Are competency assessments required for licensed practitioners (LP's) performing waived testing?

Any examples are for illustrative purposes only.

When a licensed practitioner (LP) 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 provider to perform the test(s). Through the medical staff credentialing process, individual practitioners may be privileged for those specific waived tests appropriate^^ to their scope of practice and no further assessment of skills or documentation of competence is required. At the discretion of the Director of Laboratory Services designated on the CLIA certificate or by organizational policy, more stringent competency requirements may be implemented. When a licensed practitioner (LP) performs waived testing that involves an instrument, competence to perform testing must be documented after training prior to performing patient tests and annually thereafter. Any two of the following four procedures may be used for competence assessment:

• Performance of a test on a blind specimen.
• Periodic observation of routine work by the supervisor or qualified designee.
• Monitoring of each user's quality control performance.
• Use of a written test specific to the test assessed.

^^ The appropriateness of the waived tests to the scope of practice is determined through the mechanisms of the credentialing process.