  This plan should state who is responsible for the training, what the training objectives are, what should be documented during training, what skills must be demonstrated before the trainee can perform the activity or test procedure unassisted, and how competency will be monitored.  Ideally, this plan should stipulate that training will be provided in focused, uninterrupted sessions (to prevent the trainee being called away to perform other duties, for example) for maximum effectiveness.

Provide knowledgeable trainers.  These individuals must have adequate knowledge and skill levels to deliver quality training.  Current personnel that demonstrate a high level of expertise may be able to train new personnel, but be aware that “bad habits” and “short-cuts” can be passed on by one employee training another.  When new instrumentation is installed in a laboratory, manufacturers will provide experienced trainers as a part of the installation package.  But, unfortunately today’s POLs often suffer from rapid turnover, and often new personnel do not have access to someone knowledgeable enough to train them.  In these cases, the laboratory director should search for outside training sources rather than leaving laboratory personnel to try and figure out how to perform the testing on their own.  Look for a technical consultant or check with staff at nearby hospitals to find knowledgeable individuals to provide training. Many manufacturers will provide “repeat” training sessions for additional cost.

Design and use training checklists.  Not only can checklists serve as documentation of training for each individual; they also can serve to remind the trainer of the essential elements to cover for each skill or test method.  Include reading the protocol or procedure as a part of training—it is essential that trainees know the correct way to perform an activity.  Theory, maintenance, quality control essentials, and calibration are some the elements that can be included in a training checklist.  Be sure to include limitations and precautions of each procedure.  Each checklist can then be signed by both trainer and trainee, dated, and retained in the personnel file to serve as documentation of training.  These checklists can be used again in cases of remedial training, to ensure all essentials are covered.

After Training

How do you know if the training session was effective?  Establish a test of competency and document this evaluation.  This can be done by observing the skill set to see if the trainee can perform it acceptably.  For example, if venipuncture is the focus of training, then competency can be shown by observing the completion of a set number of successful venipunctures following the correct protocol.  Utilize written or oral quizzes to check competency. Quizzes can test the trainee’s understanding of proper protocol, unusual situations, and limitations of the test method.  

Proficiency testing (PT) or split sample testing are also ways to check staff competency.  Have staff members take turns in the performance of proficiency testing challenges.  PT scores can be used to document staff members’ ongoing competency.  You could also split routine samples for testing and have personnel compare their results, or send one portion to a reference lab and compare the results obtained.  Document results in each employee’s file for use in future evaluations, but be sure to immediately investigate any results that don’t match.

Provide continuing education to encourage learning and continual development of skills.  Be sensitive to employee’s limited salaries and consider financial assistance to pay for seminars or on-line coursework.  If continuing education requirements are stipulated in job descriptions, each staff person will know what goals they must attain.

CLIA ’88 states that testing personnel must be evaluated for performance.  In addition to evaluating competency immediately after training, personnel competency evaluations must take place at least every six months in the first year and annually thereafter.  These evaluations must be documented, not only to show surveyors for compliance, but also as a means to measure each employee’s continuing competency and ongoing growth within the facility.  They should be detailed and evaluate the performance of specific skills, competency to perform and report test results accurately, compliance with facility rules and protocols, and interactions with co-workers and patients.  Ongoing problems or issues with personnel should be addressed, documented, and retained in the involved individual’s files. Evaluations can then assess if their response to corrective action was effective, or if remedial training is needed.   Personnel performance problems can be a liability to the facility and impact the quality of patient care. Evaluations can be used to ensure adequate performance and compliance.  Goals should be set each year; evaluations can then be used to see if employees have attained these goals.  If possible, reward personnel when they attain goals and demonstrate good performance by awarding salary and position advancements.  

You can create star performers in your laboratory through the development of your current pool of talented employees. Follow a few basic guidelines: have a training plan, provide quality training, monitor competency, and conduct periodic performance evaluations.