A-343 Provider Performed Microscopy Program Makeover: One Institution's Experience

Abstract

Abstract Background Provider Performed Microscopy (PPM) is a subset of moderate complexity tests performed by physicians and midlevel practitioners. Regulatory bodies require PPM to meet specific accreditation standards. Many institutions face challenges with engaging providers to complete required training and ongoing assessments. Not immune to these challenges, we set out to improve PPM compliance. We reviewed guidelines to identify potential gaps in our PPM program. The existing PPM program practitioners were not aware of specific regulations and current learning systems were not robust enough to meet the regulations. The Point of Care Testing team (POCT) set out to establish a root cause for non-compliance, identify and collaborate with practitioners, and develop a sustainable training and competency system. Quality improvement must establish sustainable solutions to ensure compliance. Method POCT focused efforts on improving practitioner training, competency, and collaboration with practitioners. Over a period of 2 months, we identified and engaged key stakeholders in each department to review historical data from training, competency completion, and result audits revealing gaps. We clearly communicated the standards and how the current program was not meeting standards such as a lack of formalized training and competency documentation, observation of result documentation, and proper reporting of results. By identifying gaps in training, we utilized stakeholders to develop simple processes to enable compliance such as creation of a tip sheet to guide the resulting process, development of a specific training checklist requiring both provider and POC technical consultant (TC) signatures. In collaboration, a system was created to identify practitioner availability for direct observation of the specific elements of assessment. We leveraged our clinical consultant (CC) to assist in the conversations on a peer level with providers to bolster the importance of compliance. Every practitioner was re-trained by our TC along with the CC. With sustainability in mind, POCT collaborated with administrative assistants and department administrators to be notified of new practitioners. Ongoing monitoring involves POCT completing periodic check-ins with the departments as a second layer of assurance. POCT maintains the records of training and competency expiry dates and assigns critical thinking assessments. Results After 2 months, significant improvements were observed. Completed trainings improved from 50% to 100%, competency from 40% to 85%, and proper result documentation by practitioners from 25% to 70%. A 6-month review showed training was maintained at 100%, competency maintained at 85%, and result documentation improved to 90%. Sustainable improvements were observed at 1 year where training and result documentation achieved 100% compliance and competency completion reached 95%. Conclusion Sustainable quality improvement with PPM compliance was achieved by collaborating with practitioners, understanding obstacles to meeting standards, and developing simple solutions specific to practitioner workflows. In doing so, we were able to develop a robust yet succinct system for initiating and maintaining compliance with PPM regulatory standards.