Q: Are competency assessments required for physicians performing waived or PPMP testing?
A: For Provider Performed Microscopy Procedures (PPMP), annual competency assessment is required for all testing personnel, including physicians.
When a physician performs waived testing that does not involve an instrument, there is no Joint Commission requirement for documentation of competency when the test is a logical part of his or her specialty and the organization has specifically privileged the physician for that test. Through the medical staff credentialing process, individual physicians may be privileged for those specific waived tests appropriate to their scope of practice and no further assessment of skills or documentation of competence would be required. At the discretion of the Medical Director of Laboratory Services designated on the CLIA certificate or organizational policy, more stringent competency requirements may be implemented.
*Note: Effective January 1, 2007 (see HR.3.10 in the Comprehensive Accreditation Manual for Laboratory and Point-of-Care Testing)