Why has the CAP added a section on Physician Performed Testing (PPT) to the Checklist? Inspecting this testing increases the amount of work we have to do, and our physicians are upset about having their work addressed.

The CAP has added a specific PPT section because it has been difficult to locate the Checklist questions that applied to this type of testing when they were included in other sections of the Checklist. We believe that the addition of this section should improve the inspection process. The PPT section does not apply to all laboratories. For example, if a medical staff has its own PPM (Provider Performed Microscopy) certificate, it will not be inspected as part of its institution’s clinical laboratory, so the PPT section will not apply under these circumstances.

PPT applies only to a list of 14 tests, and only to physicians. If others such as nurses perform any of these tests or physicians perform tests in addition to these 14, the other sections of the Point of Care Checklist apply.

Is competency testing required for physicians who perform fecal occult blood tests as part of their physical examinations?

The CAP does not require competency assessment of physicians who perform testing that is within the scope of the practice of medicine as described in the Physician Performed Testing (PPT) section of the POCT Checklist. Physician performed fecal occult blood testing is among those tests that are included in the PPT section. Under the most recent CAP POCT checklist, competency assessment of physicians who perform PPT testing has been deemed part of the medical staff credentialing process, and will no longer be included in CAP Point-of-Care inspections.

The CAP requires that all other healthcare providers, including nurse practitioners and physicians’ assistants, undergo periodic competency assessments. Finally, manufacturer quality control requirements and test instructions must always be followed irrespective of who performs a test.

How should we assess the competency of physicians who perform POC testing?

Your institution, with the participation of the medical director, should establish an institutional policy that addresses competency assessment for physicians who perform point-of-care testing. For tests that are included in the physician performed testing (PPT) section of the CAP POCT Checklist or are FDA classified waived tests, oversight of physician competency is the responsibility of your medical staff credentialing officials. Physician competency assessment for these tests will not be addressed during CAP inspections. For POCT tests that are not included within the Physician Performed Testing category and are FDA classified moderate and high complexity tests, the requirements for physician training and competency assessment will depend on the test under consideration. In some circumstances, physicians may be required to demonstrate competency in the same manner as other employees who perform these tests. Many institutions have outlined specific tests that physicians are deemed competent to perform on the basis of their training and educations. For those tests that have not already been included in the PPT section of the Checklist, no additional documentation beyond proof of completion of the requisite training is required.

Institutions have developed and implemented POCT training and competency programs for physicians. The administration of these programs need not be the responsibility of the point-of-care coordinator. Often the laboratory medical director or another designated physician supervises POCT training and competency programs for physicians.

We have Hemoccult kits available for POCT testing in most of the units at our facility. Physicians perform the occult blood testing. What are our laboratory’s responsibilities for quality control testing?

Physician performed testing (PPT) is subject to CAP inspection only if the laboratory director maintains overall responsibility for the testing.

Quality control must be documented for all tests that are subject to CAP inspection. Each PPT site must maintain a technical procedure manual that includes specimen handling information, and the laboratory must have documented evidence of an effective quality improvement program that is appropriate for the nature of the testing performed (in this case fecal occult blood testing). The quality improvement program should at a minimum address daily quality control results, instrument maintenance, and corrective actions for QC and/or reagent failure. For tests that are included in the physician performed testing (PPT) section of the CAP POCT Checklist or are FDA classified waived tests, oversight of physician competency is the responsibility of your medical staff credentialing officials. Physician competency assessment for these tests will not be addressed during CAP inspections.

The Point-of-Care Testing Checklist requires that quality control be performed and the results documented each day of patient testing. In order to verify that a Hemoccult card is working properly, the performance indicator should be tested for each card prior to reporting the patient result (refer to the manufacturer’s product insert for specific testing instructions and recommendations). Physician documentation of successful testing of the performance indicator can fulfill the requirement for daily quality control, as testing personnel must perform and record quality control results. Quality control results for PPT testing, as with all POCT must also be reviewed by the medical director or his or her designee, and there must be documentation of corrective action taken for any unacceptable quality control results.

Our physicians perform occult blood and rapid urease testing (CLO tests) during endoscopy procedures. Are we required to enroll in proficiency surveys for these tests?

The CAP classifies occult blood and rapid urease testing that is performed by physicians as part of their endoscopic examinations as Physician-Performed Testing (PPT). This testing is subject to CAP inspection only if the testing is performed under the laboratory’s CLIA certificate, or another CLIA certificate that is subject to CAP inspection. The CAP does not require proficiency testing for PPT, although such testing is subject to the requirements of the PPT section of the CAP Point of Care Checklist.

Our physicians perform KOH and Wet Prep testing in our clinics and in the hospital. Are they required to participate in proficiency surveys for this testing? If physicians are the only persons who perform this testing, are we required to maintain written procedures for it?

Procedure manuals and quality control are required for all tests that your facility performs, even those that are performed solely by physicians. The CAP does not require enrollment in proficiency surveys for PPT. However, because there are no commercially available quality control materials for these two tests, many laboratories use proficiency testing as a way to satisfy this CAP requirement.

Physicians at our institution frequently perform bedside Hemoccult testing. Do we need to document competency for these physicians? Must we document quality control results for the testing that they perform?

For tests that are included in the physician performed testing (PPT) section of the CAP POCT Checklist or are FDA classified waived tests, oversight of physician competency is the responsibility of your medical staff credentialing officials. Physician competency assessment for these tests will not be addressed during CAP inspections.

Physicians must document quality control for the tests that they perform. Specifically, in addition to patient results, daily positive and negative control results should be recorded. A requirement for external controls depends upon the presence of internal controls and manufacturer instructions. Please note that controls must be run as often as the manufacturer requires, but no less frequently than once each patient day. In the case of Hemoccult cards, for example, internal positive and negative controls should be performed with each test card development.